Skip to main content

Full text of "The Lancet 1908, 1.1"

See other formats 


























The person charging this material is re¬ 
sponsible for its return on or before the 
Latest Date stamped below. 

Theft, mutilation, and underlining of books 
are reasons for disciplinary action and may 
result in dismissal from the University. 
University of Illinois Library 


JUSO 

MW 06 


L161—0-1096 


Hfc "Tin 


\ t,2- 'i y? 






















The La.ycet, 


July 4 , 1908 . 


THE LANCET. 

H Journal of 3Brttfe& anti tforrfjjn iHrtJtrtnr, durgtrp, #tetrtrte, Jffjpertologp, 
C&rmfetrp, fl&armacotogp, publte fcrattb, ana &tm. 

' 3 o U 

19 a 

' v V 

t 

IX TWO VOLUMES AXXUALLY. 


VOL. I. fob 1908. 


*»< * 

EIGHTY-SIXTH YEAR. 


THOMAS WAKLEY, L.R.C.P. Lond. 

EDITOR. 


LONDON: 


PRINTED AND PUBLISHED 


BX THH BH 3 ISTB 1 KD PttOPBIHCDKS. AT TUB OFFICBS OP "XHB LAHOBT," Bo. «» 5 . STRAND 
AND Nos. 1 A 2 , BADi'UUD STB BBT, STB AND. 


O 


MOMVI1I. 



o 10,5 

V-k 

I'SoS 



THE LANCET, January 4, 1908. 


s oir 

SI-MAN ANATOMY IN ENGLAND DURING 
5 THE NINETEENTH CENTURY. 

Delivered to the Students of the London Hospital 

By ARTHUR KEITH, M.D. Aberd., 
j F.R.C.S. Eng., 

LECTURE!! OS ANATOMY AT THE LONDON HOSPITAL MEDICAL COLLEGE. 


Gentlemen, —In the opinion of the great majority of 
medical men the subject of human anatomy, so far as it can 
serve the purposes of the physician and surgeon, has become 
in our time as perfect as the skill of man can make it. I 
trill not venture to say that such an opinion is unreasonable. 
The human body is a comparatively small and strictly 
circumscribed field wherein generation after generation of 
anatomists have laboured during many centuries, treasuring 
and perpetuating their observations in an almost endless 
■series of tomes. If finality be possible we ought now to 
have reached it. One who believes that the stage of per¬ 
fection has been reached might cite onr modern teat-books 
of anatomy as evidence ; they seem to leave nothing further 
to be desired ; their bulk ought to betoken finality. Never 
before has the structure of the body been displayed so 
exhaustively, so accurately, or so temptingly as to the young 
man who commences the study of medicine to-day. But 
unfortunately the condition of a subject, its perfection or 
imperfection, cannot be measured by an examination of its 
text books. As regards human anatomy it can be judged 
only by seeing how well it serves the needs of medical men, 
and when modern anatomy is measured by this standard it 
seems to me to fall very far short of perfection. 

To make my meaning clear, let me cite a number of 
structures on which anatomists, physicians, and especially 
surgeons have concentrated their most strenuous endeavours 
during the last two or three decades. I will Belect the 
appendix vermiformis as my first instance. Its size, shape, 
position, variations, and development are described in the 
most elaborate detail, but nowhere can one find answers to 
these questions : Why is its lumen so small, its muscular 
coat so thick, and its supply of lymphoid tissue so abundant ? 
Why does it, like the thymus, tonsil, Peyer’s patches, and 
lymphoid structures generally tend to undergo an atrophy 
with age 1 Yet the answers to these questions seem to me 
to constitute the very essence of the anatomy of the 
appendix. Could the anatomist answer these, then indeed 
we should know something of its nature. To call the 
appendix a “vestigial structure” or a “cseoal tonsil” is 
merely a manner of covering our ignorance of its nature by 
a gloss of knowledge— a very remarkable thing in the case of 
a structure that causes the death of thousands of persons. 
The great intestine will serve as another instance. It has 
been most minutely described and demarcated into segments; 
its fixation, its taeniae, its form, and course are set forth in 
our text-books at great length. But no one asks why it is so 
placed and fixed, why its outer muscular coat is grouped in 
ticoim, or why it takes such a remarkable and tortuous 
course. Certainly the theory of its being a useless structure 
and a cesspool, promulgated by MetchDikoff and accepted bv 
so many, will not assist us in explaining the signifi- ance of 
these features. Many other structures might be cited, such 
as the gall-bladder, the prostate, the epididymis, the antrum 
of the mastoid, the nasal air sinuses, the semilunar cartilages 
of the knee, the erector spime, or the folds and arrangement 
of the peritoneum. On each one of these structures 
anatomists and surgeons have focussed their attention of late 
yetrs with the result that we have accumulated an enormous 
catalogue of their physical characters, but of their nature, 
meaning, or function little or nothing. That a generation of 
medical men in seeking to establish a scientific basis on 
which to apply treatment should rest content with merely 
describing the physical characters of parts which are so 
often the seat-of disease seems to me a very remarkable 
defect in our modem methods of anatomical inquiry. This 
grave defect I believe to be a direct result of the modern 
conception of human anatomy. 

What is our modern conception of human anatomy 1 If 

No. 4401. 


you turn to examination papers you will find it; most of the 
questions begin with the word “describe.” Turn to onr 
text-books and you will find that such aDd such a part 
“ presents for description or examination the following 
features ” as if the main reason for the very existence of the 
pait was for “the purposes of description.” Our anatomical 
text-books are what they claim to be—works on “descrip¬ 
tive ” anatomy. The art of description has become the 
chief purpose of aDatomy. We describe to you the heart in 
its utmost details—its shape, surfaces, borders, and grooves; 
we treat it as a still-life study, a thing of crests and angles 
so utterly unlike the palpitating oigan you afterwards have 
to place your stethoscope ever that you cannot imagine the 
anatomical and clinical heart to be the same thing. In my 
student days two books on anatomy were held up for 
particular commendation; one was Ward’s “Osteology,” 
the other Ellis's “Anatomy” (now in my opinion much 
improved). Both are magnificent examples of accurate and 
painstaking observation and description. If aDatomy be but 
the correct description of parts, then, indeed, onr subject has 
leached a finality. To my mind the apparent futility and 
barrenness which characterise so much of our modern 
anatomical work are due to the fact that this descriptive 
ideal has been accepted and that the business oi the 
anatomist is to describe appearances, not to explaiD them. 

The remarkable story of bow anatomy came to he 
regarded in England as a “descriptive science” com¬ 
mences towards the close of the eighteenth century. In 
the latter part of that century British anatomists were, as 
indeed they had always been, much more than mere 
descrlbers. John Hunter in London and Alexander Monro 
(seonndus) in Edinburgh had modelled themselves on the 
prototype o< English anatomists, William Harvey. In no 
sense was Harvey a descriptive anatomist: he studied the 
human body to understand the significance, not the form of 
the various parts. He peiceived that the hypotheses ot his 
time did not account for the structure of the heart nor for 
the arrangement of its blood-vessels. It was to explain 
these that he postulated the theory of the circulation ot the 
blood, the truth of which he afterwards proved by experi¬ 
ment. It was in the same spirit that Hunter. Monro, aDd the 
two Beils pursued the study of anatomy in England in the 
later decades of the eighteenth century. To Hunter the 
observation of a fact was bnt the prelude to an attempt 
to explain its significance. It was not enough to record 
that the wall of the aorta was twice as thick as that of the 
pulmonary artery or that the walls of some veins were thick 
and of others thin : he immediately set to work to find ont 
the significance of these facts ; he appealed to comparative 
anatomy, to embryology, to pathology, and experiment for 
an explanation. Monro formed a true conception of the 
manner in which the cerebral circulation was carried on from 
a consideration of the anatomy of the parts; he did not rest 
content with merely describing the venous sinuses within the 
skull but sought for the reason why the larger intracranial 
veins assume such a peculiar form. In the “System of 
Dissections” by Charles Bell, 1 and in the text-book first 
issued in 1793 by John and Charles Bell, one sees the same 
spirit at work. Thus, up to the end of the eighteenth 
ceDtury there was a strong Bchool of British anatomists who 
regarded dissecting as a means for obtaining not a descrip¬ 
tion but an understanding of the human body. By the end 
of the second decade of the nineteenth century this robust 
British school had almost ceased to exist, its extinction 
being due to the introduction of a French fashiOD. At that 
time our young men turned to Paris for their meoical ideals, 
just as now our young women seek there the standard of 
fashion. Our young anatomists preferred the clear, 
methodical descriptive manner of the Parisian school to the 
heavier methods of their predecessors. Dercriptive anatomy 
had thriven amazingly in the French schools. It. was the 
creation, 1 think, of the famous Winslow, professor of 
aDatomy, physic, and surgery iu the University of Paris, in 
the middle decades of the eighteenth century. He had 
(hut to a very high degree) that gift which many of his 
countrymen still retain of engaging the rapt attention 
of his readers and hearers by the sheer lucidity and 
orderliness of his descriptions. While merely conveying to 
his hearers or readers what they might see with their own 
eyes at a glance be left with them the pleasant impression 
that they were drinking at the very fountain-head of pure 
knowledge. This special gift of vivid de-cription has olten 

I s V \ ' "4—"3 

I ~£ 1 Edinburgh, 1798. 



2 The Lancet,] DR KEITH : HUMAN ANATOMY IN ENGLAND DURING NINETEENTH CENTURY. [Jan. 4,1908. 


deluded scholars into mistaking the shadow for the sab- 
stance. A sjstem of knowledge which settles home too 
easily in one’s understanding is jnst the knowledge to be 
accepted with scrutiny. Winslow purposely abstained from 
attempting to explain the meaning of the structures which 
he described, proposing to relegate all that related to func¬ 
tion to another volume. In so doing he emasculated anatomy ; 
but the system he initiated prospered abundantly, and at the 
end of the eighteenth century, in the hands of his able 
follower Bichat, it came to be regarded, in France at least, 
as the ideal conception of anatomy. 

In the opening years of the nineteenth century we can see 
the French influence at work in the British schools. In 1804 
and 1807 appeared Sir Astley Cooper's famous folios on Hernia. 
They differ totally in spirit from the anatomical works of the 
previous age—those of Hunter and Monro. They are minute, 
elaborate, and rather irksomely accurate descriptions of 
parts ; he never stops to ask why the parts are so arranged 
but is content to have described them. The “ London 
Dissector,” a popular guide in the dissecting-room during 
the earlier part of last century, is a purely descriptive work 
with the merit of brevity. The “ Dublin Dissector ” is un- 
mistakeably founded on the teaching of Bichat. When in 
1828 Jones Quain published the first edition of that famous 
work, which has had many rivals but, in my opinion, 
no equal, be quotes with commendation the system of 
description enunciated by BOclard—namely, that in deal¬ 
ing with a Btrncture the following order should be ob¬ 
served : (1) form and outline ; (2) situation and relationship ; 
(3) direction of its axis; (4) size ; [5) physical characters; 
(6) anatomical composition ; (7) chemical composition; 
(8) secretions ; (9) properties duriDg life ; (10) vital action ; 
(11) sex and age change ; and (12) morbid changes. 
Bedard’s is certainly a comprehensive formula, but still it 
is a formula, and nothing is more certain than that the intro¬ 
duction of a formula into any system of knowledge whatso¬ 
ever means a cessation of all rational endeavour in that 
system. But to see with what avidity the conception of 
anatomy as a “descriptive science” was accepted in Britain 
one must turn to the writings of that ill-starred whirlwind, 
the brilliant anatomical demagogue, Robert Knox of Edin¬ 
burgh. It seized him with all the force of a revelation; in 
season and out of season, by translation of French treatises 
and popular lectures, he preached the adoption of the 
methods and ideals of Bichat and Cuvier as the salvation 
of British anatomy. If other British anatomists adopted these 
ideals more quietly than Knox they were nevertheless sound 
converts and by the middle of the nineteenth century we see 
the French formularies bronght to perfection in the hands 
of Ward and Ellis. Throughout the whole of the nineteenth 
century British anatomists built on the plan designed by the 
French anatomists of the eighteenth century. That this plan 
has provided a sound foundation for the accumulation and 
systematisation of anatomical fact no one can deny who is 
familiar with our magnificent modern text-books, wherein, at 
a length of some 800,000 or 900,000 words, the medical 
student is presented with an exhaustive description of the 
dead, human body. If we had remained true to the ideals of 
the earlier British anatomists they would have portrayed a 
picture of the living human body. 

While the general trend of anatomy in this country during 
the nineteenth century was mainly determined by the accep 
tance of the French ideals, yet even a brief account would 
be altogether misleading unless other influences are noted 
which came to bear on British anatomists and determim d 
the direction of their observations. In the opening decades 
of the nineteenth century Cuvier’s influence was profound. 
He had demonstrated to all the world that anatomy pro¬ 
vided the data by which the members of the animal kingdom 
might be arranged in a natural and orderly system of groups. 
Anatomy, which had been the humble utilitarian drudge of 
medical men, was promoted to be the handmaid of men whose 
aim was pure science. Human anatomists gladly forsook the 
task of trying to discover the mechanism of the human body 
and Bet out on the high task of setting the animal kingdom in 
order. The methods of descriptive anatomy, however 
imperfectly they may answer the purposes of medical men, 
were admirably adapted for the needs of the comparative 
anatomist. Owen became the first effective exponent of the 
Cuvierian school in England and I know of no finer irony in 
fate than that the Hunterian collection which the eighteenth 
century master had built up to elucidate tbe contrivance of 
the human body in particular and the organisation of living 
things in general, should have been placed in the hands of 


one who, however brilliant his powers of description, was a 
believer in archetypes rather than in function. Owen’s fame 
and name were great, and if he exercised no direct effect on 
the body of knowledge which we call human anatomy, yet 
one can see that from 1830 onwards he gave many anatomists 
a bent towards vertebrate morphology, and thus to some 
degree modified the undercurrent of our anatomical text. 

There is a very remarkable parallelism between the three 
men who dominated anatomical work in France during the 
earlier decades of the nineteenth century and the three men 
who exercised a similar influence in England during the gre .t 
Victorian period. Cuvier was accompanied by two men, 
Etienne Geoffrey St. Hilaire and Lamarck. They were 
interpreters of fact, and Cuvier, a describer and classifier,used 
his predominating influence to suppress them. Owen was also 
accompanied by two interpreters of fact; in place of Geoffrey 
St Hilaire stands Huxley, in place of Lamarok, Darwin, but 
in England it was the interpreters of fact who proved 
victorious. Darwin and Huxley had a profound influence on 
the work of British anatomists ; they brought them back to 
the study of the human body ; evolution provided a key to 
many structures which puzzled the human anatomist. But 
while man's position in the animal world was being deter¬ 
mined with great success his place in the medical world was 
well-nigh forgotten. 

In the last three decades of the nineteenth century a 
movement in a new direction became general amongst ana¬ 
tomists. The development of the body became more and more 
a subject of investigation. In this movement the late 
Professor His exercised a predominating influence; it was 
patent to all that the reconstructional and modelling methods 
which he employed with consummate skill provided the 
material for the foundation of a sound and progressive 
system of knowledge. In the main His was a descriptive 
embryologist; he carried the ideals current amongst 
anatomists of his time into a new field of work. Far be it 
from me to deprecate the value of descriptive work in 
embryology or anatomy ; only I would most strenuously urge, 
what is so frequently forgotten, that description is only the 
beginning, not the end, of all embryological and anatomical 
investigation. 

Thus it comes to pass that a young mac commencing the 
study of medicine in 1907, although he may obtain a truer 
conception of “ Man’s Place in Nature” and a fuller know¬ 
ledge of the development of the human body than was 
possible for his predecessor of 1807, yet holds little or no 
advantage over him as regards the available stock of practical 
anatomical knowledge. For proof of what I maintain one 
may turn to the account of the heart, that organ which in 
all times has been accounted the moBt important in the 
study and practice of medicine, given in Bichat’s “ Trait 6 
d’Anatomie Descriptive” 3 and compare it with the descrip¬ 
tions given in the latest editions of our modern text-book of 
anatomy and it will be found that, as far as concerns the 
caked eve anatomy of the heart, the one account differs very 
little from the other; indeed, if anything, the older book 
gives the better working picture of the heart. The same 
parts are enumerated and described ; in the right auricle, 
for instance, the student is asked to observe the openings of 
the superior and inferior vena cava, but in neither the old 
work nor the new is any mention made of the arrangement 
of the musculature round these orifices, the student appa¬ 
rently being expected to presume that they are always open. 
Bichat, it is true, describes a rounded band of musculature 
in the right auricle crossing in front of the superior caval 
orifice but of its significance says nothing. In modern text¬ 
books this same hand is described as a crest—the crista 
terminalis, the very came showing how far anatomists 
have lost sight of function when they name a contracting 
band of muscle a crest. From the physiologist the modern 
student learns that these orifices are closed during auricular 
systole by the surrounding circular musculature, but when 
he comes to examine the human heart he will find that there 
is no circular musculature round the inferior caval orifice, 
while he will find it difficult to believe that the muscle 
round the upper orifice is sufficient for the task ascribed 
to it. 

Having compared the best of the early nineteenth 
century with the best of the early twentieth century 
anatomies, let us turn to the account in the last of the 
truly British text-books, Bells’ “Anatomy of the Human 
Body.” From an examination of the parts the anatomist 


a Paris, 1803. 





Thb Lancet,] 


PROFESSOR PETER THOMPSON : THE STUDY OF EMBRYOLOGY. [JAN. 4, 1908. 3 


there infers that neither orifice can be closed ; that they are 
always open, in systole and diastole ; and that regurgitation 
of blood duriDg the contraction of the auricle is prevented 
by the pressure in the veins being normally greater than 
the diastolic pressure in the right ventricle. I am now 
convinced that, as far as concerns the inferior caval orifice, 
John Bell’s conception is true, and I am not so certain 
as I was that the band of muscle above mentioned—the 
tienia terminalis—is absolutely sufficient to occlude the 
upper orifice in man, although there can be no doubt from 
its arrangement that it does diminish it in auricular syBtole. 
Within the right auricle, too, turning again to modern 
text-books, the student is expected to examine the tubercle 
of Lower which is believed to direct the current of blood 
flowing in from the inferior vena cava—a miniature break¬ 
water. Bichat expresses a doubt as to the tubercle ; he 
speaks of it as the “ tubercle which Lower saw or believed 
he saw.” Bell expresses a more definite doubt. “It is 
commonly absent," he states, and adds “ if it were not really 
an imagination of that celebrated anatomist.” Now, what 
Lower represents in the figure showing this “tubercle" is 
the heart of the calf or sheep, in which the upper and lower 
venae cavae enter the right auricle close together and set at a 
fairly acute angle to each other, so that the band of muscle 
between their orifices is very apparent on the interior of the 
auricle. It was to this intercaval band of muscle which 
Lower gave the name of tubercle, a term inappropriate in 
the sheep’s heart and altogether inapplicable to the human 
heart. 

Many farther instances might be cited to show how far the 
adoption of the descriptive method has obscured our real 
object in studying the anatomy of the heart. I will refer to 
only one—namely, the structures concerned in tricuspid re¬ 
gurgitation All of us who now teach human anatomy must 
have been familiar as students with the clinical doctrine that 
under certain conditions the tricuspid valve became incom¬ 
petent. Yet, in our published descriptions we never ask the 
student to look beyond the cusps of the valve and the fibrous 
ring—a very delicate ring it is—which surrounds the orifice 
as the means of securing competency. The relationship of 
the musculature at the base of the right ventricle to this 
orifice and the effect of its contraction on the size of the 
orifice were scarcely mentioned, yet from a clinical point of 
view the surrounding musculature is infinitely more import¬ 
ant than the surrounding fibrous ring. In spite of the 
teaching and discoveries of embryology we still confuse 
under the term “base” two totaily different parts of the 
heart—namely, the commencement and end of the cardiac 
tube. The conical shape of the heart—its apex and base— 
we assume as axiomatic and incapable of explanation. We 
describe the walls of its chambers as if they were rigid, over¬ 
looking the fact that they are composed of a pulsating 
musculature arranged so as to produce definite movements 
by which their contents are propelled. 

So far my argument has been to show that our progress in 
real practical human anatomy during the nineteenth century 
has not been so great as is generally supposed, the lack of 
progress being due in the fir-t place to our acceptation of 
"descriptive” anatomy as the real anatomy, and, in the 
second place, becau-e side issues have been allowed to draw 
anatomists away from their real work. But it might be 
urged that the defects I see in modern anatomy are the 
result of the separation from it of physiology—a separation 
necessitated hy the growth of knowledge. That a separation 
was necessary I fully admit, but that the dividing line should 
have been drawn where we now find it has proved, as I have 
just shown, a great misfortune, not only for the progress of 
anatomy but also of physiology. It is an artificial line 
established hy Winslow's unhappy facility of description. 
Between anatomy and physiology has been left a no man’s 
land and yet one of great importance to medical men. I 
refer especially to the muscular mechanisms of the body— 
the mechanism of respiration, circulation, digestion, 
deglutition, micturition, and locomotion, subjects at present 
indifferently taught and indifferently understood, because the 
man who teache- the action has forgotten the structures that 
are involve*', and the man who describes and knows the 
Structures has not tronhled to discover how they act. In our 
school, as in many others throughout the country, the gap 
Between anatomy and j histology, whioh tends to widen, has 
not been felt because of trie harmonious workings of the two 
departments, yet I think the time has come when a recon¬ 
sideration of i h« present dividing line is necessary in the 
interests of ail concerned. 


There are many reasons that make a reconsideration of the 
present scope of anatomy urgent. There is, in the first 
place, the enormous growth of physiology ; already those 
that teach that subject find its present scope beyond the 
powers of one teacher. There is, in the second place, the 
necessity of finding more time for the subjects absolutely 
essential to the profession of medicine—the old but ever¬ 
growing subjects of medicine, surgery, and midwifery : the 
newer subjects—pathology, bacteriology, pharmacology, 
hygiene, and special diseases. Something has to be unloaded 
to make proper room for those, and we anatomists, who 
like thrifty housewives have treasured everything, have to 
unload our share and, for my part, I will willingly let go 
much of that material we dragged ashore in our close-meshed 
descriptive net. If to the Bplendid basis of descriptive 
anatomy we have now at our disposal we were to add the 
practical spirit of the eighteenth century anatomists I feel 
certain we should secure a future of great prosperity for 
anatomy. 



ox 


THE STUDY OF EMBRYOLOGY. 

Delivered at King't College , London, 

By PETER THOMPSON, M.D.Vict., 

PROFESSOR OF ANATOMY AT THE COLLEGE. 


Gentlemen, —It may be a commonplace remark, but it is 
nevertheless true, that in tracing the evolution of the present 
state of knowledge of any subject one engages in a task which 
is at once illuminating and stimulating. How interesting it 
is, for example, to come across such observations as those of 
Rathke and Valentin, two distinguished men who lived in 
the first half of the last century and who clearly saw the 
great future which lay before the science of embryology. 
Thus Rathke, in 1832, commences his anatomical and philo¬ 
sophical researches, &c., with a praise of our subject: “In 
order to understand the laws which lie at the foundation of 
animal creation,” he says, “one must not look only at the 
fully-developed animal but also turn attention to those in 
process of development. For here yon see an organ gradually 
converted from a simple into a complex one. Moreover, it 
stands to reason that one is able to recognise the laws of 
creation sooner whilst they are actually being carried on 
than when they are completed.” And Valentin, in 1835, 
remarks : “ Almost all physiologists and anatomists who 
have been active and celebrated in onr time have directed 
their attentions to the development of the individual as 
opposed to the problem of the relationships of the animal 
world—i.e., comparative anatomy. Both together are tbe 
foundation on which the true and genuine conception of 
animal life must be based.” 

In tracing the history of embryology we see that although 
the study of the actual development of animals daring their 
evolution from the egg has attracted attention from very 
early times, little advance was made until comparatively 
recent years. Indeed, it is only within the last 20 or 30 
years that the enormouB powers of embryology as an instru¬ 
ment for unravelling the problems of early growth have been 
manifest, and one can clearly see the main factors which 
have contributed to this change of affairs : the promulga¬ 
tion of the cell theory, the invention of the microtome, 
Darwin’s theory of the origin of species, and lastly the 
many observers who, with modern weapons, have explored 
the little-known country hitherto visited by a small but 
valiant band. 

Striking, therefore, as were the advances made in all 
branches of biological inquiry during the nineteenth century, 
in few was this advance more marked than in that of 
embryology. From its commencement, through the genius 
of Harvey, Haller, and Wolff in the seventeenth and 
eighteenth centuries, little progress was made until the early 
years of the nineteenth century, which through the-researches 
of Pander and von Baer practically witnessed the birth of 
embryology as a science. Pander's investigations have 
become classical and the results of his work are to be found 
in our modern text-books of embryology and are taught 
to-day. Through the interest thus associated with Pander 
and his time it may be recalled that it was in 1817 that he 



4 The Lancet,] PROFESSOR PETER THOMPSON: THE STUDY OF EMBRYOLOGY. 


and toc Baer proceeded to Wurzburg to work nnder 
Ddllinger, and as a result of his advice and influence 
Pander carried out important researches on the develop¬ 
ment of the chick. Thus was formed, as von Baer him¬ 
self has told us, a noteworthy association, destined to 
have far-reaching results, between Dollinger, the grey¬ 
haired veteran in physiological researches, the youthful 
Pander, burning with zeal for science, and the incomparable 
artist Dalton. Von’Baer was so impressed with Pander's 
zeal that he, too, determined to devote himself to the 
pursuit of embryological problems. In 1819 he proceeded to 
Kooigsberg, and for several years enthusiastically applied 
himself to the elucidation of the developmental phenomena 
of animal organisms. The first volume embodying the remits 
of the monumental work was published in 1828, entitled 
“ Observations and Reflections on the Development of 
Animals.” The second volume was published in 1837, and a 
third one in 1888, after his death. These publications 
contain cot only the main results of Baer’s scientific inquiries 
but also form the basis on which all modern embryology 
practically rests. Referring to them, Huxley justly 
observes: “Baer’s book on the development of animals 
contains the deepest and soundest philosophy of biology and 
zoology which has ever been presented to the world,” and 
Kolliker is in agreement with him when he says “ Baer's 
works ought, on account of their richness and excellence of 
faots, the erndition and the magnitude of the developmental 
observations, certainly to be regarded as the best which the 
embryological literature of all times and all nations has to 
show.” Amongst Baer's observations one stands supreme— 
viz., the finding of the mammalian ovum in 1827. This 
discovery was published in a short pamphlet entitled “ De 
Ovi Mammalium et Hominis Genesi,”and he subsequently 
demonstrated before a society of natural philosophy in Berlin 
preparations showing the extremely small mammalian ovum 
inclosed within the Graafian follicle. 

But besides von Baer, to whom must be ascribed the first 
place amongst the workers in embryological science, many 
others were engaged abont this time in similar problems in 
Germany and other countries. In Germany, Oken and 
Meckel, Oarus and Rathke, Johannes Muller, Huschke, and 
Siebold ; in France, Butrochet, Provost, and Coste ; in 
England, Allen Thomson, Wharton Jones, and Martin 
Barry; in Italy, the famous Rusconi—each made valuable 
contributions to the rapidly growing science. 

Here let me say a few words about Allen Thomson, 
whose son we have amongst us as Vice Principal of this 
College. He is rightly regarded as the father of embryology 
in this country. He published as early as 1839 papers dealing 
with early human embryos, and even before this date—i.e., 
in 1831—he proved by means of sections cut by hand that 
the main aorta is formed by the median fusion of two vessels 
previously separate, a most interesting and noteworthy dis¬ 
covery. Moreover, we ought not to forget that prior to 1830 
little was known of embryological science in this country and 
that between 1830 and 1845 the only anatomist who was 
devoting himself to human embryology was Allen Thomson 
and that it was in this field that he won his laurels. It is an 
interesting fact and shows the bent of his mind that at 
21 years of age he published a paper on the development of 
the vascular system, and throughout his life embryology 
continued to be the favourite subject of his study and 
researches. 

N jw may I remind you that the work done in the field of 
embryology in the first half of the century was done before 
the discovery of the microtome, an instrument which, 
though universally used at the present day, is of compara¬ 
tively recent introduction. Indeed, so little advance had 
been made in methods of technique that Pander and von 
Baer practically used the same methods as Haller and Wolff 
had done in the century preceding. I gather from a paper 
by Professor Minot that “ sections, though more or less used 
in the early half of the century, were not much relied upon 
until the second half of the century had been reached, and 
we may say that it was approximately about 1860 that 
section cutting began to come in'o favour among micro- 
scopists. But it was not nntil 1874 that microtomes began 
to make their way.” How then did the old embryologists 
arrive at their conclusions ? An interesting sidelight is 
thrown on this question by Huschke mentioned above. This 
observer published in 1832 an account of the formation of 
the otic vesicle and the lens. As he studied the growth of 
the eye in the chick he noticed in the middle of the eye 
vesicle a little spot which he imagined to be the anlage of 


[Jan. 4, 1908. 


the lens. He explored it with a fine hair, with the point of— 
which he slipped into an opening. “Now I am free from a 
all doubts,” he says. “I knew at once how the lens, the 
lens capsnle, and particularly the labyrinth of the ear were:: 
developed. I saw they were formed from a depression or 
invagination of the external skin.” 

And so with snch simple apparatus as a magnifying lens, a 
scissors, knife, and razor the pioneers of embryology pursued 
their way. Then came the wonderful discovery of Schwann 
that ail animal tissues were composed of cells. With this 
new impetus it is not surprising to find that embryology was a 
for a time included as a branch of physiology. The delicate 
methods employed in histological research were just thoseu 
necessary for the study of young embryos and the subject 
was therefore taught by physiologists. But the anatomists 
soon woke up ; they saw a new world ready for exploration, 
a world which for them offered a solution of many completely 
unintelligible anatomical facts. It was therefore absolutely 
essential for them to master the new science and with as 
little delay as passible they entered into possession of their 
kingdom. Schwann's discovery ultimately had a trans¬ 
forming influence on embryological technique. The methods 
of the old teachers were no longer sufficient. It was re¬ 
cognised that what the atom was to the chemist the cell was 
to the embryologist, and nothing short of thin sections, high 
power of magnification, and elaborate methods of staining 
would suffice. It was imperative that there should be some 
means of obtaining thin even serial sections and this demand 
was soon supplied by the genius of His. 

The first microtome, the instrument by which serial 
sections of objects are obtained, which at all corresponded 
in principle to those in use at the present day is apparently e 
the one described by His in 1870. Previously to that time a 
form of microtome known as Valentin's double knife had 
been employed, but the principle of this was altogether 
different from that of the microtome in use now. The 
essential points of His's microtome were a mechanically : 
moved razor and an arrangement for mechanically advancing 
the block, and although the means of obtaining theseC 
essential points have in later years been improved they con¬ 
stitute the basis on wniob all microtomes are constructed. 

I think it may not be without interest to quote the 
following statement made by His, for nothing could better 
illustrate the enormous progress that has been made since 
1870. Professor His, speaking of the advantages of his own 
instrument, said: “I have used the instrument since 1866 
and I have prepared during this epoch (i.e., four years) over 
5000 sections.” My assistant Weston has recently cat, by 
means of a modern microtome, nearly 5000 serial sections in 
a fortnight in the odd intervals snatched during the day 
from the ordinary routine work of the department. 

Striking as was the work of Pander and von Baer in the-, 
earlier part of the century, in no less degree was that of 
Wilhelm His in later years. His influence on embryology 
has been incalculable, and if 1 were to mention particularly , 
one of his researches in preference to others, it would be the 
wonderful monument of neurological investigation, which 
stands unique. Indeed, so far-reaching has the influence 
of His's life been on all subsequent workers in the field of 
embryology that it may not be out of place to give a brief 
sketch of the career of this remarkable man. 

Wilhelm His was born in Basle in 1831 and it was there ti 
that he commenced his medical studies in 1849. In the year 
following be moved to Berne where he had some relatives 
connected with the university of that city. Here Thiele 
taught anatomy, Valentin physiology, and Bernard Studer 
geology. From 1850 to 1852 His was in Berlin, where he 
came under the influence of Johannes Muller and Remak. 
He was much impressed by the great biologist, whose lectures 
on human and comparative anatomy were at that time 
perhaps unequalled. Indeed, Professor His has left it on 
record that the first lecture of J. Muller which he attended 
was a perfect revelation in the way of teaching and erudition. 
It was, too, from Muller and Remak that he learnt the 
elements of embryology, and thus laid the foundation of the 
great work which he was destined to carry out in the future. 
From Berlin he went to Wurzburg, where he stayed three 
terms (1852-53) Here he came under the notice of Virchow 
and worked in his laboratories. Shortly afterwards, in 1854, 
he returned to Basle to complete his examinations and then 
he proceeded to Paris. In Paris he met Claude Bernard and 
Brown Sfiquard, and worked for >ome time in the laboratory 
of the Cull figi: de France. In 1857 be became a privat-docent 
under Professor Meissner, and in the same year, when only 



Thu Lancet,] 


PROFESSOR PETER THOMPSON: THE STUDY OF EMBRYOLOGY. [Jan. 4, 1908. 5 


26 years of age, he became, throngh Meissner’s promotion to 
1'reiborg, professor of anatomy and physiology in his native 
town. Owing to his youth and natural modesty, he was some¬ 
what diffident of bis power for carrying on the work of the 
two subjects, but the Chancellor of the University (Herr 
Peter Merian) remarked to him : “ Wir haben sie ins Wasser 
geworfen, sie mogen nunzusehen, wiesieechwimmen” (“We 
hate thrown you into the water, see to it that you now 
swim It is well known how brilliant his career has been 
ted how richly his labours have been rewarded in that realm 
of science over which he held almost sovereign sway. His 
has acknowledged, however, in allusion to the remark of the 
Chancellor that several times in the first year after 
his appointment, when day by day he was engaged 
in preparing lectures, demonstrations, and experiments, “Der 
Wasser ging mir allerdings weit an den Hals herauf,”or, in 
other words, that he often felt like drowniog. He remained 
in the University of Basle until 1872, when he succeeded 
E. H. Weber as professor of anatomy and director of the 
anatomical laboratories in the University of Leipsic. Simul¬ 
taneously with his appointment, VV. Braune, Weber’s son-in- 
law, became professor of topographical anatomy in the same 
University. These two men, differing in age by only a few 
days, but differing markedly in their general temperaments, 
became very close friends, and on the death of Braune in 
April, 1892. the loss was felt by His to be well-nigh irre¬ 
parable. Hls’s work was done first in the old, then in the 
new buildings of the institute at Leipsic. The new buildings 
were erected under bis supervision and have become a model 
for successive generations. With regard to his original 
work, it may be said at once that he contributed valuable 
papers to nearly every department of anatomy, but it is as 
an embryologist that he is best known in this country, where 
his name has been familiar to every medical student during 
the last 20 years. In 1885 he completed the great work 
which he published under the name of “ Anatomie Men- 
schlicher Embryonen ” and which has formed the basis of all 
subsequent text-books dealing with embryology. 11 m’s mono¬ 
graphs and miscellaneous papers exceed one hundred in 
number. He passed away in May, 1904, in his seventy-third 
year, the promise of his earlier days being amply fulfilled, 
and he has left a legacy of enormous scientific value to his 
successors. 

To the medical student anatomy very often means simply 
human anatomy. But this is anatomy in a very restricted 
sense. Anatomy when regarded as a science includes embry 
ology and comparative anatomy, whilst anatomy essential to 
the physician and surgeon is really applied anatomy. The 
three subjects, human anatomy, comparative anatomy, and 
embryology, constitute what is known as morphology and the 
specialist in anatomy of to-day must be acquainted with all 
three. Similarly a well equipped anatomical institute must 
contain laboratories for the prosecution of research in these 
three directions. Moreover, in view of the supreme import¬ 
ance of a precise and accurate knowledge of the anatomy of 
the human body and the limited time for the study of the 
preliminary and intermediate subjects, it is not surprising 
that the medical student should have less regard for the 
study of embryology and comparative anatomy than for 
human anatomy. But practical embryology is a fine training 
for anyone who proposes to enter the medical profession, 
whether he intends to be a surgeon, a physician, or a general 
practitioner. The patience, skill, and thoroughness necessary 
to work successfully through an embryo train hie powers 
exactly in the right direction, and in some of the nniversities 
in Germany medical students who have the time and inclina¬ 
tion are encouraged to take up work of this class. 

We have seen how in the prosecution of embryological 
research serial sections became imperative. Odd sections 
taken here and there and studied apart instead of in con¬ 
junction with neighbouring sections could only lead to specu¬ 
lation and error. Even with a complete series of sections of an 
embryo it is oftendifficult to read them correctly ; it is there 
fore necessary to visualise them in some way and this is now 
done by reconstruction methods. If you will pardon the 
simile, it might be said that just aB by means of a piano the 
beauties of a piece of music in manuscript can be rendered 
manifest, so by reconstruction in wax, one can visualise and 
make manifest the form of the embryo from a series of 
microscopical sections. It is easier to appreciate music 
when it is actually played on an instrument and it is easier 
to interpret and appreciate microscopical sections of embryos 
when they are reconstructed in wax in the form of a model 
the employment of serial sections therefore leads naturally 


enough to the discovery of reconstruction methods. To 
Professor His must be given the credit of perceiving the 
need of reproducing in some way the bodily form of the 
object which had been cut into sections. This necessity he 
met by his “ projective reconstruction method.” May I 
describe this very briefly ! He employed millimetre paper, 
each line Of which was taken to represent a section. 
Beginning from a base line, the back in case of a profile 
reconstruction, and the middle line of the body in case of a 
frontal reconstruction, be measured along the lines of his 
paper the distances of any organ as shown in the drawings 
which he made of the sections enlarged, say, 100 times. 
When he had entirely worked throngh his series of sections 
the corresponding points on the lines were joined up, 
and thus was projected on paper the profile form of the 
object with which he was dealing magnified 100 times. 
After working through the sections of the embryo in this 
most exact way he set to work to freely model the embryo in 
Olay or wax. That is to say : he had obtained such a know¬ 
ledge of the embryo from working through the serial sections 
that he was able to take some clay and make a model of the 
form he conceived the embryo to be, controlling all the time 
the size and distances, &c., by means of callipers and refer¬ 
ences to the enlarged drawings of the sections. In this way 
many well-known models were made which have become 
familiar to all students of biology and anatomy throughout 
the world, and I would mention particularly the series of 
models illustrating the development of the chick, the salmon, 
and the human embryo. How necessary it was to visualise 
the sections in some such way as this is shown by the fact 
that Krieger quite independently thought out the same idea. 
He employed the same methods in the study of the central 
nervous system of the crab and about the same time, or a 
little later, other methods were suggested which served the 
same purpose. His's projective reconstruction furnished 
drawings and freely modelled objects. In the making of the 
models he has had no successor. The art required a par¬ 
ticularly high technical gift to overcome the many obstacles 
and to neutralise the many sources of error. Moreover, a 
new method was suggested by Professor Born which entirely 
displaced it. This was, after various modifications, eventu¬ 
ally extensively employed and was utilised by His himself in 
his later years. 

Before proceeding to give an account of Professor Born’s 
method of reconstruction by means of wax plates I wish to 
refer to a very interesting point in connexion with the 
history of the method. Born’s method was briefly announced 
in 1876 and was fully described by bim in 1883, and there 
seems no doubt that the credit of first publishing the method 
rightly belongs to him. But when in conversation recently 
with the librarian of the Royal Microscopical Society I was 
greatly interested to hear that something similar had been 
published quite independently in England about the same 
time. On Jan. 24th, 1879, Mr. E T. Newton read a paper 
before the members of the Quekett Microscopical Club 
explaining how he bad made a model of the brain of the 
cockroach. He evidently had experienced the great difficulty 
of visualising the form of objects cut into serial sections, for 
he remarks in his paper: “Anyone who in working out 
structures by means of sections has endeavoured to trace the 
various parts through a series of sections will understand 
how difficult it is to keep in mind the structures seen in 
each, so as to picture to himself the form of any part when 
entire. And still more difficult is it to convey to others the 
knowledge which one has gained by the examination of such 
a series.” In order to explain to the members of his club the 
details of the structure of the brain as obtained by an exa¬ 
mination of the sections, Mr. Newton marie plates of soft 
pinewood, each one-eighth of an inch in thickness, each plate 
corresponding to a section and cut out by a saw in the form 
of the section. When these were piled oDe on the other an 
entire view of the brain enlarged was obtained in the form 
of a wooden model. There seems no doubt that Mr. Newton 
thought out quite Independently the main principle under¬ 
lying the method of reconstruction by plates, though it was 
some three years later than Born’s first publication. 

[A demonstration was then given of the details of Born’s 
method of reconstruction by wax plates, illustrated by 
models and lantern slides. In brief, this may be described as 
follows. The sections of the embryo are drawn on a thin 
sheet of paper either by the aid of a camera lucida or a 
projection apparatus and special drawing board at a mngnifi- 
cvtion of 25, 50. or 100 times the size of the section, as 
desired. Each sheet of paper is then placed on a stone. 


6 The Lancet,] MR. W. ARBUTHNOT LANE : THE MODERN TREATMENT OF CLEFT PALATE. [Jan. 4. 1908. 


such as is used in lithographic work, and melted wax is 
poured over it. When partly solidified it is well rolled, the 
thickness of the wax being determined by two brass strips, 
one on either side of the sheet and either one-half a milli¬ 
metre or one millimetre in thickness, according to a calcula¬ 
tion based on the thickness of the section and the 
magnification of the drawing. In this way wax plates are 
obtained from which the shape of each drawing can be 
readily cut by a sharp knife. These are all piled one on the 
other and when completed give a reproduction in wax of the 
form of the embryo magnified in accordance with the 
number arranged at the time of drawing.] 

The special features of Born’s method of wax plates are 
its comparative simplicity and its accuracy. It largely 
excludes the personal element in the making of the model 
and does not demand a great degree of technical skill or 
dexterity. Patience, thoroughness, trustworthiness, and 
enthusiasm, with dogged perseverance are the attributes 
necessary for him who will reconstruct in wax a complete 
model of a human or any other embryo in the early stages of 
development. As I said before, the training is an excellent 
one and the experience gained is invaluable for carrying on 
future work in whatever branch of medicine that work is to 
be done. I hope that the time is not far distant when some 
of our students who have the opportunity and the inclination 
will be prepared to take up work along these lines. They 
will not regret it. “ The harvest truly is plenteous, but the 
labourers are few.” 

Most of you will doubtless remember the following words 
of the Right Hon. Lord Avebury in his charming book “ The 
Pleasures of Life ” : “ There never was a time when thought 
was freer or when modest merit and patient industry were 
more sure of reward.” How very applicable these words 
are when applied to the study of embryology by means of 
modern methods. We must not, however, regard embryology 
“as a master-key that will open the gates of knowledge” 
and remove all the difficulties in our way without great 
efforts on our part. As A. M. Marshall remarked in one 
of his lectures: “It is rather to be viewed and treated as 
a delicate and complicated instrument, the proper handling 
of which requires the utmost nicety of balance and adjust¬ 
ment, and which, unless employed with the greatest skill 
and judgment, may yield false instead of true results. We 
are indeed only just beginning to understand the real 
power of our weapons and the right way of employing 
them, and in the future embryology, especially when 
studied in connexion with palaeontology, may be con¬ 
fidently relied on to afford a far clearer insight than we 
have yet obtained into the history of life on the earth.” 
Born’s method is obviously a most valuable aid in embryo- 
logical research and is almost universally used in the German 
universities. In England, up to the present, it has not been 
much in evidence and there is, I think, a great future for an 
embryological school in London. If our University could see 
its way to provide such an institution, properly equipped 
and endowed, there might be a better chance of contributing 
our fair share towards the elucidation of the multitudinous 
problems in embryology which are still waiting solution. A 
great deal has already been done in this country but there is 
an enormous amount still to be accomplished, and this can 
best be dealt with by providing special facilities for those 
who are anxious to take a share in the task. 

Much has been made in the past of the similarity in 
external form and internal structure which characterises the 
embryo of man and other animals in the early stages of 
development. That this is an embryological truth of the 
first magnitude no one will deny, and Haeckel, Darwin, and 
Huxley have drawn important deductions from this striking 
law. Von Baer himself having three unnamed embryos in 
his collection could not say in which group of vertebrates, 
reptiles, birds, or mammals, they were to be placed, and a 
still more striking illustration is afforded by the remarkable 
controversy which was kept up for many years over Krause’s 
famous embryo. “In 1875,” Marshall tells us, “Krause 
described an early human embryo which appeared to differ 
from all known human embryos in having a large vesicular 
allantois like that of a chick or a reptile instead of the 
allantoid stalk by which the human embryo is normally 
connected with the chorion. The peculiarity with regard to 
the allantois was so marked that doubts were at once raised 
as to the embryo being really a human one, and Professor 
His asserted roundly that Krause must have made a mistake 
and that his specimen was a chick embryo and not a human 
one at all. An ardent, almost furious, discussion arose and 


continued for many years ; indeed, it was only in 1892 that 
the points at issue were finally put at rest, and it was shown 
that while Krause was right in describing his embryo as a 
human one he was mistaken in regard to the supposed 
peculiarity in the allantois, the bladder-like vesicle which h& 
took for the allantois being merely a pathological dilation 
of the allantoic stalk.” 

There seems, however, very good reason for believing 
that when the early embryos of man, ape, dog, rabbit, 
and other animals are reconstructed and enlarged in the 
same way as the human embryo shown this afternoon and 
compared there will be little or no difficulty in distin¬ 
guishing one from the other. I anticipate that as other 
models are made by Born’s method certain characteristics 
will become evident in each series—characteristics difficult 
to recognise and appreciate before the enlargement is carried 
out. I wish I could obtain embryos of the gorilla, chimpanzee, 
and orang outang of approximately the same age as the 
human embryo, the model of which is on the table. If these 
could be reconstructed in wax enlarged, say, 100 times, I 
would not be surprised if certain differences became apparent, 
from a study of which it would be possible to realise that the 
human embryo as early as the third week of development/ 
possesses certain characteristics by which it can at once be 
separated from those to which it is, zoologically speaking, 
nearest akin. 

I trust, therefore, it is clear that the evolution of 
embryology as a science took place to a greater extent; 
in the nineteenth century than in the centuries before. 
It is, indeed, at the beginning of the twentieth century 
still a comparatively new kingdom with vast territories 
still waiting to be explored. There is no royal road 
to it, only the strait gate and narrow path. There are 
few excitements; only the daily round and common task. 
There are no rewards as the world would count them ; only 
the joy and gladness which come from a close communion 
with Nature and the chance of wresting from her some of her 
secrets. In “Sartor Kesartus” Carlyle has sounded the call 
afresh which men have heard all down the ages, “ Produce I 
Produce ! Were it but the pitifullest infinitesimal fraction 
of a Product, produce it in God’s name, ’tis the utmost thou 
hast in thee : out with it then.” The torch of science burns 
brighter than ever to-day, and who can foresee what it shall 
illumine ’ As the illustrious von Baer eloquently ex¬ 
pressed it: “Die Wissenschafb ist ewig in ihrem 
Quelle, unermesslich in ihrem Umfange, endlos in ihrer 
Aufgabe, unerreichbar in ihrem Ziele ’* (“As for science, its 
source is eternal, its comprehension is immeasureable, its 
task is endless, and its final goal is unattainable”). 

References .—I Bhould like to acknowledge my great indebtedness to 
the following writers whose works I have freely drawn upon for this 
lecture: (li Dr. Oscar Hertwig (“ Handbuch der Entwickelungs-lehre 
der Wirbeltiere Erato Lieferung”); (2) Karl Peter (“Die Methoden 
der Iteconslruktion”); (3) C. 8. Minot (“The History of the Micro¬ 
tome”); and (4) A. M Marshall (“Lectures and Addresses”). The 
sketch of HIb'b life is taken from the obituarv notice which I contri¬ 
buted to the British Medical Journal in May, 1904. 


THE MODERN TREATMENT OF CLEFT 
PALATE. 

By W. ARBUTHNOT LANE, M.B., M.S. Loxd., 
F.R.C.S. Eng., 

SURGEON TO (TOY'S HOSPITAL; SENIOR SURGEON TO THE HOSPITAL FOB 
SICK CHILDREN, GREAT OSMOND STREET, LONDON, W.C. 


In The Lancet of Feb. 22nd, 1902, p. 498, my teaching on 
e’eft palate, together with the technique of my operative 
procedure, was explained, and I now propose to submit with 
as little repetition of my former communication as possible 
my present-day practice in regard to the more difficult cases 
of cleft palate. 

In early infancy it is possible to provide a well vascularised 
thick flap which is practically three times as broaij as can be 
obtained when the teeth have begun to encroach materially 
on the mucous membrane or to perforate it, since the muco- 
periosteum covering the under and the outer surface of the 
alveolus can be made to form the outer two-thirds of the 
flap. In Fig. 1 there is represented an infant with gags in 
position for operation, the tongue being drawn forwards by a 
silk thread passed through the tip. The ligure gives a 
good idea of the space gained for operating. 

The general principle underlying the various operations 




THE Lancet,] MR. W. ARBUTHNOT LANE : THE MODERN TREATMENT OF CLEFT PALATE. [Jan. 4, 1908 . 7 


which I perform for cleft palate is to close In the interval 

I between the edges of the cleft by mnco-periostenm in the 
case of the hard palate and by mucous membrane and sub¬ 
mucous tissue in the case of the soft palate. In the latter 
every care is taken to avoid damage to the muscles and 
nerves, the interval between the segments of the palate 
being filled in by a soft elastic curtain made up of opposing 
layers of mucous membrane and submucous tissue. If hare¬ 
lip exists the cleft or clefts in it are closed at the same time 
as the cleft in the palate. This is done for three reasons. The 
first and most important is that the soft parts which are re¬ 
moved necessarily from the margins of the lip may be of the 
greatest service in completing the closure of the anterior part 
of the cleft. The second reason is that I find that postponing 
the hare-lip operation for a time reduces the chances of union. 
The third reason is that the sooner the pressure of the 
complete lip is brought to bear upon the segments of the 


aloog the length of the edge of the cleft. The reflected flap 
with its scanty supply of blood derived from small vessels 
in its attached margin is then placed beneath the elevated 
flap the blood-supply of which is ample and it iB fixed in 
position by a double row of sutures. In this manner two 
extensive raw surfaces well supplied with blood and un¬ 
influenced by any tension whatever are retained in accurate 
apposition. If, on the other hand, the cleft is too broad to 
admit of its safe and perfect closure in this manner, one flap, 
comprising all the mucous membrane, submucous tissue, and 
periosteum, on one side is raised except at the point of entry 
of the posterior palatine vessels, while the soft parts on the 
opposite side are raised in a flap from which the posterior 
palatine supply has been excluded and which turns on a 
base formed by the margin of the cleft. Here we have a 
mobile, well-vascularised flap which can be thrown as a 
bridge in any direction and can be superimposed on the flap 


Fig. 1. 


Shows gags in position for opera: ion, the tongue being drawn forward by a silk thread passed through the tip. 



t upper jaw as well as upon a displaced premaxilla, should it 
< exist, the more rapid is the approximation of the bones 
t forming the front of the cleft and the restoration of the pre¬ 
maxilla to its normal relationship. The muco-periosteum 
covering the premaxilla is also uselul in helping to close the 
cleft. 

Practically the flap formation employed to close in the 
<’ hard and soft palate resolves itself into two methods. If the 
It | soft parts overlying the edges of the cleft are thick and 
vascular a flap is cut from the mucous membrane, submucous 
ic tissue, and periosteum of one side, having its attachment or 
base along the free margin of the cleft. The palatine 
j'ascular supply is divided while the flap is being reflected 
1 1 inwards and it depends for its blood-supply on vessels 
i l entering its attached margin. The mucous membrane, sub¬ 
mucous tissue, and periosteum are raised from the opposing 
S margin of the cleft by an elevator, an incision being made 


of the opposite side, the closure being necessarily rendered 
complete by flaps from the edges of a hare-lip. Obviously 
the surgeon must be guided entirely by his instincts and 
experience as to the best mode of closing any particular 
cleft, and this description of methods must be of necessity 
of a general character. 

As time goes on the damage done to the temporary teeth 
by the separation of the superjacent mucous membrane 
becomes steadily greater. Still, this is a matter of no 
moment as compared with the importance of the early 
closure of the cleft, since the milk teeth are often un¬ 
satisfactory in cases of cleft palate apart from operative 
interference, while the permanent teeth escape damage from 
it if undertaken sufficiently early in life. 

I now purpose to describe in detail the measures by which 
the principles that l have laid down for the closure of clefts 
are applied. In Fig. 2 I have attempted to indicate 






8 The Lancet,] MR. W. ARBUTHNOT LANE : THE MODERN TREATMENT OF CLEFT PALATE. [Jan. 4. 1908. 


diagrammatically the details of the first method which I have 
described. It is intended to represent the roof of the mouth 
of an infant, showing a broad cleft involving almost the 
entire palate. The position of the alveolus is indicated by 
the three crosses X x X. 1 represents the incision which 


Fig. 2. 



A broad cleft involving almost tho entire palate. The 
incisions indicated by dotted lines. 

extends forwards and outwards through the muco-periosteum 
from the anterior limit of the cleft and which passes over 
and beyond the alveolus to its outer surface; while 2 com¬ 
mences at its outer limit and runs back along the outer 
surface of the gums about the junction of the cheek and 
alveolus. An incision (3) is then made from its posterior 
extremity along the free margin of the palate to the uvula. 
The flap included between these incisions is raised from the 
subjacent structures. It happens not uncommonly in the 
type of cleft palate illustrated by Fig. 2 that the 
septum presents a free margin which extends almost, 
if not quite, to the level of the cleft. In these 
cases I make an incision (4) through the mucous membrane 
and periosteum or perichondrium along the middle line of 
the septum with two small transverse incisions (5) at either 
end and turn down laterally the narrow Saps so formed, 


Fig. 3. 



The flaps indicated in Fig. 2 shown in position. 


leaving the cartilage or bone bared and exposed. By 
placing the flap, which has been raised, in position, the line 
along which it will rest on the septal margin can be readily 
defined. With a sharp knife the surface of the reflected 
flap is denuded of its covering of mucous membrane along 
the area of impact. By a series of sutures perforating the 
superjacently impo»ed flap and the margin of the septum if 
it be not too hard, or the flaps of mnco-perio-tenm if the 
edge be bony, the reflected flap is pinned securely to the 
septum. 6 shows the incision along the free margin of the 
cleft continued as 7, obliquely outwards and backwards 
aloDg the upper surface of the soft palate. The incision 8 
extends from the posterior limit of 7 along the lower free 
margin of the soft palate to the tip of the uvula and the 
incision 10 forwards and outwards from the anterior limit 
of 6 on to the alveolus. This last incision facilitates the 


raising of the flap on this side and of the introduction 
beneath it of the reflected flap from the oppo-ite side. 
After the muco-periosteum external to the incision 6 has 
been raised from the bone, the soft palate is freed from the 
posterior margin of the hard palate and the mucous mem¬ 
brane on its upper surface turned outwards to the position 
of 9. 

in Fig. 3 the flaps are shown in position. The sutures 
along the line 1 represent those attaching the septum to the 
reflected flap. Those along the line 2 show the sutures which 
unite the free edge of the raised flap to the under surface of 
the reflected flap, those along the line 3 anchor the edge of 
the reflected flap, and those along the line 4 connect the flaps 
where they form the free margin of the new soft palate. 

In Fig. 4 is illustrated the method of fixation of the 
reflected flap A A A A beneath the elevated flap b b b. The left 
portion of the diagram shows the flap raised from the bone 
through an incision along the free margin of the cleft while 

FIG. 4. 



Mode of fixation of reflected flap beneath elevated flap. 


fixed to it by a double row of sutures is the reflected flap 
which has been separated from the roof through a marginal 
incision along the outer aspect of the gum. 

Another common type of cleft palate in which the same 
method is frequently applicable is that illustrated in Fig 5. 
The cleft in the hard palate is to one side of the mesial line 
where the septum is formed continuous with the margin of 
the cleft. The cleft in the soft palate is much broader owing 
to its inclination towards the side containing the septum. 
The alveoluB, which is cleft also, is represented by three 


Fig. 5. 



A type of complete cleft, the incisions being indicated by 
dotted lines. 

crosses—xxx. The reflected flap is obtained from the 
segment of roof, shown in the left portion of the diagram, by 
an incision extending from 7 to 5 to 6 to 8. The mucous 
membrane, submucous tis*ue, and periosteum are raised from 
the bone and apoDeurosis of the soft palate. On the other 
side an incision is made from 9 to 1 along the edge of the 
cleft t,o 2, along the upper aspect of the Boft palate to 3, and 
from 3 to 4. The triangular area of mucous membrane and 
submucous tissue included within the triangle of flap on the 
upper surface of the soft palate is reflected inwards to the 
free margiD of the cleft, while the muco-periosteum is raised 
from the bone by an elevator and scissors introduced through 
the incision 1 to 2. The reflected flap is then placed beneath 
the elevated flap, and is retained firmly in position by a 
double row of interrupted sutures. 

Fig. 6 shows the flaps sutured firmly in position. Along 
9 to 4 are indicated the deep sutures which pass through the 
margin of the reflected flap and perforate the superjacent 
elevated flap, while those along 1. 2, and 3 represent the 
superficial sutures uniting the edge of the elevated flap to 
the adjacent under surface of the reflected flap. Along 3 to 









The Lancet,] MB. W. ARBUTIINOT LANE : THE MODERN TREATMENT OF CLEFT PALATE. [Jan. 4, 1908. 9 


4 the posterior free margins of the reflected Haps are shown 
joined by sutures. 

Should the cleft involve only the soft palate, as is shown in 


Fia. 6. 



Flaps indicated in Fig. 5 shown in position. 


Fig. 7, the same method can usually be applied. The uvula 
on the left side of the diagram is pulled forwards so that the 
upper surface of the palate is exposed, and an incision is 
made from 1 to 2 to 3 to 4, through the mucous membrane 
and submucous tissue, which are dissected off the subjacent 


Fig. 7. 



Broad cleft of soft palate, incisions being indicated bj’ 
dotted lines. 

parts inwards to the margin of the cleft. From the area of 
the soft palate corresponding to the right portion of the 
diagram a flap is raised from its under surface by an incision 
from 1 to 5 to 6 to 7 to 8, and is reflected inwards to the 
margin of the cleft. 

Fig. 8. 



Reflected flaps indicated in Fig. 7 shown in position. 

Fig. 8 shows the flaps sutured firmly in position, the 
darkened area representing the portion of the palate left 
uncovered by mucous membrane. The deep sutures uniting 


the edge of the flap obtained from the under surface of the 
palate on the right side to the raw upper surface of the 
palate on the left side are indicated between 6 and 7, while 
along 1 2, and 3 are shown the sutures connecting the edge 
of the flap reflected from the upper surface of the left side 
of the palate to the raw under surface of the palate on the 
right side. Between 7 and 3 are the sutures connecting the 
posterior free edges of the flaps. The terms right, left, 
refer to the diagram and not to the body. 1 would point out 
that within a fortnight or three weeks any raw surface left 
becomes so perfectly covered in by new tissue as almost to 
defy differentiation from the adjacent mucous membrane. 

The application of the combination of reflected and 
pivoting flap is well illustrated by Fig. 9. This^is intended 


Fig. 9. 



to represent a double cleft palate with the premaxllla (p m) 
lying well in front of the level of the alveolar arch and fixed 
to the under surface of the tip of the nose, I. being the 
small mesial segment of lip fixed to the anterior surface of 
the premaxilla. The reflected flap is obtained by an Incision 
extending from 1 along the outer aspect of the alveolus, 
through 2, and on to 3, when it bends inwards aloDg the free 
margin of the soft palate to the uvula 4. The pivoting flap 
is obtained by an incision from 5, along the outer aspect 
of the alveolus, through 6, along the margin of the 
cleft in the hard palate from 7 to 8, along the upper 
surface of the soft palate to 9 and then to 10. 


Fig. 10. 



The area of mucous membrane corresponding to the tri¬ 
angle 8, 9 and 10 is raised and reflected inwards. The area 
of muco periosteum included in 5, 6, 7, and 8 is raised from 
the subjacent bone except at the point of entry of the 















iO THB Lancet,] MR. YV. ARBOTHNOT LANE: THE MODERN TREATMENT OF CLEFT PALATE. [Jan.4,1908. 


posterior palatine vessels and nerves, which form the pivot 
on which this flap rotates. The mucous membrane is stripped 
from the premaxilla and from the free edge of the septum in 
the manner indicated by the dotted lines showing incisions in 
the diagram. Large flaps are cut from the portions of lip 
forming the edges of the cleft and great care is taken that 
they have an extensive attachment at their bases. The 
mucous membrane covering the lateral and lower aspects 
of the piece of lip lying in front of the premaxilla is 
removed (L). 

The reflected flap is first put in position: the mucous mem¬ 
brane, where it comes into contact with the under surface of 
the septum, having been rendered raw, is secured to it by 
sutures. The pivoting flap is then moved inwards upon the 
reflected flap, to which it is united firmly by a double row of 
sutures. Finally, the soft palate is closed in a similar 
manner. This is represented in Fig. 10. 

After this the triangular areas of muco-periosteum which 
were reflected from the premaxilla are fixed in position (see 
Fig. 11) where these are indicated by y. The flaps from the 


Fig. 11. 



Additional Saps to those in Fig. 10 shown in position. 

lips shown as F F are arranged with their raw surfaces 
upwards. These are united to the raw surfaces of the flaps 
from the premaxilla and of the reflected flap, and are also 
sutured by their margins to one another and to the free edge 
of the pivoting flap (see Fig. 12). 


Fig. 12. 



Lastly, the ala of the nose is cut away from the cheek on 
either side and is displaced inwards where it is united by 
sutures to the septum, and is sewn to the cheek in its new 
position. This I have attempted to indicate in the same 
diagram. Having brought the edges of the lip into accurate 
apposition by means of separate sutures, two sutures of linen 
thread are passed in the manner indicated in Fig. 13. The 


Fig. 13. 



needle perforates the lip from behind and is made to 
re-enter the anterior aspect of the lip through the same 


hole, and after traversing the lip transversely it again 
emerges and enters through the same hole, the needle passing 
directly backwards through the lip. When this thread is 
made taut and tied the opposing raw surfaces of lip are 
held in accurate apposition, and no scar whatever results 
from the presence of these deep sutures, which can be readily 
removed when they have served their purpose. In Fig. 13 
only one cleft in the lip is represented. Occasionally 
in clefts involving the soft palate, with probably a pro¬ 
portion of the hard palate, the soft parts forming the 
anterior two-thirds of the margin of the cleft are as thin as 
paper. In such circumstances the splitting of the flaps can 
only be effected up to a considerable distance from the free 
margin, or some means other than splitting must be adopted. 
In splitting a thin flap there is a risk of a failure of nutrition 
of a part of it, so that a hols remains at the anterior limit of 
the cleft. An aperture in this situation is often very difficult 
to close. I have met this difficulty most effectually by deal¬ 
ing with the cleft in a manner which at first sight appears to 
be more complicated than it really is. The object is to 
employ a large flap the vitality of which is of a very high 
order and this is insured by its containing the descending 
palatine vessels and nerves of one side. 

Fig. 14 shows a cleft involving the 6oft and part of the 
hard palate. On the left half of the diagram an incision 
represented as a dotted line commences at 1 well outside and 
behind the aperture through which the descending palatine 
vessels emerge. From that point it is carried forwards along 
the alveolar margin across the middle line 2 and along the 
alveolar margin of the opposite side to 3. It then extends 
along the outer limit of the soft palate to 7 and along 


Fig. 14. 



its lower free margin to 6. An incision is carried outwards 
and slightly forwards from the anterior limit of the cleft 4 
to meet the first incision at 3, and another from 4 along the 
upper surface of the palate to 5, and from 5 along the free 
edge of the palate to 8. The four-sided flap of the soft parts 
forming the anterior surface of the palate included between 
the lines 4, 3, 7, and 6 is raised and reflected inwards to the 
free margin of the cleft. The large flap 4, 3, 2, 1, con¬ 
taining the vessels and nerves, is elevated from the hard 
palate and is separated from the margin of the cleft in the 
hard palate. The triangular area of mucous membrane 
included between 4, 5, and 8 is reflected inwards from the 
upper surface of the soft palate to the margin of the cleft so 
as to leave a raw area of considerable size. 

The free edge of the quadrilateral reflected flap of soft 
palate 4, 3, 7, 6 is pinned by deep, indicated as 1 to 2, 
sutures to this bare surface so that sufficient areas of the 
raw surfaces on either side are brought securely into accurate 
apposition (see Fig. IS). The large flap is then buckled up 
so that its lower margin comes into apposition with the free 
margin of soft palate on the same side. These edges are then 
retained in apposition by sutures which also perforate the 
surface of the subjacent reflected quadrilateral flap. This 
junction is represented along the line 3 to 4. The remaining 
free edge of the large flap is then sutured to the lower edge 
of the soft palate 2, 4, 5, 6 and to the outer limit of the 
quadrilateral incision 6 to 7. It happens occasionally that 







The Lancet,] MR. W. ARBUTHNOT LANE: THE MODERN TREATMENT OF CLEFT PALATE. [Jan. 4,1908. 11 


it i8 impossible to close the whole length of the cleft by one 
single operation. 

Fig. 15. 



Reflected and pivoting flaps in position. 


Fig. 16 illustrates such a condition. The cleft is a very 
wide one and it is found inadvisable to attempt to close it 
by the reflection of flaps in the manner already described. 
An incision is made along the entire outer aspect of the gum 
along the line indicated 1, 4, 4, 4, 4. Two are made along 


Fig. 16. 



the direction of 2 and two others along the free inner 
margins of the cleft aloDg dotted lines 3, 3. Flaps are also 
separated from the septal margin. 

The flap included between 1 and 2 on either side is turned 
back, great care being taken of its posterior attachment, 


Fig. 17. 



The reflected and pivoting flaps of Fig. 16 shown in position. 

which is usually very thin. The flaps comprised between 2, 
3, and 4 are raised from the bone from before backwards, 
care being taken to avoid any damage to the descending 
palatine vessels. These flaps are then displaced inwards as 
in Fig. 17, upon the subjacent flaps 3, 4, 5, 6, the margins 


of which are united by sutures to the superjacent pivoting 
flaps 1, 2, 7, 8. The apposing margins of the pivoting flaps 
are then sutured together and to the subjacent mesial flap 
and, if possible, to tbe septum also along the line 1, 2. 

At a later period the posterior portion of the cleft may be 
closed in various ways, the method varying with the breadth 
of the cleft and the extent of material at disposal. The 
first and more generally applicable method is by reflecting a 
flap inwards on one side, leaving it attached by its inner 
margin, the other flap being rendered raw on its posterior 
surface and its area extended, as in Figs. 7 and 8. Tbe 
second method is to reflect a flap Inwards as before, while 
tbe flap from the opposite side is raised from the subjacent 
parts by an incision extending along its inner, posterior, and 
outer margins, so that it pivots anteriorly and can be made 
to cover the flap reflected from the opposite side. Or both 
flaps may be made, as in Fig. 18, to pivot upon their anterior 
attachments ; their internal edges are sutured carefully 
together, the outer free margins being anchored wherever a 
suitable attachment can be found. The free inner margins 
of the cleft are also pinned down to the superjacent flaps by 
sutures. 

In Fig 18 the dotted outline 1, 2, 3, 4 represents the form 


Fig. 18. 



Mode of employment of pivoting flaps to close gap left in 
Fig. 17. 

of the flap cut from the under surface of the palate. This 
pivots upon its attachment 1, 4. 

In Fig. 19 these pivoting flaps are shown 'in apposition 
along the line 4, 5, where their edges are united to one 


Fig. 19. 



Pivoting flaps outlined in Pig. 18 shown in position. 

another. Their outer margins are united to the exposed 
surface of the soft palate along the line 1, 2. 

Cavendish square. W. 


The Sanitary Inspectors Examination Board. 

—An examination for certificates of qualification for appoint¬ 
ment of sanitary inspector or inspector of nuisances under 
Section 108 (2) (d) of the Public Health (London) Act, 1891, 
will be held at the Examination Hall, Victoria Embankment, 
London, on Tuesday, Jan. 14th, and the four following 
days. Particulars will be forwarded on application to the 
honorary secretary, the Sanitary Inspectors Examination 
Board, 1, Adelaide Buildings, London Bridge, London, E.C. 










12 The Lancet,] DR. H. CAMPBELL THOMSON: THE KINEMATOGRAPH IN MEDICINE. 


[Jan. 4,1908. 


A PRELIMINARY NOTE ON THE KINE¬ 
MATOGRAPH IN MEDICINE. 

Bv H. CAMPBELL THOMSON, M.D. LONl),, 
F.R.O.P. Lone., 

PHYSICIAN TO OUT-PATIENTS AT TBS MIDDLESEX HOSPITAL; PHYSICIAN 
TO THE HOSPITAL FOB EPILEPSY AND PARALYSIS, HAIDA VALE. 


The results which I have obtained with the kinematograph 
as an aid in the teaching of nervous diseases, and which I 
have been able to demonstrate at the Middlesex Hospital and 
elsewhere, have met with such expressions of encouragement 
from my colleagnes and other members of the medical pro¬ 
fession as to lead me to think that it may be of some interest 
to publish a few notes on the nses and possibilities which 
this method of demonstration appears to offer. In connexion 
with the teaching of medicine diseases of the nervous 
system are especially well adapted for bioscopic illustration, 
since the abnormalities of movement can be all faithfully 
reproduced. 

The illustrations accompanying this article are enlarged 
from isolated examples taken from a section of films and 
they depict the momentary attitudes of the patients as 
photographs were being taken of them at the rate of 16 a 
second. For the care and trouble taken in producing these 
films I have to thank Mr. Charles Urb in. From the appear¬ 
ance of these enlargements some idea may be gathered of 
the sharpness of definition which is obtained in the original 
films. These are all pictures of abnormal movements of 
pronounced character and will form the basis of the demon¬ 
stration which, at the invitation of the council, I hope to 
give before the Medical Section of the Royal Society of 
Medicine at the end of January. 

ill The first figure illustrated is that of a man with ataxy of 
the limbs who is depicted in this photograph as he is in the 
act of turning and the position of the left leg, in which the 
trouble is the more pronounced, gives some idea of the type 
of gait which can be so well seen in the moving pictures, as 
likewise can the incoordination of the arms, and the tendency 
to fall backwards, to which he is also subject. 

The next two figures are illustrations from a case of 
disseminated sclerosis. The ataxic-paraplegic walk and the 
attempts to preserve the balance by the movements of the 
arms are well shown ; in the second picture the patient has 
been photographed while in the act of drinking in order to 
bring out the “ volitional ” tremors. His efforts to raise the 
glass to his lips, accompanied as they are by tremors of 
increasing amplitude and spilling of the water, make up a 
picture which cannot fail to impress itself on all who see it. 
From this case films have also been taken to show nystagmus 
and the rapid oscillations of the eyes as they are turned to 
one side or the other can be clearly seen and, moreover, can 
be contrasted with an example of slow nystagmus which has 
been obtained from a case of Friedreich’s disease. 

In the fourth figure we have an example of a paraplegic 
gait resulting from a myelitis. 

The fifth picture is taken from a case of pseudo-hyper- 
trophic paralysis in which the characteristic waddling 
method of progression is shown, and here the instantaneous 
photograph has depicted the patient’s right leg in the posi¬ 
tion of “ high-stepping” gait which is so apt to be assumed 
by patients with such muscular weakness as makes it difficult 
for them to clear their feet from the ground. Bioscopic 
illustrations have also been obtained of the method by 
which this patient gets up from the ground by 1 ’ climbing up 
his legs.” 

The sixth figure is taken from a case of cerebral diplegia 
with athetosis. The continual squirming, involuntary move¬ 
ments which affect the head and face as well as the hand, are 
realistically shown and films have also been obtained of the 
patient walking. 

The seventh figure illustrates the posture of a case of para¬ 
lysis agitans, and by means of the bioscope the characteristic 
tremor of the hands can be seen. The typical “mask’’-like 
face can be easily identified by a series of pictures which 
show the rigidity of the countenance being maintained while 
the patient is talking, and this has been made atill clearer by 
comparison with the facial expression of another case in 
which tremor has arisen from a different cause. 

The last picture shows the act of testing the kDee-jerks. 

Enough has been said to give a general outline of some 
of the movements which have been already photographed 
for demonstration, but it is, of course, possible to record all 


the main diagnostic points of a case, as in one instance has 
been done. The absence of signs can also be recorded as 
well as their presence and the presence or absence of anaes¬ 
thesia can be demonstrated by asking the patieDt to raise his 
hand or to make other signs indicating his abilities to feel or 
not as the case may be. To begin with, one has natnrally 
chosen cases where the movements have been of an ex¬ 
aggerated nature, but the fact that nystagmus can be shown 
is a clear indication of what can be done with movements 
which are less pronounced. Indeed, given a suitable light, 
it is possible to take the finest movements and I hope 
shortly to be able to demonstrate this by showing the move¬ 
ments which occur during the electrical reactions of muscles. 

No doubt ideas will occur to readers in which a record of 
many medical cases other than those of nervous diseases will 
be useful, for the whole aspect of a case is often different 
according to whether it can be seen in lifelike movements 
or only in stationary illustrations. The practice of surgery 
would also seem to offer great facilities for demonstration by 
kinematograph, but hitherto, so far as I am aware, little 
or no serious work has been undertaken for purposes of 
teaching. It is true that a French surgeon has had bioscopic 
pictures taken of some of his operations, and extremely 
Interesting as these pictures are in depicting technique and 
in demonstrating the possibilities which are thns opened np 
they caDnot be regarded as being of serious use for sys¬ 
tematic instruction. For the purpose of instruction it is 
necessary that the great principles should be illustrated and 
for this purpose it will almost certainly be best to take 
photographs from the cadaver where the desirable positions 
and lights can all be arranged at leisure. Operations on the 
eye would probably afford excellent examples for teaching 
purposes, as also would the manipulations of dislocations 
and fractures. Needless to say it is neither necessary nor 
desirable that the identity of the operator should be brought 
into the pictures. Only his hands need be taken and, indeed, 
apart from obvious ethical reasons, to do otherwise would 
to a large extent decrease the value of the photograph by 
obtaining an extended field at the expense of a loss of 
detail. 

Photographs of moving micro-organisms must be ranked 
among the most striking results that have hitherto been 
obtained with the kinematograph. The movements of the 
various bacilli—e.g., those of typhoid fever—can be shown 
on the screen and should be of value in the teaching of 
hygiene and bacteriology. The teaching of physiology 
should also benefit by this method, inasmuch as various 
physiological experiments which it is frequently impossible 
to repeat before a class could be demonstrated as often as 
required. 

For the general purposes of class teaching in medical and 
other forms of education there can be no doubt that the 
kinematograph will prove to be very useful and its manage¬ 
ment is but little more trouble than that of the ordinary 
lantern. Moreover, with the most modern types of machine 
it will be possible to stop at any one picture and thus to 
combine with the kinematograph all the advantages of an 
ordinary lantern without any danger of firing the films. 

It may be taken, however, that we are as yet only at the 
beginning, so to speak, of this method of observing pictures 
of moving life, and, indeed, I am given to understand that 
at the present time a small hand machine in which the 
movements will be obtained by a simple clockwork motor 
and for the illumination of which the reflected light of an 
ordinary electric lamp, candle, or daylight will be sufficient, 
is in course of construction. Such a contrivance will form 
an important addition to the equipment of the practitioner 
who is unable to keep in touch with the larger centres of 
education, for in addition to his reading he will be able to 
study many of his cases as they appear in life, and to the 
student there will be given another valuable method of 
revising and summarising his knowledge. 

Queen Anne-street, IV. 

Descriptions of Illustbations on Page 13. 

Fig. 1 .—Case of ataxy showing patient in the act of turning. 

Fig. 3 .—Case of disseminated Bclerosis showing an ataxic-paraplegic 
gait. 

Fig. 3.— Intentional tremors in disseminated sclerosis. Note the 
spilling of the water as the patient attempts to raise the glass to bis 
mouth. 

Fig. 4 _a caso of paraplegia following myelitis. Note the manner 
in which t he left foot is being dragged along. 

Fig. 3 .—A case of pseudo-hypertrophic paralysis Bbowing the 
waddling and ** high steppage ” gait. 

Fig. ti —A case of cerebral diplegia with bilateral athetosis. 

Fig. 7 .—A case of paralysis agitanB in characteristic attitude. 

Fiff. 8 .—Photograph to show the knee-jerks being tested. 




The Lancet,] 


DR. H. CAMPBELL THOMSON: THE KIXEMATOGRAPH IN MEDICINE. [Jan. i, I9C8. ]3 



















































14 The Lancet,] DR. W. CECIL BOSANQUET : DIABETES MELLITUS IN TWO BROTHERS, ETC. [Jan. 4,1908. 


DIABETES MELLITUS IN TWO BROTHERS, 
WITH NECROPSIES. 

By W. CECIL B03ANQUET, M.A., M.D.Oxon., 
F.R.C.P Lond., 

ASSISTANT PHYSICIAN TO CHAKING CROSS HOSPITAL, LONDON, W.C., 
AND TO THE HOSPITAL FOR CONSUMPTION AND DISEASES 
OF THE CHEST, 1JROMPTON. 


The following cases of diabetes appear to possess some 
points of interest which may render them worthy of record. 
The first patient came under my care on the occasion of his 
first stay in hospital, after the most acute period of his 
attack was past, the credit for the successful treatment being 
due to Dr. F. W. Mott, whom I have to thank for permission 
to publish these notes. 

Case 1.—The patient, a boy, aged 14 years, was admitted 
to Charing Cross Hospital on May 16th, 1905. complaining 
of increased hunger and thirst, of loss of flesh, of the 
passage of large quantities of urine, and of pain in the 
abdomen. All these symptoms were of five weeks’ duration 
and had apparently arisen almost suddenly. For the last 
three weeks the lad had noticed that his sight was bad and 
he had stayed away from school in consequence. His past 
history had been uneventful, but he had suffered from 
alopecia areata for the past five years and at the time of 
admission exhibited extensive areas of baldness chiefly affect¬ 
ing the right side of the scalp. His mother and a cousin had 
died from diabetes, and both of these relatives had been 
affected with alopecia in the same region as the present 
patient. 

On examination the patient was fonnd to be a somewhat 
emaciated youth, with a flushed face and somewhat dirty 
tongue. The lower border of the liver was palpable just 
below the coetal margin ; no knee-jerks or plantar reflexes 
could be obtained. His mental condition was dull and 
drowsy but he answered questions intelligibly when 
roused. During the first 24 hours—being on an ordinary 
diet—he passed 56 ounces of urine containing 9'1 
per cent, of sugar (nearly 153 grammes). No acetone 
or diacetic acid was detected by the ordinary tests. 
On the 17th he was ordered a strict anti-diabetic diet 
with the exception of a daily allowance of two pints of milk, 
He was also given 25 minims of solution of morphine three 
times a day. The quantity of Bugar in the urine increased 
instead of diminishing. On the 19th he passed 374 grammes 
of sugar; the drowsy condition had deepened and acetone 
and diacetic acid were now present in the nrine in consider¬ 
able amounts. On the 20th and 21st he was practically 
comatose but could just be roused to take nourishment; no 
symptoms of “air hunger” were noticeable. On each of the 
last-mentioned days he was given an enema of saline solution 
containing one drachm of bicarbonate of sodium and on the 
23rd the doBe of eolation of morphine was increased to 
40 minims thrice daily. The lad's mental condition gradually 
improved and the quantity of sugar passed decreased con¬ 
currently. Some slight recurrence of the drowsiness was 
observed between July 3rd and 6th, but it did not become 
deep. Acetone and diacetic acid were detected daily in the 
urine up to June 14th and a trace of one or other was found 
on a few subsequent occasions. On the whole, fairly steady 
improvement took place. On the 16th it was discovered that 
by a mistake on the part of the nursing staff the patient had 
been receiving a daily “portion” of milk pudding (rice, 
tapioca, sago). This was ordered to be discontinued. The sub¬ 
sequent history of the case while in hospital was uneventful. 
The reduction in diet was not immediately followed by any 
marked diminution in the amount of sugar excreted in the 
urine bat gradually the quantity of urine fell, the percentage 
of sugar remaining at first pretty constantly about 4 per 
cent. The dose of morphine taken was reduced on July 1st 
to 25 minims and on August 8th to 15 minims thrice daily. 
The boy left the hospital much improved on August 19th. 

The patient was readmitted on Jan. 9th, 1906. His weight 
was then 6 stones 4i pounds. For the first month of his 
stay in hospital, during which he was plaoed on a Btrict anti¬ 
diabetic diet with the exception of the same allowance of 
milk as before, he passed on an average 266 grammes of 
sugar per diem. On Feb. 23rd he was ordered one ounce 
daily of acid extract of duodenum (secretin) kindly supplied 
by Professor E. H Starling. The amount of sugar excreted 
appeared quite uninfluenced by the remedy ; the acetone and 
diacetic acid present in the urine Beemed to increase slightly 


but they were not quantitatively estimated. The secretin 
was discontinued on March 1st. On the 7th the patient was 
given a daily portion of tapioca padding ; again there seemed 
to be some increase in the amount of acetone bodies excreted 
in the nrine but the amount of sngar did not rise, the 
average at this period being approximately 200 grammes 
daily. Gradual diminution in the quantity of urine was 
recorded after this date. On April 11th the boy was allowed 
four ounces of potatoes daily but still no increase in sugar- 
excretion occurred. He left the hospital, improved in general 
condition, on April 18 h. Subsequently he attended at 
intervals in the out patient depart meat, remaining apparently 
in much the same state. At the beginning of November, 
however, be got rapidly worse and was readmitted on the 
27th of that month—bis first appearance at the hospital for 
some weeks. He was now very drowsy and was roured with 
difficulty. The urine contained 2 5 per cent, of sugar and 
much acetone and diacetic acid. His weight was 5 stones 
2i pounds. His temperature rose to 102 4° F. and he died 
comatose on the second day after admission. 

At the necropsy no apparent cause for the fever was dis¬ 
covered. The pancreas was extremely atrophic, weighing 
only one ounce. Microscopically it exhibited slight fiorosis 
and some fatty change ; the islands of Langerhans appeared 
normal. The kidneys were large, weighing seven ounces each, 
and on microscopical examination they Bhowed parenchy¬ 
matous nephritis. 

Case 2—The patient, a yonth aged 20 years, was admitted 
to hospital on Dec. 17th, 1905. His illness had begun 
gradually five years before with thirst as the prominent 
symptom. Three months before admission the thirst had 
increased and the patient became weak. His vision grew 
indistinct and his gnms became sore and swollen. 

On admission the patient appeared to be weak and listless. 
He had a small carbuncle on the right cheek, and Mr. 
E Treacher Collins found commencing cataract in both eyes. 
The urine contained a considerable quantity of sugar, reach¬ 
ing 340 grammes in the first 24 hours and 470 grammes on 
the second day. He suffered from what he called “ diarrhoea,” 
the frequent passage of large formed motions. On the 20th 
he was strictly dieted, with the exception of an allowance of 
two pints of milk. After this the average amount of sngar 
passed in 24 hours was about 160 grammes. From Jan. 9th 
to 12th, 1906, he was drowsy ; his skin was moist and the 
“ diarrhoea ” continued. On the 23rd he was put on secretin, 
two ounces of the acid extract of duodenum supplied by 
Professor Starling being given daily. This was continued 
till Feb. 11th. The amount of sngar passed dnring this 
period was on an average 170 grammes. Aostone bodies, 
which had appeared previously, increased in amount, and the 
diarrhoea became more troublesome. The motions contained 
some undigested muscle fibres and 12i per cent, of fat. On 
Feb. 7th he surreptitiously ate a currant bun and true 
diarrhoea with liquid stools supervened. The patient became 
obviously more ill and drowsy. On discon tinning the secretin 
gradual improvement occurred—subjective at first, but after¬ 
wards objectively apparent. From the 11th to March 2nd 
the average daily amount of sugar secreted was approximately 
124 grammes ; the acetone bodies varied in quantity from 
time to time. On March 8th he was again worse, being 
more drowsy and haviDg more diarrhoea. He was given 
strychnine, brandy, and doses of sodinm bicarbonate. 
During the 12ih and 13th he was put upon a milk 
diet alone. In spite of everything the diarrhoea continued 
to be troublesome and the patient appeared to be 
getting weaker. On April 4th a change of diet was tried, 
four ouncee of potato being added to the daily portion. The 
sugar in the urine rose somewhat, averaging during the first 
week 171 grammes daily. The patient seemed in spite of 
this to gain strength ; the diarrhoea was no worse. On the 
11th he was given in addition to the potato a portion of 
milk-pudding and again the sugar rose slightly, reaching 
180 grammes, but the general improvement continued. On 
the 23rd a final addition of four ounces of bread was made. 
The sugar rose no further but tended rather to fall in 
amount, the subsequent average being 136 grammes up to 
May 7th, the last estimation made. He was discharged to 
the convalescent home on May 30th still suffering from slight 
diarrhoea but stronger than he had been for some time. At 
the end of a week at the home the diarrhoea became so 
severe as to render it advisable for him to return to 
hospital. 

The patient was readmitted on June 9th, 1906. The 
diarrhoea was troublesome and there was Borne edema of the 





Thb lancet,] DR. A. B. SLATER: “ DIPHTHERIA OF THE SKIN” TREATED BY ANTITOXIN. [JAN. 4, 19(8. 15 


ankles. The pulse was weak and frequent and the patient 
seemed ill and exhausted. His weight was now 6 stones 
11 pounds. He was again dieted and was treated with 
enemata of starch and opium for the first lew days, 
receiving later a mixture containing salicylate of bismuth. 
The diarrhcea gradually lessened in severity but remained to 
some extent throughout his stay in hospital. At one period 
he developed a small carbuncle in the left external auditory 
meatus and the parotid lymphatic glands became swollen ; 
this condition subsided satisfactorily. The record of the 
daily excretion of sugar at this period is unfortunately so 
imperfect as to render it impossible to draw any valid 
inferences therefrom. The patient gradually gained 
weight, reaching 6 stones 5 pounds, and went home 
on August 22nd at bis own desire. He came up as 
an out-patient on Sept. 7th and again on the 14th. 
On the latter occasion he looked weak and ill but 
professed to be as usual and declined admission. In the 
following week, however, he was much worse and seemed 
scarcely able to walk. He complained of nothing but the 
diarrhcea and would not admit that he suffered from thirst, 
polyuria, cough, or any other trouble. He was readmitted 
rather against his inclination, it being obviously dangerous 
to allow him to leave the hospital. On admission he became 
much collapsed, the pulse being scarcely perceptible. The 
urine contained a large percentage of sugar but no acetone 
or diacetic acid. He rallied a little under the influence of 
stimulants. His temperature rose to 103 8° F. Signs of 
consolidation of the upper lobe of the right lung were dis¬ 
covered, incontinence of urine and farces ensued, and he died 
on the next day from exhaustion without any sign of coma. 

At the necropsy the upper lobe of the right lung was found 
to be covered with a layer of fibrinous exudation. The lung 
itself was the seat of caseous pneumonia. The duodenum 
and upper part of the jejunum were thickened throughout 
and the mucous membrane was covered with a layer of 
mucoid material. Microscopically the mucosa was infiltrated 
with leucocytes and the epithelium exhibited an undue 
number of goblet cells; the peritoneal coat was slightly 
thickened. There was pigmentation from chronic conges¬ 
tion in the region of the caacnm and here and there through¬ 
out the colon. The kidneys showed some cloudy swelling 
but were otherwise normal. The liver was somewhat fatty. 
The pancreas was much reduced in size, weighing only 
H ounces (37 grammes). The secreting substance was 
especially diminished in amount, there being a considerable 
quantity of fibrous tissue around the duct of Wir-ung which 
helped to make up the small weight actually recorded. 
There was no fibrosis of the gland, although the arteries 
were much degenerated (arterio-Bclerosis). The islands of 
Langerhans were visible in fair numbers and appeared 
normal in structure. 

Comment» —1. The hereditary incidence of diabetes is 
well illustrated in the cases recorded, no less than four 
members of one family being affected. The coincidence of 
alopecia areata in three of them is remarkable. 

2. In Case 1 the rapid onset of the disease is noteworthy, 
as is also the abdominal pain by which its appearance was 
accompanied. The occurrence of some aente affection of the 
pancreas is suggested. In the other brother the disease had 
lasted for five years and held begun more insidiously. No 
exciting cause was traceable in either instance. 

3. In Case 1 the recovery from so deep a condition of 
coma was remarkable. The lad subsequently died comatose 
and the kidneys showed acute inflammation. The associa¬ 
tion of coma in diabetes with renal defect is worthy of 
careful investigation, as the rapid accumulation of the 
poisons at work is most easily explained by the occurrence 
of some failure in the excretory apparatus. In a recent case 
of fatal coma occurring in Charirg Cross Hospital there was 
fonnd suppurative nephritis, and in my own experience it 
is usual to find signs of renal mischief in such cases. The 
relation of coma to acetomemia is illustrated in these cases, 
the second patient who died from pulmonary disease without 
coma not exhibiting these bodies in the urine at the end. 
It was noteworthy, however, that Case 1 on first admission 
was drowsy but exhibited no acetonuria. The dependence 
of acetonremia on lack of carbohydrate food was not 
apparent, the first boy passing into coma and out again 
while taking a daily portion of milk padding, and some 
increase in the amount of the acetone bodies excreted being 
noted on one occasion (March 7th) immediately after an 
increase in the allowance of starchy food. 

4. In Oase 1 the amount of sugar in the urine varied inde¬ 
pendently of the diet taken. It rose notably as a sequel '.o 


putting the boy on a stricter diet—he had been taking 
ordinary food previously to admission. The subsequent 
omission of the unauthorised milk pudding did not cause an 
immediate fall in the excretion of sugar, nor on a subsequent 
occasion did an addition to the allowance of carbohydrate 
increase it. In the second case the lad seemed to improve 
considerably when allowed an additional amount of carbo¬ 
hydrate, iD spite of the slight increase of sugar excreted in 
the urine. The phenomena observed in these two cases seem 
to me to be in favour of the explanation of the origin of 
sugar in diabetes which I set out in my Goulstonim lectures 
in 1905—viz., that some portion of the sugar arises from a 
breaking-down of the cells of the body, in addition to that 
which may be due to some defect in the process of absorp¬ 
tion of sugar from the alimentary canal or of its destruction 
in the body. If this be the case a parallel may be drawn 
between the formation of sugar and that of uric acid, part 
of each beiDg exogenous, part endogenous. 

5. The failure of secretin to act bent ficially in either of 
these patients was disappointing. Since, however, the 
action of secretin as recognised by its discoverers is to 
increase the Dow of pancreatic (digestive) juice, its employ¬ 
ment in diabetes can only be upheld on the principle that 
the formation of the internal secretion of the pancreas and 
that of the digestive fermi nts take place as a single chemical 
action, the living substance breaking down simultaneously 
into both these substances. Now if, as I previously sug¬ 
gested, the action of the pancreas lies in neutralising some 
poison formed elsewhere in the body—such neutralising 
action consisting perhaps in making use of the substance 
in question for its own metabolism—the absorption of 
secretin will not directly affect the relation of the gland to 
the formation of sngar. 

6. The anatomical condition of the pancreas in these two 
cases was striking ; in each there was marked atrophy of the 
organ without noteworthy alteration of structure, the 
fibrosis in the second case being comparatively slight. In 
each case there were plenty of normal-looking islands of 
Langerhans. It is therefore difficult here to associate 
diabetes with structural lesions of these islands. The cases 
tend to support the view of Hansemann that the typical con¬ 
dition of the pancreas in diabetes is atrophy, affecting the 
secreting cells as a whole. In each of these cases there was 
well-marked arterio-sclerosis, which is in my experience the 
most constant feature in the pancreas in cases of diabetes, 
having been present in every one of eight cases which 1 have 
examined in the last two years. The hyaline change met 
with in the islands in some instances appears to be mosb 
often of the nature of an arterio capillary fibrosis ; in other 
cases hyaline blood-clots and degenerate cells may present a 
homogeneous appearance. 

7. The condition of the small intestine in the second case 
is noteworthy. It was clearly associated with the diarrhcea 
which was so troublesome daring life How far the diminished 
assimilation of fat and of muscle-fibre was due to the 
intestinal disease and how far to the pancreatic defect cannot 
be determined. The fact that some fibrosis of the pancreas 
occurred in the first case and not in the patient who suffered 
from duodenal catarrh suggests that this lesion was de¬ 
pendent upon the arterial condition and was not inflamma¬ 
tory. 

Harley-street, W. 


A CASE OF “DIPHTHERIA OF THE SKIN” 
OF THREE YEARS’ DURATION 
TREATED BY ANTITOXIN. 

By ALAN B. SLATER, M.D. Edin., 

PHYSICIAN TO THE SKIN nFPARTMFNT, FARBINGDON UFNERAL 
DISPENSARY, 


A GIRL, aged 13 years, came under my charge on June 20tb, 
1907, with the following history. Three years previously she 
was taken to an eye hospital for inflammation ot the eyes. 
She was treated there at the time but the medical officer at 
the hospital told the mother that the child was very ill and 
that Bhe cught to have a medical man to attend her at home. 
The child, however, improved at home and no medical 
practitioner was sent for. A week or two later, the exact 
time is not known, the mother noticed when washing the 
child’s clothes that her linen was stained and on examining 
the child herself she found two white patches, one on the 
inside of each labium, and also a thin discharge. This was 




16 The Lancet,] DR. A. B. SLATER: “DIPHTHERIA OF THE SKIN ” TREATED BY ANTITOXIN. [Jan. 4,1908. 


treated by the mother by bathing with water. Shortly 
after this blisters began to develop round the vulva and 
spread on to the abdomen. The child was then taken to a 
general hospital and was admitted, the vesicles having spread 
so rapidly that she was practically covered by them about 
the body and neck, and there were a few on the face and 
head. She remained in the hospital about five months and 
during that time made little or no progress, the only change 
being that the abdomen cleared and the vesicles were con¬ 
fined to the parts round the vulva, the chest, the neck, and 
the head (including all the face). Since then she has been 
treated for syphilis, a section taken of one of the vesicles 
showing some appearance of syphilis. 

Mercury and iodides were given for about two years with¬ 
out much effect, but the child’s general condition improved 
and the vesicles still were confined to the vulva, the chest, 
the neck, and the head, the face being especially affected. 
Lotions of almost every kind were used without having any 
effect. Some idea of the amount of discharge from the 
whole surface of the skin, due to the vesicles rupturing, may 
be obtained from the fact that during the whole time since 
she left the hospital her mother has had to change all 
her clothes, always twice, and as many as four times a 
day, in addition to wrapping all the affected parts in linen 
or cotton. 

On June 20th the child’s appearance and condition were as 
follows. There were masses of vesicles round the left 
Bide of the mouth extending to the cheek, but not into the 
mouth; others on both eyebrows, the right being worse than 
the left. The external meatus of both ears was filled with 
thick semi-purulent discharge, the lobes of the ears and 
behind the ears being covered with discharging vesicles. 
Upon the head were large masses of vesicles and some dried 
scabs where former ones had been. The neck and shoulders 
had large quantities of vesicles on them extending down to 
the nipples on either side and as far as the middle of the 
scapulae on either side at the back. In the areas affected 
the space between the vesicles was dark red, but in other 
areas which had been affected and where the vesicles had 
disappeared the skin was only slightly erythematous or even 
normal, no scarring being left behind. The region of the 
vulva was erythematous and studded with vesicles, but this 
condition did not go back further than the vulva itself ; the 
whole affected area thereabouts extended to three or four 
inches down the inner part of the thighs and about 
four inches up the abdominal wall. All the areas 
were discharging freely, a thin clear fluid dripping from 
the chin at the rate of a drop per minute In many 
places the vesicles were arranged in crescentic form as 
though the discharge had run over the surface of the skin 
and infected it as it went along. The general condition of 
the child was good ; she was well nourished and felt quite 
well in herself and also ate well. There was no sign of any 
constitutional disturbance, the spleen was not enlarged, the 
heart was normal, and the urine was free from albumin. 
From the following bacteriological investigation I decided to 
treat her by means of diphtheria antitoxin. 

Bacteriological report by Dr. J. G. Hare. —On June 30th 
I made a bacteriological examination of the serous fluid 
which was dripping from the face. Smears were made 
from the fluid and stained with methylene blue and 
by Gram’s method. In these were observed organisms 
resembling the diphtheria bacillus. I inoculated an agar 
tube and also a blood serum tube with the fluid and 
incubated them at 37° C. A growth appeared on the 
media 18 hours later. These were then plated and the 
staphylococcus aureus and albus were isolated, together with 
a bacillus which formed small cream-coloured colonies on 
agar. On smears being made from these colonies and stained 
with Ldflier’s methylene blue and examined a bacillus was 
observed closely resembling the bacillus of diphtheria. The 
organism also reacted to Neisser's stain. (In inoculating the 
tubes the needle was never allowed to touch the skin, the 
fluid being merely allowed to drip on to the needle.) The 
organism waa obtained in pure culture on blood serum 
and when stained and examined showed the characteristic 
involution (club-shaped) forms. Subcultures were then 
made on gelatin, on potato, in milk, and in broth. On 
gelatin the growth was slow and without liquefaction. In 
broth there was a whitish granular deposit at the bottom of 
the tube, the broth otherwise remaining clear. On potato 
a faint, almost invisible, growth was seen. Milk was not 
coagulated. Gas was not generated in any of the media. 
The indol reaction was obtained by the addition of a nitrite. 


Through the courtesy of Professor R. T. Hewlett animal 
inoculations were carried out at King’s College. A 300 
gramme guinea-pig was inoculated per peritoneum with two 
cubic centimetres of serum-suspension of this culture and 
at the same time another guinea-pig was inoculated with the 
same quantity of culture -+-1*5 cubic centimetres of diph¬ 
theria antitoxin. The first guinea-pig died in ten days ; the 
second developed no symptoms. The post-mortem appear¬ 
ance of the first guinea-pig showed extensive oedema of the 
peritoneum, haemorrhages, and enlargement of the spleen. 
Cultivations were obtained from the heart and peritoneal 
fluid and showed the Klebs-Loffler bacillus in pure culture. 

Antitoxin treatment .—This was begun on July 2nd. 2000 
units of Burroughs and Wellcome’s ordinary anti- 
diphtheritic serum were injected into the subcutaneous 
tissue of the abdomen at 3 p.m. At 10 P.M. there was 
some oedema at the seat of injection together with an 
erythematous rash all over the body and limbs and also 
discomfort from thirst. There was vomiting at intervals 
of an hour until 8 am. when it stopped and the child 
had a good sleep. By 1 p.m. on the 3rd the rash had dis¬ 
appeared and the patient was quite comfortable. By this 
time there was a marked change in the appearance of 
the vesicles, which had not only ceased to discharge but 
were, in many places quite dry and beginning to form a 
crust, the change being remarkable. The temperature 
remained at 99 8°F. On the 4th constitutional symptoms 
were still absent and at 1 p.m. 1000 units were injected. At 
6 p.m. no rash or other result of antitoxin was present but 
two of the areas became active again and discharged during 
the evening. The temperature was 99 8°. On the 5th 
2000 units were injected. No constitutional symptoms were 
observed during the day. The affected areas were reduced 


Fig. 1. 



Before antitoxin treatment. 


to three patches, the largest being one inch across. The 
discharge from others and from the ears had quite stopped 
and in many places the crusts had already come off, 
leaving healed skin. The diet was exclusively milk. 
The temperature was 99 6°. On the 6th no sym¬ 
ptoms were noticed until the evening after an egg 
and bread-and-butter had been eaten, when a slight 
erythematous rash appeared on the legs and abdomen. 
The patient was well in herself and hungry. The tem¬ 
perature was 99 6°. The vesicles were about the same. 
On the 7th there was a fine papular rash over the abdomen 
and thighs but no other symptoms. The vesicles were still 
discharging a little but no more had appeared and large 
areas on the shoulders and neck and head were quite free, 
only erythematous skin remaining. The vesicles were con¬ 
fined now to an area one inch across on the right side of the 
mouth, one similar on the left eyebrow, and two smaller ones 
on the front of the scalp. The vulva was quite free from 
vehicles but was utill erythematous. The temperature was 
99 4°. On the 8th the rash had all disappeared and the 
child was quite well in herself. The bullae were painted with a 




The Lancet,] CAPTAIN C. H. TURNER: UNUSUAL CONDITION OF MECKEL’S DIVERTICULUM. [Jan. 4,1908. 17 


mixture of carbolic acid and glycerine. The temperature was 
99'4°. On the 9th the vesicles were discharging more and an 
affected area behind the right ear measuring three quarters 
of an inch across had appeared. 2000 units were injected. 
The temperature was 99 '2°. On the 10th there was no con¬ 
stitutional disturbance from the last injection. With the 
exception of that behind the ear all the others were drier 
and smaller in extent. The neck, the shoulders, and all the 
back of the head were free from even crusts. The vulva was 
free from vesicles also. The affected areas were painted 
with carbolic acid 1 to absolute alcohol 20 and afterwards 
dusted with boric acid powder. The temperature was 99°. 
On the 11th 2000 units were injected. All the vesicles were 
much drier, including the ear. The temperature was normal 
and the painting was continued. On the 12th no constitu¬ 
tional symptoms were observed. The vesicles were reduced to 
areas of a quarter of an inch behind the ear, one over the 
left eyebrow, and one of half an inch on the right Bide of the 
month. Painting was continued. The condition on the 13th 
was the same as on the previous day. On the 14th one vesicle 
reappeared on the front of the scalp and one on the left 
cheek : others were the same in extent but were discharging 
a little more. Other areas had kept entirely free and in 
many places the skin was normal; there was no scarring. 
The temperature was normal. On the 15th 2000 units were 


Fig. 2. 



After 7000 units had baen injected. Showing erythema left behind. 


injected. Withholding the antitoxin evidently allowed the 
disease to become active again, as single vesicles appeared in 
two new places on the face and the other ones were dis¬ 
charging more. On the 16th the discharge was less again, 
the single vesicles were dried up, and other areas 
were much drier; only three areas were discharging. 
On the 17th 2000 units were injected. There were no con¬ 
stitutional symptoms and every area was drier. The 
temperature was normal and painting was continued. On 
the 18th the patient was quite well generally. The affected 
areas were still smaller and there was very little discharge. 
The temperature was normal. On the 19th 2000 units were 
injected into the thigh. All the areas were frequently 
bathed with 1 in 20 carbolic lotion, then painted with 1 in 20 
carbolic in absolute alcohol, and dusted with boric powder. 
A culture was taken from the only discharging spot. On the 
20th the injection had caused the thigh to swell to almost 
twice the size and there had been great pain all night. The 
glands in the groin did not enlarge. The temperature ro=e 
to 101°. All discharge had completely stopped and a few 
crusts only remained. The tube inoculated on the previous 
day showed no growth of any kind after 24 hours’ incuba¬ 
tion. On the 21st the swelling of the thigh had disappeared. 
There was slight swelling over the seat of the injection. 
The condition had greatly improved and the temperature was 
normal. On the 22nd the improvement was maintained. 

Remark !.—There seems to be no doubt that the most 
important factor in this case was the Klebs-LofHer bacillus. 


The disease apparently commenced as an acute attack of 
diphtheria, the primary seat of infection being the eyes. 
From this focus the vulva became infected and then the 
bacteria in some way found their way into the superficial 
lymphatic circulation, producing a condition resembling 
herpes, probably as the result of peripheral neuritis set up 
by the bacilli themselves. This theory is based on the fact 
that during the whole of the duration of the disease, since 
the primary acute symptoms, the lesions have been confined 
to the superficial layers of the skin (proved by the fact that 
no scarring was left). Whether the staphylococci played 
any important part is difficult to say, but they probably had 
only a mild influence, if any at all, as the use of various 
lotions, such as 1 in 40 carbolic lotion, and perchloride of 
mercury 1 in 1500 had no effect on the lesions, whereas the 
effect of the antitoxin was remarkable. 

Bryanston-street, W. 


AN UNUSUAL PATHOLOGICAL CONDITION 
OF MECKEL’S DIVERTICULUM. 

By C. H. TURNER, M.R.C.S. Eng., L.R.C.P. Lond., 

CAPTAIN, R.A.M.C. 


The patient, aged 23 years, was admitted to the Station 
Hospital, Rawal Pindi, on Jan. 4th, 1907. As history it was 
stated that on the morning of the 3rd, on getting up, he was 
seized with violent pain in the abdomen, chiefly the lower 
part, and vomited. He was admitted to the Cavalry Hospital 
and treated by enemata and fomentations to the abdomen ; 
these were effectual in opening the bowels, which had been 
constipated, and in relieving the pain considerably. He was 
transferred on the following morning to the Station Hospital. 

On admission the patient’s general appearance was good, 
both as regards colour and facial expression ; his tongue was 
furred but moist at the edges. The temperature was normal 
and the pulse was 100. He gave an intelligent account of 
the onset of his illness and complained at the present time of 
pain in the iliac fossa on the right side, radiating towards 
the umbilicus. He had vomited once during the night and 
had not had the bowels open or passed flatus since having 
the enemata the night before. On examining the abdomen 
there was seen to be Blight distension, and movement on 
respiration was impaired. There was slight general tender¬ 
ness over the abdomen, but more marked in the right lower 
quadrant; resistance here, too, was marked. No tumour 
could be made out. The percussion note was hyper-resonant 
over all the abdomen, with the exception of the right flank 
where the note was duil. A diagnosis of acute appendicitis 
with fairly extensive localised peritonitis was made and it 
was decided to operate if the pulse-rate had not dropped by 
the morning. The patient passed a restless night and the 
temperature, which had been normal on admission, was 
101° F. and the pulse was 112 ; he had vomited slightly twice 
during the night; the physical signs were the same, the 
pain if anything being more severe. 

Operation .—Chloroform being administered, the abdomen 
was prepared, as no previous satisfactory preparation had 
been possible owing to the tenderness. An incision four inches 
long was made over McBurney’s point, but a little farther 
out, the muscles being split in the direction of their fibres. 
On opening the peritoneum about six ounces of turbid peri¬ 
toneal fluid escaped, and distended and somewhat congested 
coils of 6mall intestine presented. The csecum could not be 
felt in the iliac fossa nor could any large intestine be pulled 
out. The incision was extended a couple of inches and the 
whole hand was introduced. A portion of the large intestine 
could then be felt quite collapsed and lying high up. This 
was pulled down easily and traced first in one direction 
where it was found to be continuous with the transverse 
colon; traced in the other direction it was found to take a 
turn upwards and forwards towards the umbilicus, and here 
a slight adhesion gave way and the caecum was brought out 
of the wound and examined; it was also collapsed and the 
appendix was found to be healthy. The ileum was then fol¬ 
lowed up and the first foot was collapsed and found to be 
firmly adherent at this point to the anterior abdominal wall, 
just at the level of, and to the right of, the umbilicus. The 
first incision was covered up with sterilised gauze and a 
second incision three inches long was made through the 
fibres of the right rectus muscle. On incising the posterior 
layer of the sheath of the rectus what was apparently an 


18 The Lancet.] DR. L. NAPOLEON BOSTON: DELIRIUM TREMENS (MANIA E POTU). 


[Jan. 4, 19C8. 


abscess cavity containing four ounces of very off- nsive pus 
was opened. This was swabbed up and washed out with 1 in 
40 carbolic lotion and then explored with the finger; the 
walls were quite smooth and felt as though formed by 
mucous membrane. The peritoneal cavity was opened next 
and carefully packed off. The abscess cavity described 
above was then found to be the inner surface of the fundus 
of a dilated and gangrenous Meckel’s diverticulum, which 
was adherent to the anterior abdominal wall. It was then 
carefully separated and the coil of bowel from which it arose 
was drawn out ot the wound. The diverticulum arose from 
the ileum, about 12 inches from the ileo-cjccal valve ; its 
proximal portion was stenosed and its distal portion or fundus 
was gangrenous and dilated (as far as could be judged, 
for it had contained four ounces of pus) to the size of a 
Tangerine orange. The pathological condition was on a par 
with the “appendicitis with stenosis, empyema " classified 
by Mr. C. B Lockwood. The diverticulum was removed in 
the same way aB an appendix and the stump was tucked in, 
the wall of the intestine being brought together over it with 
Lembert's sutures. The displacement of the caecum was due 
to the mesentery of the ileum being adherent to the meso 
caecum and meso colon, and to slight adhesion of the 
omentum to the outer and posterior wall of the caecum. 
These were separated and all bleediDg points secured. A 
drainage-tube was placed in the whole length of the wound 
in the middle line and brought out at its lower extremity, 
and the abdominal walls were brought together over it with 
one layer of sutures, a separate layer for the peritoneum not 
being practicable owing to its friability. The wound in the 
iliac region was closed in separate layers. 

The after history of the case was as follows. The patient 
did not suffer from shock, though the operation lasted about 
one and a quarter hours. His condition gave rise to some 
anxiety for the first 26 hours, owing to the difficulty of over¬ 
coming the paralytic distension of the bowel, but this was 
effected by calomel and enemata, and the second day after 
the operation the bowels opened naturally and the hiccough, 
which had been rather persistent, stopped and the pulse-rate 
dropped from 120 to 98 Convalescence was uninterrupted 
and the wound in the iliac region healed by first intention. 
There was a fair amount of discharge from the tube in the 
other wound, but at the end of a week this had stopped and 
the wound soundly healed in 14 days. 

Remark *.—Cases of Meckel’s diverticulum are sufficiently 
uncommon to warrant their publication, and the above case 
is one of unusual interest from a pathological point of view. 
Cases in which the diverticulum has caused acute obstruc¬ 
tion by strangulating tbe bowel have been frequently re¬ 
ported, but I have not the literature at my disposal to look 
up the subject. I should be glad to hear if any cases of a 
similar nature have come under the notice of any readers of 
The Lancf.t. 

Kavval Pindi, Punjab, India. 


DELIRIUM TREMENS (MANIA E POTU): 

STATISTICAL STUDY OP 136 CASES. 1 

By L. NAPOLEON BOSTON, A.M., M.D., 

ADJUNCT PROFESSOR OF MEDICINE AT THE M F.DICO-CH1RURG1CAL 
COLLEGE; PHYSICIAN TO THE PHILADELPHIA HOSPITAL; 

AND DIRECTOR OF LABORATORIES FOR CLINICAL 
RESEARCH AT THE AMERICAN HOSPITAL FOR 
DISEASES OF THE STOMACH. 

I have made a statistical analysis of the hospital records for 
156 cases of delirium tremens treated at the Philadelphia Hos¬ 
pital (Blockley) between Jan. 1st. 1904, and March 1st, 1907. 
In compiling statistics so as to display them in the form of 
tables it was found that the records of 16 of these cases were 
incomplete, therefore these have been omitted, and the 
tables include but 140 of the 156 cases treated. A number 
of cases that have occurred in my private practice could 
have been added, but it was deemed advisable to include 
only cases tbat bad received hospital treatment in order that 
one might obtain statistics that would be of definite value. 
An analysis of the 140 case records showed age to be not only 
a predisposing factor to delirium tremens but also to exercise 
a decided influence upon the gravity of this condition. The 
number of cases observed at tbe different decades, the 
number of deaths, and percentage of mortality are set forth 
in Table I. __ 

1 Published through the courtesy of Dr. Joseph Neff, Director of 
Public Health and Charities, Philadelphia. 


Table I. 


Age. 

Total number 
of cases. 

Total number 
of deaths. 

Pecentage of 
mortality. 

20 to 30 years... 

24 

8 

33 3 

30 ,, 40 . 

48 

18 

37*5 

40 .. 50 . 

41 

14 

32-1 

50 „ 60 . 

21 

9 

42-3 

60 „ 74 . 

6 

3 

50-0 


Delirium tremens is most common between tbe ages of 30 
and 50, yet the death-rate remains almost the same during 
the second, third, and fourth decades. The prognosis is 
decidedly unfavourable in those suffering from this condi¬ 
tion after the age of 50 years, ami while the above statistics 
show a mortality of between 42 and 50 per cent, for such 
patients I am confident tbat a much higher death-rate is seen 
in private practice. Many of the cases included in Table I. 
had had a number of admissions to the delirium tremena 
wards of the hospital during the past 20 years. The greatest 
number of admissions for any one patient was 42. while 
many of the patients had had from six to 15 admissions, 
from each of which attacks they recovered and had been 
discharged from the institution as comparatively cured. 
These facts, though not included in any of my tables, are 
contradictory to the rather popular belief that those suffer¬ 
ing from delirium tremens usually end in death during the 
second or third attack. i 

Further analysis with reference to season as a predisposing 
factor and its influence upon the gravity of the condition is 
revealed by Table II. :— 


Table II. 


Month. 

Number of 
cases. 

Number of 
deaths. 

Percentage of 
mortality. 

January . 

14 

7 

50-0 

February . 

15 

2 

133 

March . 

11 

5 

454 

April. 

10 

1 

10 0 

May . 

14 

i 

71 

June. 

5 

3 

60-0 

July . 

7 

2 

285 

August . 

28 

13 

46 7 

September 

10 

4 

40 0 

October . 

7 

s 

42 8 

November 

8 

3 

37-5 

December. 

11 

8 

72 7 


It will be seen by Table II. tbat tbe largest number of cases 
developed during the month of August when in this climate 
tbe heat is extreme. It is further of special interest to note 
that August gives a death-rate of 46 7 per cent., while the 
average death-rate is but 37 • 1 per cent. Extreme cold is 
not without influence upon the mortality-rate, since 
December and January gave the correspondingly high 
death-rate of 72'7 and 50 per cent respectively. During 
the spring months (May, April) delirium tremeDs is fairly 
common but the proportionate number of deaths is low, 
7-1 and 10 per cent. 

The following table (Table III ) is designed to present the 
various pre-existing and complicating conditions found to 


Table III. 


Pre-exlBting or complicating 
diseases. 

Total 
number 
of cases. 

Deaths. 

Percentage 

of 

mortality. 

Cases with pre-existing cardiac ( 
disease.. . f 

13 

11 

84 6 

Cases developing cardiac com plica ( 
tionB .i 

10 

8 

800 

Cases with pre existing kidney t. 
disease. i 

11 

11 

100 * 

Cases developing renal complies- ( 
tions .> 

4 

4 

1000 

Cases with pre-existing lung disease 

11 

5 

500 

Cases developing pulmonary com- )_ 
plications ... .. S 

53 

35 

66-0 







The Lancet,] 


CLINICAL NOTES. 


[Jan 4 1908 1 9 


influence materially the mortality in 140 cases of delirium 
tremens studied, and of which 62 were fatal. 

Twenty-two of the cases displayed more than one pre¬ 
existing or complicating condition of which ten displayed 
kidney and lung involvement; seven heart and lung ; two 
kidney and heart; and three heart and stomach. Thirty - 
eight of the 140 cases were uncomplicated and all of these 
were followed by recovery. Most striking in connexion with 
Table III. ie that all of the 15 cases showing renal complica¬ 
tions terminated fatally. Again, great importance is to be 
attached to the prognostic significance of pre existing cardiac 
disease which gave a mortality-rate of 84 6 per cent.; and 
acute cardiac complications are of but little less importance 
as regards the seriousness of the condiLion in question. Those 
cases developing acute pulmouary conditions (bronchitis and 
broncho-pneumonia) gave a death-rate of but 66 per cent. 

Philadelphia. 


dismissed in April, 1906, all the wounds had healed. About 
this time the patient noted a swelling at the lower end of 
the sternum but did not consult a medical man about it. 
On Maj 4th, as she was fixing hef handkerchief round her 
neck, she suddenly discovered another swelling near the 
upper end of the sternum and went to the out-patient 
department of the Salford Royal Hospital. I saw her in the 
out-patient room and admitted her into the hospital under 
the care of Dr. A. M. Edge. 

On admission she had two distinct and separate swellings 
in the region of the sternum, one at the lower end in the 
middle line and ODe at the upper end slightly to the right of 
the middle line. The lower swelling was about 3 inches long 
by 2 inches wide, tympanitic, soft, and moveable to a certain 
extent under the skin. There was no impulse on coughing, 
no breath sounds over it, and it was unaffected by taxis or 
pressure—evidently a collection of air in the cellular tissue. 
This gradually disappeared in a month’s time. The upper 


(SMral gales: 

MEDICAL, SURGICAL, OBSTETRICAL, AND 
THERAPEUTICAL. 


NOTE ON A CASE OF HERNIA OF THE LUNG. 

By Thomas E. Cout.son', M.B., Ch B. Edin., 

1A*E SENIOR HOUSE SUR3E0N TO THE SALFORD ROYAL HOSPITAL, 
MANCHESTER. 


Owing to the rarity of the condition the following case 
seems worthy of record. 

In November, 1905 a female, aged 56 years, was admitted 
into the Halford Union Infirmary suffering from a septic 

Fig. 1. 



Hernia before reduction. 


wound of the wrist and resulting cellulitis of the right 
axillary region with abscess formation. This was incised 
very thoroughly in three or four places and when she was 


Fig. 2. 



After reduction of hernia. 

BwelliDg gradually increased in size and presented all the 
signs of pneumocele. 

The notes at this time were as follows. On inspection it 
is situated over the upper end of the sternum, 5 inches in 
length and 3 inches in width. The outline is well defined 
and smooth and tapering to a blunt point over the first right 
intercostal space. It moves slightly with respiration rela¬ 
tively to the chest wall. On palpation it is fonnd to be soft 
and fluctuating. The skin moves over it and it can be 
moved a limited amount both up and down and side to side. 
Vocal fremitus is much increased over it and it has 
a most marked impulse on coughing which is easily visible 
as well as palpable. It does not pulsate. On percussion it 
is tympanitic to a marked degree. On auscultation there is 
bronchial breathing over it, low pitched, and interrupted. 
Vocal resonance is increased with whispering pectoriloquy 
There are no adventitious sounds. When the patient speaks 
the swelling bulges out and becomes quite tense. There is 
no pain. The temperature is normal and the pulse is normal. 











20 Thb Lancet,] 


CLINICAL NOTES. 


[Jan. 4, 1908, 


On manipulation the swelling can be entirely reduced within 
the chest by gently pressing upon the fundus and fixing the 
blunt neck at the first intercostal space. The swelling 
vanishes with a squeaking sound quite audible both to the 
patient and to the operator. The sitting posture and a few 
coughs bring the hernia again into prominence. 

The photographs here reproduced were kindly taken for 
me by Dr. \V. B. Anderton. The one shows the hernia before 
and the other after reduction. 

My best thanks are due to Dr. Edge for kindly allowing me 
to record the case. 

Bristol. 

OPEN SAFETY PIN IN THE (ESOPHAGUS OF A 
CHILD AGED FIVE MONTHS. 

By J. S, Manson, M.B., Ch.B. Edin., 

SENIOR HOUSE 8UHGEON, OLDHAM INFIRMARY. 

A mali: child, aged five months, was admitted to the 
Oldham Infirmary on Oct. 26tb, 1906, with a history of 
having swallowed a safety pin one hour previous to admis¬ 
sion. A skiagram was taken and the pin was seen to lie 
about the middle of the cesophaguB, open with the point 
upwards. It seemed a hopeless task to try to get the pin up 
by means of a probang, so it was resolved to push the pin 
down into the stomach and hope for the best. An 
ordinary stomach tube of small size was pushed down 
the oesophagus, and after withdrawing another skia¬ 
gram was taken showing the pin lying in the stomach. 
The child was kept in bed and watched carefully. 
Milk diet was given and four days after admission 



a dose of castor-oil. On the afternoon of Nov. 2nd the pin 
was found sticking half-way out at the anus. The pin took 
:ix and a quarter days to accomplish the journey from the 
mouth to the anus and only once or twice did the child seem 
at all fretful. 

The case ,-eems worthy of not) in showing the power of 
the alimentary canal in dea inr with a loieign hotly of a 
somewhat foimidable nature. I append a skisgram of the 
pin in the oesophagus. 

A CASE OF “MIRROR-WRITING.” 

By Vaughan Pkni>rei>, M.D. Durh, F.R.C.S. Encj. 

A curious condition that justly has been called “mirrcr- 
writiDg ” has recently come under my observation. A bright, 
intelligent little lad, aged six rears, has been learning to 
write for the past six months. His governess reports favour¬ 
ably of his application and progress, and no abnormality 
save the one here reported has been noted. From a copy 
the boy writes correctly but if left to himself to exercise his 


new-found accomplishment, of which he is very proud, he 
starts at the right hand side of the paper and writes back¬ 
wards, so that to decipher the writing the paper has to be 
held up to a mirror. One day his mother suggested that he 
should write a letter to his grandmother. He began the 
letter as shown in Fig 1 (the G is correctly formed 
as he copied from a letter in his mother’s hand¬ 
writing). He selects the “ mirror-writing ” when asked 

Fig. 1. 


which is correct. He reads with equal facility both the 
normal and the abnormal types. For example, his mother 
indited in “ mirror-writing ” the invitation contained in the 
three first lines of Fig. 2, to which he instantly wrote, 
cnrrente calamo, the reply contained in the remaining lines 
of the same illustration. The most extraordinary confusion 
arises when he attempts “sums,” as shown in Fig. 3. A 
drawing that he made of a Great Northern locomotive 
engine illustrates the defect in a very marked way. The 

FIG. 2. 





engine is shown travelling to the left and is very well drawn 
for so youthful an artist; the letters G.N.R. on the tender 
are in “ mirror-writing.” In writing from dictation, unless 
he is corrected and carefully watched, he reverses his 
work. 

Are the pictures of letters in the boy's memory-centre 
incorrectly stored and therefore incorrectly reproduced ? 
Does the receptive apparatus in the occipital lobes play this 
strange prank with the naturally inverted picture of letters 

Fig. 3. 

svos: si is Cl 

received on the boy’s retinae ? It must be noted that the 
letters are not inverted as would be the case if the brain 
merely failed to right the retinal images. I incline to the 
former hypothesis as it is only in the reproduction of written 
words that he fails and is quite secure in making a copy. 

Coventry. 





The Lancet,] 


ROYAL SOCIETY OF MEDICINE: THERAPEUTICAL SECTION. 


[Jan. 4, 1908. 21 


Stelriral Badtins. 


ROYAL SOCIETY OF MEDICINE. 


THERAPEUTICAL AND PHARMACOLOGICAL SECTION. 
Action of Digitalis in Cardiac Dictate.—Reminiscences of an 
Apprentice 50 Years Ago. 

* A* meeting of this section was held at the Apothecaries’ 
Hall on Dec. 17th, 1907, Dr. F. H. Burton-Brown, the 
President of the section, being in the chair. 

Dr. James Mackenzie read a paper on the Action of 
Digitalis in Cardiac Disease. The results of animal experi¬ 
ments, he said, must be accepted with caution. In man 
the effect of digitalis was entirely dependent upon the 
particular leBion. If dilatation was absent, and if the 
tonicity of the heart was preserved, then no good resulted 
from the use of digitalis. If the heart was of normal 
size dropsy was not of cardiac origin. The irregular 
pulse of mitral disease was to be explained by the observa¬ 
tion that in these cases of mitral disease there was a ven¬ 
tricular inception of the heart beat. To illustrate these 
and other points Dr. Mackenzie showed a series of tracings 
He also showed a heart dissected to display with great 
clearness the auriculo-ventricular bundle.—In the discus¬ 
sion which followed Professor A. R. Cushny spoke of 
the immense value of the accurate scientific observations 
made at the bedside by Dr. Mackenzie. The difficulty 
of the subject was very great. Even in experimental work 
with the same dose of digitalis, given in the same way 
to the same animal, the results varied widely from time to 
time.—Dr. H. 0. Cameron asked whether l)r. Mackenzie's 
work had led him to form any opinion as to the rapidity with 
which digitalis acted.—Dr. Mackenzie, in reply, stated that 
as a rule the characteristic changes in tracings due to 
digitalis were not apparent for about 10 days. 

Dr. W. Soper then read an interesting paper on Remini¬ 
scences of an Apprentice 60 Years Ago. He described the 
forms of treatment which prevailed 50 years ago and com¬ 
pared them with more modern methods. The system of 
apprenticeship, he maintained, had many advantages. 


UNITED SERVICES MEDICAL SOCIETY. 


Recent Work on the Cause , Prevention , and Treatment of 
Mediterranean, or Undulant, Fever. 

A meeting of this society was held on Dec. 12th, 1907, 
Sir Herbert M. Ellis, the President, being in the chair. 

Fleet-Surgeon P. W. Bassijtt-Smith, R N , in a paper on 
the above subject gave an interesting historical rtsume of the 
work that had been done in late years, more especially under 
the anspices of the tropical diseases committee of the Royal 
Society. This work was divided into experimental, epidemio¬ 
logical, and prophylactic. Under the first head he instanced 
the work of Horrocks, Shaw, himself, and others on the life- 
history and identification of the micrococcus Melitensis and 
its recovery from the blood and other secretions, and also 
experiments directed towards discovering the channels by 
which infection was conveyed in this disease. Under the head¬ 
ing of epidemiology were mentioned the reports of Davies 
and Johnstone, and under prophylaxis the work of Eyre and 
Shaw on sera, antisera, and toxins. The most important 
points brought out step by step were : (1) the great vitality 
of the organism outside the body when not exposed to direct 
sunlight; (2) the constant presence of the organism in the 
peripheral blood of cases suffering from the disease ; (3) the 
escape of the organism from the body chiefly through the 
wine; (4) the presence of the infective organism in the 
urine of apparently healthy men ; (5) frequent infection of 
domestic animals, chiefly goats ; (6) infectivity of the urine 
and milk of these animals ; (7) the high incidence of cases in 
patients and Btaff of hospitals ; (8) the high incidence in 
officers, women, and children; (9) occurrence of localised 
epidemics ; (10) rare recovery of the organism from local 
mosquitoes and very donbtfnl possibility of their being dis¬ 
tributors of the disease; and (11) complete cessation of 
cases where Infected milk was removed from the dietary or 
when it was properly sterilised. The prevention of the 
disease by “protective inoculations” still remained tub 


justice. As regards treatment he had little to say in favour 
of antisera or vaccines, though in chronic cases the latter 
seemed to have some slight beneficial effect. No specific 
drug had yet been discovered, quinine in large doses was 
harmful, cyllin was disappointing, fresh yeast was inoperative, 
and quinine combined with chlorine water was very uncertain 
in its results. Symptomatic treatment might, however, do 
much to relieve the insomnia and the persistent neuritis of 
the later stages. For this Fleet-Surgeon Bassett Smith 
recommended salicylate of quinine, while arsenic and 
iron were of use in the later cachexia and strychnine 
for irritable heart should this be a seqneia. Touching 
briefly on pathology he pointed out that the evidence 
in favour of a general septicemic infection was very 
strong, the organism being recoverable not only from the 
peripheral blood but also from the internal organs. In one 
case he had known an infective endocarditis to develop. 
Local lesions also occasionally occurred, sometimes in the 
form of soft fluctuating swellings, not containing pns bat a 
turbid fluid from which the characteristic organism could be 
isolated. Ulceration of the small intestine and enlargement 
of the liver and spleen in chronic cases were also found. 

Lieutenant-Colonel VV. B. Lkisiiman, R A.M.C., considered 
that it was very desirable that investigation should be 
directed towards ascertaining the line of communication 
from diseased to healthy goats. He suggested that the 
disease might be attacked by immunising these animals by 
means of injection of attenuated cultures of the micrococcus, 
pointing out that good results had been achieved by this 
method in other diseases—e g., in cholera by Haffsine and 
more lately by Strong of Manila in the case of plague. 

Lieutenant-Colonel A. M. Davies, R.A.M C., quoted 
instances which inclined him to doubt whether milk was 
the only source of infection in this disease, and thought 
that the mosqnito might still be found to play a part in 
its dissemination. 

Lieutenant-Colonel D. V. O'Connell, R.A.M.C., was 
inclined to agree with the former speaker. He considered 
opium and morphine as being of great value in treatment-bat 
condemned the bromides as useless. 

Fleet-Surgeon Bassett-Smith, in replying, said he 
thought that the Maltese would raise no objection to 
immunisation experiments amongst goats if threatened 
with destruction of infected animals. He thought that the 
remarkable success of the Malta Fever Commission was a 
strong argument in favour of experiments on animals, since 
without these the work of the Commission could never have 
been carried out. 

The President then proposed a vote of thanks to Fleet- 
Surgeon Bassett-Smith for his interesting paper, which 
was carried by acclamation. The proceedings terminated 
with an exhibition of objects of interest in the Pathological 
Laboratory of the Royal Army Medical College. 


LIVERPOOL MEDICAL INSTITUTION. 


Exhibition of Cases and Specimens.—Plastic Roentgeno¬ 
graphy.—Method of Inflation of the Bladder with Oxygen. 
—Life History of Leucocytes. . 

A meeting of this society was held on Dec. 12th, 1907, 
Mr. Frank T. Paul, the President, beiDg in the chair. 

Dr. G. G. Stopford Taylor and Dr. F. P. Wilson 
showed a specimen from a case of Enchondroma Cutis.— 
Dr. Wilson stated that the specimen had been taken 
from a female child. The mother had had a haemorrhage 
during pregnancy and had been delivered a month before full 
time. When the child was about five months old the 
mother noticed a bluish stain on the inner side of the left 
leg just above the knee. This gradually developed into a 
hard plate. Similar plates subsequently appeared in the 
skin of other parts of the body. The specimen shown was 
taken from a plate over the right costal arch. It was so 
calcified in parts that a considerable effort was required to 
cut through it with a scalpel. A microscopical examination 
showed that the epidermis was normal. The corium was 
somewhat thickened and contained sweat glands with 
rudimentary hair follicles. In the deepest part of the corium 
were large irregular blocks of cartilage containing small 
cartilage cells and fenestrated here and there by spaces filled 
with a vascular connective tissue. In parts the cartilage 
seemed to merge indefinitely with the fibrous tissue of the 
corium. Dr. Wilson then commented on the extreme rarity 



22 The Lancet,] NORTH OF ENGLAND OBSTETRICAL AND GYNAECOLOGICAL SOCIETY. [Ja» 4, 1908. 


of enchondromata of the skin and the fact that none of the 
cases hitherto recorded resembled the present one which was 
remarkable for the number of the new growths.—Dr. 
Stopford Taylor said that clinically the disease was one 
of cartilaginous plates imbedded in the corinm at various 
depths, and that in one plaque on the outside of the left 
thigh distinct ossific spicules could be seen and felt, 
stretching the epidermis—Dr. R. W. MacKenna said that 
the plaques were distinctly cartilaginous but were undergo¬ 
ing ossification. The condition was an extremely rare one 
and he had only been able to find one similar case in 
literature which was associated with fragilitas ossium 
and which ultimately degenerated into sarcoma.—Dr. 
F. H. Barbxdt believed the tumour to have originated 
in the subcutaneous tissue and to have grown into the cutis 
vera. The fact that the corium was implicated in the 
growing ends supported this view, as well as the islets of 
sweat glands and adipose tissue embraced by the tumour. 
He regarded the tumour as bony in nature and thought that 
there were distinct appearances of attempts at a Haversian 
system. Other portions of the section no doubt favoured 
the cartilaginous view which Dr. Wilson and others held. 
Possible dislocation of temporary cartilage during the 
development of the bones was the primary source of this 
rare condition and subsequent ossification. 

Dr. Nathan Raw showed a specimen of Carcinoma of Both 
Suprarenal Glands and Root of the Left Lung.—Dr. A. G. 
Gullan said that he considered Dr. Raw’s specimen of bi¬ 
lateral carcinoma of the suprarenal organs of special interest 
and importance because, although the suprarenals had been 
almost completely replaced by new growth, the patient had 
not shown symptoms or manifestations of Addison’s disease. 
This case thus supported the view which he felt inclined to 
believe—i.e., that Addison’s disease was the result of tuber¬ 
culous lesions of the suprarenal and their sequelae and was 
sot due to other pathological affections of the organ.—Dr. 
Bradshaw said that in the case of a patient with malignant 
disease it was not an easy matter to determine whether the 
symptoms of Addison’s disease were present or not. Pig¬ 
mentation was not a constant symptom in Addison’s disease 
and the other symptoms of that condition, asthenic and 
gastric irritability, if they were met with in a patient known 
to be suffering from malignant disease in any part of the 
body would probably be looked on as symptomatic of the 
cancer and not as due to the special involvement of the 
suprarenal bodies. 

Dr. David Morgan read a note on Plastic Roentgeno¬ 
graphy and showed several photographs and lantern elides of 
this new method. He described fully the methods of pro 
ducing the plastic effect, for the discovery of which they were 
indebted to Dr. Bela Alexander of Kdsmdrk, Hungary. 

Dr. Morgan also demonstrated the Method of Inflation 
of the Blander with Oxygen for the purpose of diagnosis in 
vesical trouble and showed a photograph of stone in the 
bladder obtained by this method. The radiograph displayed 
the structure of the stone and the ontlines of the bladder 
with remarkable distinctness. The oxygen inflation Dr. 
Morgan considered to be of great value in elucidating obscure 
affections of the bladder. Owing to the transparency of the 
medium (oxygen) any irregularity of the vesical mucosa 
would be readily discernible. 

Dr. Raw showed a specimen of Tuberculosis of Fish.— 
Dr. R. K. Harcoukt considered that the proof was not 
sufficient to say that it was the tubercle bacillus, since the 
Ziehl-Neelsen acid fast staining acted in leprosy as well, 
and under the microscope it was scarcely possible to dis¬ 
tinguish between the two bacilli. Again, Jonathan Hutch¬ 
inson’s theory that leprosy was caused by eating uncooked 
pntrid fish might point to this being the bacillus leprae and 
not tuberculosis. 

The President showed specimens of Myeloid Tumours.— 
Dr. Harcourt stated that in the early part of the year he 
was shown a section from a tumonr of the lung which was 
said to be secondary to a myeloid tumonr of the lower jaw. 
As the section was certainly a myeloid growth these tumours 
must be considered to be more malignant than was generally 
taught, as some authors (e.g., Mr. J. BlandSutton) taught 
that they were so benign that they placed them in a separate 
class, the myelomata. 

Mr. 0. E Walkkr read a paper on the Life History 
of Leucocytes. He described how some of the leuco¬ 
cytes in the bone marrow of mammals passed through 
the meiotic phase—that is, the number of chromosomes they 
exhibited when dividing was reduced to one-half of the 


normal somatic number. He drew a comparison between 
this phenomenon and what happened in the case of certain 
cells in plants. He then went on to describe how in some 
leucocytes which had not passed through this phase granules 
were developed in the cytoplasm His observations upon 
the derivation of the granuhs in leucocytes were communi¬ 
cated in a paper sent to the Royal Society in July, 1906. He 
described a small coiled-up thread as arising in the archo- 
plasm of these leucocytes. This thread grew until it 
occupied tl e whole of the cytoplasm and completely 
surrounded the nucleus. It then broke up into a number of 
6hort segments which subsequently assumed an oval or a 
round shape. The bulk of the cells which had passed 
through the meiotic phase he described as being converted 
into red corpuscles in the bone marrow. He showed that 
the series of changes which he described as occurring in 
these reduced leucocytes were completely checked by 
what could be observed actually happening under the 
microscope in the case of the red corpuscle of amphibia, 
reptiles, and birds. He pointed out that the condition of the 
leucocytes which were reduced was exactly similar to that of 
the sexnal elements, in that these cells had gone through the 
necessary preparatory changes for fertilisation. In plants 
only a few of the cells which reduced ever conjugated with 
other reduced cells ; the bulk of them merely served a 
nutritive purpose. Thus the fact that the bnlkof the cells was 
converted into red corpuscles was just what happened in the 
case of many plants. He then described what he claimed to- 
be a process of fertilisation occurring among a few of the 
reduced leucocytes. Two adjacent leucocytes sent out 
processes from their nuclei which join, forming a tube. The 
contents of one nucleus then passed over through this tube 
into the other nucleus, leaving one cell with a unclear 
membrane devoid of linin and chromatin and the other witb 
a double complement. He showed that this process was very 
different from the destrnotion of one cell by another. The 
latter phenomenon was very common but seemed always to 
take the form of engulfment of the whole or part of the cell 
destined to destrnotion into the cytoplasm of another cell. 
The nsnal sequence was that one leucocyte or other kind 
of cell engulfed another bodily into its cytoplasm ; the 
engulfed cell was then gradually disintegrated, but was 
never taken into the nucleus but remained in the cytoplasm 
of the engnlfing cell. Here the absorption of the contents 
of one leucocyte nucleus by that of another seemed to involve 
the development of a special and complicated apparatus, 
formed in such a manner that the chromatin and linin of 
the one nucleus might be transferred directly to the other 
without any process of digestion by the cytoplasm being 
possible. Mr. Walker therefore concluded that the pheno¬ 
menon which he described was a process of fertilisation. 
From this he farther concluded that the leucocytes passing 
out of coordination with the soma lived as parasites npon 
the parent organism, and in themselves possessed a complete 
life cycle. 


NORTH OF ENGLAND OBSTETRICAL AND 
GYNAECOLOGICAL SOCIETY. 


Hamatoma of both Broad Ligaments—Gonorrhoea and 
Uterine Sepsis —Cersarean Section for Petrie Deformity .— 
Diffuse Adenoma.—Primary Unilateral Superficial papil¬ 
loma of the Uvary.—Supports of the Pelvic Viscera. 

A meeting of this society was held at Manchester on 
Dec 20th, 1907, Dr. E. O. Cruft (Leeds), the President, being 
in the chair. 

Dr. \V. Walter (Manchester) related a case of Haema- 
toma of both Broad Ligaments occurring a few hours alter a 
supravaginal hysterectomy on a patient, aged 37 years, who 
was exhausted by prolonged metrorrhagia. The tumour grew 
from the posterior wall of the uterus and extended laterally 
to the sides of the pelvis. Incising the uterus deeply the 
myoma was enucleated from its attachments but general 
oozing from the broad ligaments gave trouble. The pulse 
was 84 at the completion of the operation, four hours 
later it was 96, and at 6 p.m. it was 116 and a small 
amount of blood was coming through the vagina. At 
8 p.m. the patient became collapsed and complained 
of abdominal pain. Saline injections were giveD, ether 
was administered, and the abdomen was opened. Not 
more than eight ounces of free blood were found in the 
abdomen, but both broad ligaments were distended with 




The Lancet,] 


ROYAL ACADEMY OF MEDICINE IN IRELAND. 


[Jan. 4,1908. 23 


blood and clots. There was no bleeding apparent from the 
main vessels nor had their ligatures slipped. The collapse, 
simulating extensive haemorrhage, was the chief interest 
in this case and may have been doe to intense pain from 
over-distension of the ligaments in a patient already 
■debilitated by previous haemorrhage. Particulars were also 
given of a case of Abdominal Distension arising the day 
after supravaginal hysterectomy had been performed on a 
single woman, aged 40 years, who sought relief on account 
•of excessive menorrhagia and retention of urine, produced by 
a myoma. The operation took place on Oct. 29th in the 
Trendelenburg position. Three hours afterwards the pulse 
was 88 and the patient was fairly comfortable. On the day 
following the abdomen was slightly distended and flatus 
could not be passed voluntarily. The pulse gradually rose 
and in the evening it was 130; vomiting and pain were 
troublesome and nutritive enemata were no longer retained. 
On the third day symptoms were more pronounced and the 
pulse was 152. It was decided to open the abdomen unless 
some improvement took place. At 8 p m. one of the enemas 
took slight effect and the pulse fell to 140 and on the next 
day it was 128. Hot fomentations and gentle massage aided 
the ordinary treatment by enemata and calomel. The 
obstruction was possibly due to a kinking of the intestine 
when being replaced after Trendelenburg’s position. Both 
cases made good recoveries. 

Sir William J. Sinclair (Manchester) mentioned a case 
of Gronorrhcea and Uterine Sepsis occurring in a patient aged 
28 years, who had been married for seven years and had had 
one abortion. Curettage and removal of the uterine 
appendages had been previously carried out. The patient 
aought bis advice for constant abdominal pain and on 
Nov. 15th he extirpated the uterus per vaginam. Steady 
and continued improvement followed. He advocated con¬ 
servative measures from the outset in these cases. 

Dr. J Lloyd Roberts (Manchester) related two cases in 
which he had performed Casrarean Section for Pelvic 
Deformity. In one the patient had had eight pregnancies. 
'Craniotomy had been necessary five times and premature 
labour was induced twice, the child being stillborn on both 
occasions. Four years ago Caesarean section was successfully 
performed and now for the second time. It was interesting 
to note that there was no union between the uterus and the 
parietes following the first operation. In the second case 
oraniotomy had been performed once. Both patients made 
uneventful recoveries. 

Dr. Arnold W. W. Lea (Manchester) narrated two cases 
of Diffuse Adenoma occurring in Fibroid Uteri and drew 
attention to the features of pathological interest in this 
condition. Multiple polypoid projections of the endo¬ 
metrium, microscopically of a benign character, were present. 
The uterine wall was uniformly thickened to the extent of 
two inches in some situations. The specimens and micro¬ 
scopical sections were also shown. 

Dr. E. Emrys Roberts (Liverpool) gave a pathological 
report, illustrated by lantern slides, on a case of Primary 
Unilateral Superficial Papilloma of the Ovary and expressed 
the view that the ascites present in such cases was the result 
of secretion by the epithelium covering the papillm. The 
tumour was removed by Professor H. Briggs in the Hospital 
for Women at Liverpool. 

Dr. John Cameron (Manchester) exhibited a number of 
dissections demonstrating the Supports of the Pelvic Viscera. 
After pointing out that the muscles forming the pelvic floor 
in man were now recognised as vestigial structures he 
directed attention to the fact that they must regard the 
fascia surrounding the visceral branches of the internal iliac 
vessels (the perivascular fascia) as forming the most 
important support of the pelvic viscera both in the male 
and in the female. He then went on to suggest that opera¬ 
tive treatment for prolapsus uteri must be directed not to 
the pelvic outlet alone but also to this perivascular fascia. 


ROYAL ACADEMY OF MEDICINE IN 
IRELAND. 


Section of Medicine. 

Diphtheritic I'ever.—Eye Strain. 

A meeting of this section was held on Dec. 6th, 1907, Dr. 
A. R. Parsons being in the chair. 

Sir John W. Moore gave details respecting a remarkable 
Outbreak of sore-throat which had come under his observation 


in a large girls’ Bchool in Dublin during the autumn of 
1906 Bacteriological examination proved the outbreak to 
be due to an infection with a form of the Klebs-Loffler 
bacillus diphtheriae. The resulting illness failed to present 
the typical features of classical diphtheria—it might be 
described as “ diphtheroid,” and he had ventured to call it 
“diphtheritic fever.” From Oot. 2nd to Nov. 11th, 1906, 
out of a total of 43 girls in the school 18 were attacked— 
that is, 41 9 per cent. There were five distinct outbreaks. 
In the first, one girl sickened on Oct. 2nd ; in the second, 
one girl sickened on Oot. 10th ; in the third, two girls 
sickened on Oct. 19th, two on the 21st, two on the 22nd, 
two on the 23rd, and one on the 24th; in the fourth, one 
girl was attaoked on Oct. 28th, two on the 29th, one on 
Nov. 1st, and one on the 2nd ; and in the fifth, one girl was 
attacked on Nov, 7th (for the second time), one on the 8th, 
and one on the 11th. After this last date no further 
cases occurred for a long time. Diphtheria was carried 
home to the country in two instances by the girls when, 
nearly two months after their illness, the school broke 
up for the Christmas holidays. Nearly 12 months afterwards 
a little epidemic of a precisely similar nature occurred in 
the school. On Sept. 30th, 1907, three cases of sore-throat 
occurred in the school ; the patients were moderately 
feverish, with swollen tonsils and enlarged cervical glands 
but little or no exudation. A bacteriological examination, 
made by Dr. W. Boxwell on Oct. 1st, showed that the milder 
form of the diphtheria bacillus was present in considerable 
quantities in two of the three cases. In the third case— 
clinically the most severe—Dr. Boxwell failed to find it, 
probably because streptooocci and staphylococci were so 
numerous that they crowded out, as it were, the Klebs- 
Lofiier bacilli—a fact well known in true diphtheria. Lastly, 
the symptoms which by their more or less constant presence 
made np the clinical syndrome of diphtheritic fever were: 
(1) a more or less severe coryza ; (2) a moderate tonsillitis, 
usually one-sided, and unattended by high fever or by much 
exudation ; (3) thickly coated tongue and foul breath, the 
tongue desquamating as in scarlet fever; (4) a patchy or 
punctate rash on the roof of the mouth and buccal mucous 
membrane ; (5) swelling of the cervical lymphatic glands ; 
(6) a roseolar rash on the skin ; and (7) distinct desquama¬ 
tion (in three cases), the peeliDg being particularly marked 
on the hands. — Dr. T. P. O. Kirkpatrick said shat some¬ 
times 10 or 11 recruits came into Bteevens’ Hospital, 
Dublin, in one day from the Constabulary Depot, com¬ 
plaining of symptoms resembling those described by Sir 
John Moore. They usually recovered in a 6hort time. 
In no case bad there been any suspicion of membrane, and 
bacteriological examination showed no trace of the diph¬ 
theria bacillus in many cases. The organism in the majority 
of cases was some form of coccus. The condition was looked 
npon as ao epidemic of catarrh and in no case had the roseolar 
rash or enlargement of the cervical glands been observed.— 
Mr. John Burgess said that the recruits mentioned by Dr. 
Kirkpatrick were brought up from the country and were not 
used to the ordinary hygiene. They were given swimming 
lessons and kept in the water for half an hour or more. This 
chilled them and they complained of sore-throats.—Dr. J. M. 
Day said that it was not necessary to find a membrane 
to diagnose diphtheria. He had pointed oat in a paper 
some years ago that cases having soft tonsils, coated 
tongue, and enlarged glands had given the diphtheria 
bacillus on a swab. Diphtheria was much commoner 
in the city than people supposed and there were two main 
predisposing causes—namely, bad teeth and constipation. 

Dr. Kirkpatrick read a paper on Eye Strain as a Factor 
in the Production of Functional Neuroses. One patient to 
whom he referred had complained for years of recurrent 
attacks of migraine and though he made no complaint of 
his vision his condition was completely relieved by the 
correction of some faulty muscle balance of his eyes. Cases 
were also quoted to show the advantage of the correction of 
errors of refraction in the relief of persistent headache. A 
patient who had complained of severe and more or less per¬ 
sistent headache for nearly 15 years was completely relieved 
by the use of proper correcting glasses. 

Dr. Herbert C Mooney read a paper on Eye Strain, in 
which he expressed the opinion that the relation between 
headaches and errors of refraction was not as fully realised 
by physicians as it might be. He pointed out the part 
played by errors of refraction, accommodation, and the 
balance of the extrinsic muscles of the eye in the causation 
of headache, migraine, giddiness, and nausea, and said that 




24 The lancet,] 


DEVON AND EXETER MEDICO-CHIRURGICAL SOCIETY. 


[JAN. 4, 1908. 


headaches met with in young students were often wrongly 
put down to the quality or quantity of the illuminant instead 
of to some degree, often quite small, of astigmatism. 


Devon and Exeter Medico-Chirorgical 
Society.— A meeting of this society was held on Deo. 12th, 
1907, Mr. R. Coombe, the President, being in the chair.—The 
President showed a boy, aged about 12 yearB, on whom he had 
successfully performed the operation of Submucous Resec¬ 
tion of the Septum Nasi.—Dr. J. D. Harmer, house surgeon 
at the Royal Devon and Exeter Hospital, showed for Dr. 
J. Delpratt Harris a case of Actinomycosis of the Jaw. The 
patient, who was a girl aged 18 years, gave a history of three 
months’ illness. The whole of the left side of the face was 
swollen and brawny and the eyelids were oedematous. There 
were several sinuses, from which exuded thick, yellow, 
offensive pus. She could only separate her teeth a short dis¬ 
tance and was in a serious general condition, with quickened 
pulse and elevated temperature. She was by occupation 
a domestic servant in Exeter, but her father was a farm 
labourer and she was at home in the summer.—Dr. R. V. Solly 
showed a microscopic slide of the pus from the foregoing 
case, which exhibited branching mycelium but no clubs.— 
Dr. Solly read a paper on Leukemia. He began by report¬ 
ing the following cases which occurred in the Royal Devon 
and Exeter Hospital. The first patient was a man, aged 
34 years, who had served in the Marines and had been to the 
tropics but had never been ill there. There was a history of 
syphilis four years ago. The present symptoms were 
amemia, indigestion, and palpitation. The spleen reached 
nearly to Poupart’s ligament. The patient’s temperature 
was generally normal. The blood contained about 3.000,000 
red cells and 340,000 white cells per cubic millimetre, with 
40 per cent, polymorphs, 56 percent, neutrophile, and 2 2 
per cent, eosinophile myelocytes. The patient remained in 
the hospital for three months and was discharged unrelieved. 
The second and third patients were women, aged respec¬ 
tively 40 and 30 years; they both died within three months 
after coming under observation. The fourth case was one of 
acute lymphatic leukaemia, which was fully reported in 
The Lancet of June 23rd, 1906. The patient was a girl, 
aged 13 years, whose whole illness only lasted 14 days, 
and whose blood contained the enormous proportions of 
796,000 white cells per cubic millimetre with only 16 
per cent, polymorphs and 86 per cent, large and 11 
per cent, small lymphocytes. Dr. Solly commenced his 
paper by stating that the diagnosis of leukaemia was 
almost entirely dependent on the blood examination. 
It was necessary, however, that a differential as well as 
a total leucocyte count should be made, as cases of 
leukaemia occurred in which the total count of the white cells 
was little raised above normal, but the differential character 
of the leucocytes was profoundly altered. Acute lymphatic 
leukiemia might give all the appearance or an acute infection 
and might have to be diagnosed by the blood examination 
from such diseases as typhoid fever or general septicaemia, 
and as it was almost invariably rapidly fatal it was well to 
make a diagnosis as soon as possible. Conditions such as 
splenic anaemia and lymphadenoma, where the leucocytes 
were little changed, were diagnosed immediately from 
leukaemia by a stained blood film, and the same could be 
said of enlargements of the liver and spleen due to syphilis 
or malaria. Spleno-medullary leukaemia, lymphatic leukiemia, 
and pernicious aniemia should be considered together as 
arising from Borne dyscrasia of the blood-forming organs, 
and particularly of the bone marrow. Dr. Solly then 
referred to cases described by Leube under the name 
of leukamemia which exhibited the characters of leukiemia 
and pernicious anosmia combined. Dr. Solly gave it 
as his opinion that the most probable cause of per¬ 
nicious amemia and the ieukiemias was some toxin 
acting in the bone marrow and possibly produced in the 
inter tines, and causing in pernicious amemia megaloblastic 
degeneration, destruction of red cells, and some myelocy- 
tosis, and in the Ieukiemias myelocytosis or lymphocytosis. 
The view that it was an intoxication was supported by the 
fact that both infection by the bothriocephalus latns and 
saponin poisoning produced megaloblastic degeneration as 
in pernicious aniemia. In these cases no improvement was 
produced by exposure to the x rays. In one case the spleen 
became smaller and the number of leucocytes diminished 
but the patient became more amomic and shortly died. 
Dr. Solly suggested that the fresh bone marrow sandwich 
treatment as carried out by Dr. A. G. Gullan of Liverpool in 


pernicious amemia might be tried in leukaemia.—Dr. W. 
Gordon in discussing the paper remarked that he felt 
certain that the large lymphocytes of acute lymphatic 
leukiemia were not the normal large lymphocytes of the 
blood, as these leuksemio lymphocytes frequently showed 
quite different staining characteristics, the normal lympho¬ 
cytes having a dark nucleus and a lighter rim of protoplasm, 
while frequently in these abnormal lymphocytes of leukaemia 
the rim of protoplasm took the basic stain more deeply than 
the nucleus. 

Sheffield Medico-Chirurgical Society.— A 

meeting was held in the society's room in the University on 
Dec. 19th, 1907, Dr. R Gordon being in the chair.—Professor 
J. M. Beattie showed the more interesting recent additions 
to the museum. These were accompanied by microscopic 
specimens and included specimens from cases of Delayed 
Chloroform Poisoning, Haemochromatosis of the Liver in 
“ Bronzed Diabetes,” a Lung Full of “ Sand ” which the 
micro-section showed to be due to Calcified Corpora 
Amylacea, a section of the Liver from a case of Argyria 
showing Silver Deposit, Malaria Parasites, Lymphatic 
Leukiemia of the Kidney and Liver, a Kidney from a case 
of Hicmoglobinuria, Endothelioma of the Lung, and Fat 
Necrosis of the Omentum.—Dr. Arthur J. Hall showed 
specimens of Hiemorrhage into the Cerebellum and Cerebrum 
due to Purpura Hiemorrhagica, a Liver and Spleen Two 
Years after Epiplorrhaphy for Cirrhosis of the Liver, and 
other cases.—Dr. H. G. M. Henry showed a series of 
Cerebral Tumours and specimens from a case of Congenital 
Syphilis.—Dr. H. Leader showed Macro- and Micro¬ 
specimens from a case of Lympho-sarcoma.—Dr. W. H. 
Nutt showed a series of Skiagrams illustrating bron¬ 
chiectasis, thickened pleurae, pulmonary tuberculosis, renal 
calculi, Intrathoracic growths, tumours, foreign bodies, 
fractures, and one of a child with absence of cervical 
vertebra;.—Dr. A. Rupert Hallam showed a series of Skia¬ 
grams illustrating fractures, foreign bodies, pulmonary tuber¬ 
culosis, renal and ureteric calculi, and a stereoscopic view 
of a skiagram of the hand.—Mr. Arthur M Connell showed a 
series of Pathological Specimens and a number of enlarge¬ 
ments of Micro photographs which showed very clearly 
several varieties of carcinoma and perithelioma.—Mr. A. W. 
Cuff showed a Sarcoma of the Shoulder removed by Berger's 
Operation, a Renal Stone from Perforated Pyo nephrosis, Anal 
Fistnlie which had been dissected out, and other specimens.— 
Mr. H. Lockwood showed specimens of Cystic Kidneys.— 
Mr. R. J. PyeSmith showed a Glioma of the Brain 
with microscopic specimen.—Mr. A. Garrick Wilson 
showed a specimen of Calculous Nephritis in an Infant.— 
Dr. Fercival J. Hay showed an Equatorial Staphyloma 
of the Sclera, Glioma of the Retina, a Rare Tumour of the 
Optic Nerve (Primary Glioma), Hydrophthalmos due to 
Ophthalmia Neonatorum, and a specimen showing Perfora¬ 
tion of the Cornea and Mode of Infection of the Posterior 
Chamber.—Mr. Miles H. Phillips showed a collection of 
Gynaecological Specimens, consisting chiefly of those added 
to the museum during the year. There were six prepara¬ 
tions of ectopic pregnancy, two of early rupture of the 
isthmial sacs, two tubal abortions, a five-weeks unruptured 
gestation in a rudimentary horn, and a full term unruptured 
sac, apparently tnbal. Other important specimens illustrated 
"red degeneration” of a fibroid during pregnancy, abscess 
of the corpus luteum, cystic degeneration of fibroids, and a 
good example of a fibroid polypus of the vagina.—Dr. F. H. 
Waddy showed three interesting Uterine Moles from cases 
of Missed and Concealed Abortion and a Six-months Hydro¬ 
cephalic Foetus with Deficiency in the FingerB of One Hand, 
possibly due to intra uterine amputation. 

Clinical Society of Manchester. —A meeting 
of this society was held on Dec. 17th, 1907, Dr. H. R. 
Hutton, the President, being in the chair —The meeting 
was devoted to the exhibition of cases.—Mr. E. Stanmore 
Bishop showed four cases of Gastro-enterostomy. Two 
of these had been done for ulceration of the stomach, 
one for ulceration of the duodenum, and one for hyper- 
chlorhydria. One of these cases was that of a young woman 
who at the time of operation was much emaciated from 
constant vomiting and loss of blood. After operation she 
rapidly improved and gained three stones in weight in four 
months. In another symptoms of perforation had been 
noted a month previously. When the abdomen was opened 
the omentum was found adherent to a thickened ulcer in the 
anterior wall of the stomach. Posterior gastro-enterostomy 





Thb Lancet,] NOTTINGHAM MEDICO-CHIRURGICAL SOCIETY.—.35SCULAPIAN SOCIETY. [Jan.'4, 1908 . 25 


wag done and the patient lost all previous symptoms and 
rapidly increased in weight. Mr. Bishop described the 
evolution of the operation and pointed out the drawbacks 
of the earlier methods.—Dr. J. A. Knowles Renshaw 
showed : 1. A case of Papilloma of the Larynx. The 
patient, a female, aged 30 years, had suffered from 
hoarseness for three years. There had been no cough 
or discomfort; during the last year the hoarseness had not 
been so noticeable. On examination a small pedunculated 
growth was seen arising from the lower surface of the right 
cord at the junction of the anterior and middle third. On 
phonation the growth rose above the cords. The improve¬ 
ment in the voice which had latterly taken place was due, no 
doubt, to the increase in length of the pedicle which allowed 
this free movement of the growth. 2. A case of Ethmoiditis 
and Ulceration of the Septum Nasi. The patient, a woman, 
aged 32 years, complained of obstruction of the right nostril 
and swelling over the right nasal bone, which she attributed 
to a blow on the nose eight months since. There was a large 
amount of infiltration in the ethmoidal region, the middle 
turbinal being especially thickened. Over the septal cartilage 
was a shallow irregular ulcer, on the anterior edge of which 
were several small masses of granulation tissue. Although no 
definite history could be obtained the general appearance was 
strongly suggestive of specific disease. 3. A case of Chorditis 
Tuberosa. The patient, a woman, aged 25 years, had over¬ 
strained her voice by talking amid loud machinery. The 
node on the left cord was much larger than that on the right 
and was semi-translucent, having the appearance of a small 
myxoma.—Dr. G. II. Lancashire showed (1) three cases 
illustrating Different Phases of Lupus Erythematosus ; (2) a 
case of Hereditary Syphilis in a girl, aged 14 years, rapidly 
responding to five-grain doses of iodide of potassium ; and 
(3) a case of Molluscum Confagiosum. The back had been 
covered with an enormous number of lesions. Cure had been 
effected within a fortnight by expressing the contents of the 
tumour and rubbing in a 40 per cent, resorcin ointment.— 
Dr. K. W. Marsden, Dr. C. H. Melland, and Dr. C. C. 
Heywood also exhibited cases. 

Nottingham Medico-Chirurgical Society.— 
A meeting of this society was held on Dec. 18th, 1907, Dr. 
L. W. Marshall, the President, being in the chair.—Dr. 
Thomson Henderson gave a lantern demonstration illus¬ 
trating some of his recent work on the Anatomy and Patho¬ 
logy of the Eye. He pointed out that the unity of patho¬ 
logical processes throughout the body was an important fact 
and pathological conditions in the eye obeyed the same laws 
that applied elsewhere. The only clinical or pathological 
differences observable resulted from the anatomical condi¬ 
tions peculiar to the eye as a special sense organ. After 
describing in detail the anatomy of the angle of the anterior 
chamber and the formation of the aqueous by the ciliary 
body it was demonstrated how the fluid drained away by 
Scblemm'8 canal assisted by the iris. By means of crypts on 
its surface the latter allowed the aqueous fluid to penetrate 
its stroma and so to come ‘nto d re< tcontai t with the veins of 
the iris. When the pupil contracted these crypts were widely 
open, but when it dilated these openings were closed and 
outflow by way of the iris was prevented. After demonstrating 
the venous connexions of bchlemm’s canal Dr Henderson 
discussed their bearing on glaucoma. He stated that the 
open network or cribriform ligament on the inner side of the 
venous sinus of Schlemm’s canal became thickened in this 
disease so that the interspaces were reduced and free outflow of 
the aqueouswashinderedandintraoculartensionraised. This 
thickening was a physiological process going on throughout 
life and only in its results was the effect pathological. In 
virtue of its crypts the iris was an absorbing surface and the 
operation of iridectomy produced a large crypt—namely, three 
sides of a square, through which the aqueous readily escaped, 
as the cut surface of the normal iris never healed. The reason 
for this apparently startling fact was clear when they con¬ 
sidered that cicatrisation was a protective process, resulting 
from the reaction of the cells of a tissue to irritation or to 
altered conditions of life. As a successful iridectomy did 
cot alter the relation of the severed tissue cells to their 
immediate surroundings but left them still bathed by the 
aqueous, no stimulus was imparted to them to cause them to 
lay down a dense and protective layer. The iris tissue thus 
remained unaltered and presented a large raw surface, by 
means of which the aqueous could readily drain away pro¬ 
vided the operation was done before atrophy and damage to 
its structure had proceeded too far.—The subject was dis¬ 
cussed by Dr. F. H. Jacob, Dr. E. C. Kingdon, Dr. J. Watson, 


Dr. T. D. Pryce, and the President, and Dr. Henderson 
replied. 

^sculapian Society.— A meeting of this 

society was held on Dec. 20th, 1907, Dr. W. Langdon Brown, 
the President, being in the chair.—Mr. Peter L. Daniel read a 
paper on Common Urinary Diseases and Some Points in 
their Etiology and Treatment. In the early stage of acute 
infection of a first attack of gonorrhoea the only germ present 
was the goDococcus. At the end of four or five weeks the 
infection of the gonococcus subsided and the urethra 
became aseptic and continued so for eight or ten days, but 
if not treated properly it got infected by streptococci and 
staphylococci which caused gleet. In the early stage 
of gonorrhoea the urine should be kept acid so as to 
inhibit the growth of the gonococci and prevent their 
spread from the anterior to the posterior urethra. For 
this the best drugs were urotropine or helmitol, and 
acid sodium phosphate, together with some preparation of 
sandal wood oil. The amount of liquids should be restricted 
so that drugs were given in a concentrated form. Local treat¬ 
ment should be started at once by injecting the anterior 
urethra alone, using a two-drachm Herring’s syringe with solu¬ 
tion of silver nitrate, 1 to 12 000, or potassium permanganate, 
1 to 8000. Stricture was not produced by gonorrhoea itself 
but by added sepsis, so the secret of treatment was cleanliness. 
Enlarged prostate in roost cases was the result of sepsis 
in the urethra. All other symptoms except difficulty in 
micturition and nocturnal frequency were due to sepsis 
setting up cystitis. Hence in enlarged prostate the cystitis 
should be treated. In kidney troubles, in order to get 
specimens of urine from different kidneys it was not neces¬ 
sary to catheterise the ureters, for a segregation answered 
perfectly well. Most kidney troubles were due to infection 
passing up along the “open door,” so if the lower genito¬ 
urinary tract was kept clean there would be less kidney 
mischief.—Dr. Herbert T. Herring said that nearly all urinary 
surgery was due to sepsis introduced by examination with 
dirty instruments. In treating a septic disease like gonor¬ 
rhoea it was essential that instruments, hands, and penis 
were aseptic so as to prevent any fresh infection. It was 
almost impossible to get formation of phosphatic stones 
without sepsis. 

South-West London Medical Society.— A 
meeting of this society was held on Dec. 11th, 1907, Dr. 
A. D Itoe, the President, being: in the chair.—Dr. Hector 
Macker zie read a paper on the Treatment of Pneumonia and 
its Complications. After defining pneumonia as a local 
infection of the lung by the pneumococcus, accompanied 
or followed by the entrance of the microorganism 
into the blood-stream, Dr. Mackenzie emphasised the 
importance of an abundant supply of fresh air in the treat¬ 
ment of all cases. In the past there had been three main 
forms of treatment, each of which had been successful in a 
measure: by bleeding, by brandy, and by the expectant 
treatment. The use of alcohol as a routine treatment was 
diminishing, but there were cases, especially amorg the old, 
where alcohol was of great benefit. Though bleeding was 
now out of fashion it was indicated in cases of marked 
cyanosis with cardiac dilatation; leeches, a dozen or more, 
might be employed in its place. Where there was prune- 
juice expectoration indicating oedema of the lungs and a 
watery condition of the blood calcium chloride should be 
given; in other conditions citrates were more useful. 
Oxygen had been much administered and greatly overrated, 
but it did no harm if no good. As to local applications, Dr. 
Mackenzie preferred hot to cold for the relief of pain. Sleep¬ 
lessness was best met by veronal or trional. With regard to 
the serum treatment, there was no evidence of any good 
result. The vaccine treatment was more encouraging, bnt 
there was much work to be done before any definite con¬ 
clusion could be reached.—The paper was discussed by the 
President, Dr. B. Baker, Mr. E J. Pritchard, Dr. E. C. 
Lambert, Dr. M. Mackintosh, and Mr. T. A. Howell. 

Medico-Legal Society.— A meeting of this 
society was held on Dec. 17th, 1907, Mr. Justice Walton, 
the President, being in the chair.—Dr. W. A. Brand 
showed to the meeting a “ Bill of Mortality,” dated 
1800, which referred to the number of deaths which 
had occurred in the various London districts for one 
week.—The President referred to the fact that 23 execu¬ 
tions were chronicled but the burials of only 11 were 
recorded, the probability being that the other bodies were 
sent to the anatomy schools.—Mr. E J. Blackett read a note 





26 The Lancet,] 


REVIEWS AND NOTICES OF BOOKS. 


[Jan. 4, 1908. 


on a case of Drowning of a Newly-born Child, and Mr. D. 
Cotes-Preedy brought to the notice of the meeting a case of 
manslaughter tried at the last Stafford summer assizes, the 
deceased’s death following a fracture of the thyroid cartilage. 
—Dr. T. Claye Shaw read an interesting paper on the Radical 
Care'. Certification of Inebriates.—In the discussion that 
followed Dr. F. W. Mott, Dr. Charles A. Mercier, Dr. 
F. J. Smith, Dr. James Scott, Dr. W. Scott Tebb, and the 
President took part.—The President remarked that no 
judge with experience of criminal work could be of any 
other opinion than that so far as crimes of violence were 
concerned drink was generally the cause. As to whether 
drunkenness led to crimes of dishonesty his impression was 
that it was not the primary cause but that drink prevented 
efforts of reclamation. Dr. Claye Shaw seemed to have 
found fault with the criminal law, but he (the President) felt 
sure that the criminal law would never deal with inebriates 
as inebriates. The criminal law of this country did not 
punish habits but only specific acts. 


anb States 


A 8ystem of Medicine by Many Writert. Elited by Thomas 
Cufford Allbutt, M.A., M.D. Cantab., LL.D., D.Sc., 
I.R O.F, Lond., F.R.S., F.L.8., F.S.A., Regius Professor 
of Physic in the University of Cambridge, &c. ; and 
Humphry Davy Rollkston, M.A., M.D. Cantab., 
F.K.C.P. Lond., Physician to St. George's Hospital, ka. 
Vol. III. London: Macmillan and Co., Limited. 1907. 
Pp. 1040. Price 25s. net. 

The preface to this volume tells ns that ‘ 1 as regards the 
more Important articles [it] is a re-written rather than a 
revised snccessor of Vol. III. of the original edition ” and 
uuch is indeed the case. In the opening article on Rheu¬ 
matoid Arthritis Dr. A. E. Garrod now distinguishes two 
separate affections which he calls respectively rheumatoid 
arthritis and osteo-arthritis, a distinction which has recently 
been emphasised by the researches of a special committee 
at Cambridge. Spondylitis Deformans also receives separate 
consideration. The article on Gonorrhoeal Rheumatism is 
now amplified into one on various infective lesions of joints, 
dysenteric, syphilitic, pneumococcal, and so forth. An 
article on Intermittent Hydrarthrosis is also new. Dr. H. 
Batty Shaw now writes on Pulmonary Osteo-arthropathy in 
place of Mr. A. A. Bowlby who is still, however, responsible 
for the sections dealing with Osteitis Deformans and Mol- 
lities Ossium. Dr. F. J. Poynton, who now assists Dr. W. B. 
Oheadle in the article on Rickets, contributes a new section 
on Achondroplasia which is illustrated by two good repro 
ductions of photographs. 

The article on Gout, written by the late Sir W. Roberts, is 
revised by Dr. J. Rose Bradford who gives some account of 
recent investigations on the purin bodies and their relation to 
the disease. We cannot help thinking that one or two graphic 
formulas would have made this part of the subject clearer to 
those who have not specially studied the chemistry of 
these Bubstances. Professor R. Saundby’s article on Diabetes 
Mellitus is not much altered but the author now admits the 
possibility of a failure of the tissues to utilise sugar as part 
of the explanation of the condition, holding that “failure of 
the glycogen reservoir in the liver and reduction of the power 
of the tissues to consume sugar” together constitute “an 
adequate hypothesis of diabetes." The discussion of the 
relation of the pancreas to this malady is not very full 
and Cohnheim's hypothesis as to the interaction of the 
pancreas and the muscles is not mentioned. Dr. Rose 
Bradford is responsible for the section dealing with Diabetes 
Insipidus and apparently favours a nervous theory of the 
condition. Meyer’s views as to the inability of the kidneys 
to excrete the salts of the blood except in extreme dilution 
(hyposthenuria) are not apparently thought worthy of 
notice. The senior editor’s contributions on Sea-sickness 


and Mountain-sickness are now transferred to the division 
embracing General Diseases of Obscure Origin, where they 
are better situated than among ailments of the alimentary 
canal. Diseases of the Mouth are now intrusted to Mr Walter 
G. Spencer, while the most noteworthy alterations in the 
division dealing with diseases of the alimentary canal arise 
from the division, among other contributors, of the large 
proportion of work originally allotted to Sir Frederick 
Treves. Thus the subject of Enteroptosis, now disfigured 
by the name of visceroptosis, a barbarous hybrid term, is 
dealt with by Dr. A. Keith, while Appendicitis—this name 
having prevailed over the more correct perityphlitis—is 
intrusted to Mr. C. B. Lockwood, whose article is full of 
excellent matter if the style is not quite equal to that of his 
predecessor. Intestinal Obstruction is fully dealt with by 
Mr. H. L. Barnard, and Acute Peritonitis, as well as other 
affections of the peritoneum, is in the hands of Sir W. H. 
Allchin. A new section on Shock has been contributed by 
Dr. T. G. Brodie ; this condition is looked upon by the author 
as one of depression of the nervous centres. We are not 
quite sure of bis meaning when he attributes this to “an 
inchoate and excessive series of impulses ” (the italics are ours) 
which act on many parts of the cord simultaneously. The 
late Dr. W. S. Playfair’s article on Diagnosis of Abdominal 
Conditions from a Gynrecological Standpoint is omitted in 
the present edition, presumably as being more suited to the 
companion volume edited by Professor Allbutt, with the 
assistance of Dr. T. W. Eden. Lardaceous Disease is also 
treated of elsewhere in the present edition. The section on 
Diseases of the Anus and Rectum, originally written by the 
late Mr. Herbert Allingham, has been revised by Mr. J. P. 
Lockhart Mummery who has added some coloured illustra¬ 
tions of appearances seen through the sigmoidoscope. The 
late Dr. Dreschfeld’s revision of his articles on Gastric and 
Daodenal Ulcer was fortunately finished by the author 
before his death and these represent perhaps the last con¬ 
tributions made to medical literature by this distinguished 
physician. New sections which deserve notice are that on 
Congenital Hypertrophy of the Pylorus, written by Dr. 
G. F. Still, and thit on Subphrenic and other forms of 
Peritoneal Abscess from the pen of Dr. T. D. Acland, which 
replaces the original contribution of Dr. Lee Dickinson. 

The present volume well maintains the credit gained by 
those which have previously appeared and there is every 
indication that the new “ System ” will retain the place secured 
by the former edition as the most popular standard medical 
text-book in this country. ItB 1040 pages are packed into a 
book of convenient size for reading, while the printing is 
excellent and singularly free from typographical errors. We 
are inclined to think that a rather more liberal allowance of 
Illustrations would be an advantage hut can understand the 
editor’s reluctance to sacrifice more space in view of the 
expansion which ten years’ increase of knowledge has 
necessitated in the total bulk of the work. 


A Text book of Embryology for Students or Medicine. By 
J. C. Heisler, M.D., Professor of Anatomy in the 
Medico-Cbirurgical College, Philadelphia. With 212 
illustrations, 32 of them in colours. Third edition. 
London and Philadelphia: W. B. Saunders Company. 
1907. Pp. 432. Price 13s. net. 

The first edition of this work appeared in 1899 and this 
may partly account for the following remarkable state¬ 
ment : ‘ ‘ Prior to the beginning of the present century, little 
or nothing was definitely known concerning reproduction and 
development.” Obviously the author has not revised this 
statement since the end of last century. The work is a plain, 
straightforward account of embryology—not in its widest 
sense but rather of human embryology. Very few 
authorities are cited and references to literature are practi¬ 
cally absent. The sources of the borrowed illustrations—which 




Thb Lancet,] 


REVIEWS AND NOTICES OF BOOKS. 


[Jan. 4. 1908. 27 


are rmmerous, from the works of His, Bonnet, and others— 
are duly acknowledged. Here and there certain facts of 
comparative embryology are given but the work is essentially 
one on human embryology adapted for students. The author 
follows the natural order in his treatment of the subject, 
beginning with the sexual elements and their physiology and 
passing on to segmentation of the ovum, germ layers, and 
the beginning differentiation of the embryo, the formation 
of the body wall, intestinal canal, and the foetal membranes, 
placenta, and umbilical cord. Then there is the more 
detailed description of the development of the external form 
of the body, its connective tissues and lymphatic system ; 
and subsequently there is set forth the story of the develop¬ 
ment of the face and mouth, the vascular, digestive, respira¬ 
tory, genito-urinary, cutaneous, nervous, and muscular 
systems ; and lastly, the development of the skeleton and 
limbs. With His he takes three stages of intra uterine de¬ 
velopment—the stage of the “ovum,” then that of the 
“embryo,’’beginning at about the fourteenth day ; the events 
from day to day are traced but the fourth week marks the 
most active growth of the embryo ; and finally, the 6tage of 
the “foetus,’’which comprises the time between the beginning 
of the second month and the end of pregnancy. The events 
that make up this period are described in order. The 
descriptions of development of the various organs are clear 
and not too long. Though the skeleton is taken last, and 
although it is the framework of the body in the anatomical 
or mechanical sense, it is not so embryologically. Its 
development is not begun, at least, not to any important 
extent, until all the principal organs are well differentiated, 
and its growth is largely subsidiary to that of the structure 
which it supports and protects; hence the story of its 
development naturally comes in at the end. 

There is an elaborate tabulated chronology of development 
running to several pages, setting forth in parallel columns 
the chief events in the development of the human emtryo 
from week to week and month to month. The work is, as we 
have already said, a plain, straightforward account of the 
human embryology for students of medicine rather than for 
those studying embryology from the point of view of science. 


The Nervous System of Vertebrates. By J. B. Johnston, 
Pi. D , Professor of Zoology in West Virginia University! 
With 108 illustrations. London: John Murray. 1907. 
Pp. 370. Price 15». net. 

This work deals with the nervous system from a broad 
point of view and endeavours, we think successfully and 
succinctly, to trace its phylogenetic hisiory and to show the 
factors which have determined the course of its evolution. 
More especially is attention given to its functional relations. 
There is little of mere descriptive anatomy. The account of 
the phylogecy of the forebrain differs from that usually given, 
while the statement is made that the taste buds are 
developed in the entodermal lining of the pharynx. If this 
be so it establishes an exception to the statement that all 
nervous structures are derived from the ectoderm. 

The work is set forth under the following heads : general 
morphology, development, nerve elements and their func¬ 
tions, and the functional divisions, including the somatic 
afferent division, the visceral afferent division, general and 
special, and the somatic motor and visceral efferent divisions 
of the nervous system. Then follow a chapter on the 
sympathetic system and others on centres of correlation 
and the cerebellum, the evolution of the cerebral hemi¬ 
spheres, and the neopallium. 

The short description of the general morphology is 
excellent and the account of brains in fishes is suggestive. 
The chapter on development forms a natural and excellent 
corollary to the foregoing. As to the importance of 
cephalisation this has brought with it, or rather the pro¬ 
cess consists in the development of, special sense organs, 


consequent enlargement of the brain and the formation of 
a rigid cranium to protect these organs, the disappearance 
of certain muscle segments and a change in position and 
functions of other muscles—e.g., eye muscles, the reduction 
in the number of gills, and with this the disappearance of 
various nerves and somites, the shifting of position of 
various organs and nerve roots due to these changes, and, 
lastly, the great development of the higher centres. The 
experiment of Bethe on the nerve cells of the crab 
C-trcinas seems to show that nerve impulses can pass 
through the processes of a nerve cell without traversing the 
body of the cell itself. There is a careful but not captious 
analysis of the neuron theory and it is now admitted 
that the part of this theory which treats of the doctrine of 
contiguity is definitely disproved. The nervous system as a 
whole may be considered as a complex of neurons variously 
linked together into functional systems, representing at once 
the mechanism by which certain work is done and a record 
of the experience of the individual and the race. 

When treating of functional divisions of the nervous 
system the general plan of the body shows actions in rela¬ 
tion to the external world and those related to internal 
activities having to do with the processes of nutri¬ 
tion and reproduction—i.e., somatic and visceral. This 
scheme is admirably set forth and worked out in the brain 
of selachians and in man. In fact, these chapters are 
amongst the best in the book Anyone making a careful 
study of these systems—afferent and efferent—as set forth 
by Professor Johnston will find new light on the complex 
problems and cumbrous nomenclature of the mammalian 
brain. The cutaneous division, with the special sense 
organs in fishes and the differentiation of cutaneous and 
auditory centres and the cerebellum, are well worked out, 
and this is the case also with regard to the study of the visual 
apparatus and visceral system and its components. The 
description of the development and evolution of the 
sympathetic system is compactly set forth and the same 
may be said of the cerebellum, and here we may point out 
t^e fallacy of the statement that the cerebellar hemispheres 
of mammals are new formations not found in sub¬ 
mammalian classes. The hemispheres are formed first. 
Ti e evolution of the cerebral hemispheres is made plain and 
interesting. In connexion with the study of the neo¬ 
pallium the work of Golgi, Cajil, and Flechsig naturally is 
largely drawn on. There are references to literature at the 
end of each chapter and also short notes on laboratory work. 
The book is such as could only be written by a skilled 
zoologist. It contains many original observations. We 
strongly commend it to the study of the youDger zoologists 
and neurologists. _ 

Studies in Laboratory Work, By C. W. Daniels, 
M.B. Cantab., and A. T. Stanton, M.D. Tor. Second 
edition. London: John Bale, Sons, and Danielsson, 
Limited. 1907. Pp. 491. Price 16* net. 

A NEW edition of this excellent work for research in 
tropical diseases has been necessitated by the rapid 
advances which have been made in all branches of 
tropical medicine since the first was published. These 
advances have in the volume before us been considered and 
especially information as to the known carriers of disease 
has been added, including ticks, biting flies, and fleas. 
Dr. Daniels also has had the advantage of the cooperation of 
Dr. Stanton in the preparation of the volume ; the result 
has been to furnish the student of tropical medicine with a 
work thoroughly np to date. 

In their opening chapter the authors show how the medical 
man practising in the tropics can best cope with the dis¬ 
advantages entailed by the absence of the well-equipped 
laboratory which is usually found in European institutions. 
An excellent chapter then follows with reference to post¬ 
mortem examinations, the statements contained therein being 




28 Thb lancet,] 


REVIEWS AND NOTICES OF BOOKS, 


[Jan. 4, 1908. 


only too familiar to those who have had experience in 
the dead house in the tropics. The all-important subject 
of the examination of the blood is next considered; 
the different varieties of the corpuscles are described, 
as well as the methods of making blocd Alms and the 
various particulars as regards staining. The succeeding four 
chapters deal with the question of the parasites found in 
the blood and here the student will find a very complete 
account of the organisms of malaria. The Leishman-Donovan 
bodies receive due attention, as do also the filarim. Certain 
properties of blood plasma and blood serum are then 
considered ; here Sir A. E. Wright's theory of opsonins 
finds due expression. The authors give a brief but quite 
satisfactory account of the blood-sucking dies, mosquitoes, 
ticks, and fleas, illustrated by some excellent drawings. The 
student of the subjects connected with malaria and yellow 
fever is taught how to dissect mosquitoes, whilst the eggs, 
larv;e, and pupas and their breeding places are demonstrated. 
Fleas, lice, bed bugs, and ticks are classified and described, 
after which the pigments and various forms of degeneration 
found in the tissues are dealt with. The subject of the 
parasites is finally concluded by an account of their presence 
in the tissues. 

The important subject of the faeces is considered and 
the various points requiring observation are laid down ; the 
method of examination of the various parasites contained 
therein is demonstrated. The chapter would, however, have 
been rendered more complete had the method of washing the 
dysenteric stools as laid down by the late Dr. E. Goodevebeen 
mentioned, for by this method the observer is enabled to 
determine better than by any other with which we are ac¬ 
quainted the condition of the affected bowel and the pro¬ 
gnosis that should be formed concerning the outcome of the 
disease. After that of the fceces comes the examination of 
the urine in which we note mention of Cammidge's researches. 
The volume concludes with the subject of bacteriology as 
practised in the tropics. Here the difficulties of the subject 
as experienced in these conditions are noted and an excellent 
table is given of the organisms of special interest as regards 
tropical countries. The last two chapters are occupied with 
the questions of measurements of the various eggs, parasites, 
and normal and abnormal cells, and with that of statistics in 
the tropics. 

The authors have placed at the disposal of the student of 
tropical medicine a mine of information without which he 
cannot be considered properly equipped. 

The Ttiintgen Bays in Medical Work. By David Walsh, 
M.D, Edin., Senior Physician, Western Skin Hospital, 
London. Fourth edition. London : Bailliere, Tindall, and 
Gox. 1907. Pp. 433. Price 15*. net. 

This work was one of the first, if not the first, of its kind 
to be published in this country, and that its publication was 
justified is well shown by the issue of a fourth edition. The 
general arrangement of the work is essentially the same as 
before. The first part dealing with apparatus has been again 
written, or rather rewritten, by Dr. H. Lewis Jones. All 
the essential details are fully gone into and it is refreshing 
to observe that the usual “ padding,” consisting of one or 
more chapters on elementary electrical physics, so commonly 
found in works of this kind, has been omitted. The second 
and major part of the work is devoted to the application of 
the x rays in medicine and surgery. The localisation of 
foreign bodies in both civil and military practice comes 
in for a very full share of attention and here, as in the other 
parts of the book, we note the superior character of the 
illustrations which go so far to elucidate a subject of this 
kind. Those prepared from radiographs by Dr. David 
Morgan of Liverpool are worthy of special mention In the 
purely medical section the author rightly insists on the great 
and valuable help which this agent is capable of giving in the 


diagnosis of thoracic disease. From an almost daily experi¬ 
ence of the method we can bear testimony to its value ; and 
the facility and speed with which an otherwise doubtful 
point can be satisfactorily settled are sufficient to impress 
the most sceptical. The closing chapters are devoted to legal 
medicine, anatomy, and physiology. We can confidently 
recommend the volume to all those who are interested in 
x ray work of any kind. 


Post-mortem Pathology: A Manual of the Technic of Post¬ 
mortem Examinations and the Interpretations to be Drawn 
Therefrom. By Henrv W. Cattell, A.M., M.D., some¬ 
time Pathologist to the Philadelphia, Presbyterian, and 
Pennsylvania Hospitals. Third edition, copiously illus¬ 
trated with coloured plates and figures. London and 
Philadelphia : J. B. Lippincott Company. 1906. Pp. 547. 
Price 18*. net. 

The third edition of Dr. Cattell’s book has been enlarged 
and very considerably improved. In our review of the first 
edition we commended the practical character of the work 
as a handbook for the post-mortem room but pointed out 
that the descriptions of morbid conditions were meagre and 
incomplete and that the literary style was marred by the 
abrupt and unfinished character of many of the sentences. 
In this edition we are glad to see these defects remedied. 
The description of the methods of post-mortem examination 
and the general account of the technique of the exa¬ 
minations, of the dissections necessary to expose various 
organs, and of the methods of section remain as 
before thoroughly practical, clear, and easy to follow. 
The copious illustrations, which are mostly reproductions 
from photographs, contribute in no small degree to the value 
of the book. Careful general descriptions of the manner of 
using the various instruments are included and many prac¬ 
tical hints are given. Where various methods are in use for 
the examination of special regions Dr. Cattell Is careful to 
describe them in detail and to indicate those which in his 
own extensive experience have given the best results or to 
point out the value attaching to each for any particular 
purpose. 

Among the chapters of special merit we may mention those 
devoted to the examination of the skull and the brain and to 
the investigation of the naso-pharynx, the eyes, and the ears. 
The descriptions of diseased conditions and morbid organs 
have all been considerably extended and improved, while a 
great deal of recent work has been incorporated in a form 
convenient for reference. The directions given for the 
preservation of tissues and for the bacteriological investiga¬ 
tion of post-mortem tissues are succinct and thoroughly 
useful. A chapter on post-mortem examinations of the newly 
born contains valuable information on the subject and like 
all those referring to matters of technique is copiously 
illustrated, while the sections devoted to restricted post¬ 
mortem examinations and to the restoration and preservation 
of the body afford highly useful accounts of those subjects, 
containing a great deal of practical advice. A section on 
weights and measurements given in English and metric 
figures leaves nothing to be desired, while that devoted to 
post-mortem examination of the lower animals gives a few 
general hints in regard to their performance in such 
mammals as the horse, ox, sheep, and dog, and also in 
birds. A very brief chapter on plant pathology is perhaps 
hardly necessary, as it includes but little of practical import¬ 
ance, although various suggestive lines of research are 
indicated. A long chapter headed “medicolegal sug¬ 
gestions ” we have read with interest, since it incorporates 
a considerable amount of the author’s personal experience 
as “ coroner’s physician ” in Philadelphia. 

Many useful references are appended to the text and it is 
a pleasure to recommend this book in its improved form as a 
valuable handbook for the student in the post-mortem room. 




Tbw Lancet,] 


REVIEWS AND NOTICES OF BOOKS. 


[Jan. 4, 1908. ‘49 


or for the practitioner who is called upon to perforin exami¬ 
nations of the dead bod; for medico-legal or other purposes. 


Manvel Pratique ie Manage et de la Dymnastique Medical 
Sucdoue. ( Practical Manual of Manage and of Sneduh 
Medical Exercises.) By J. E Marfort. Third edition, 
with 111 figures in the text. Paris : Vigot Fiferes. 1907. 
PP 319. Price 6 francs. 

A well-illustrated handbook which shall be at once 
intelligible and of moderate size, describing in simple terms 
the general methods employed in massage and in the varions 
forms of exercises adapted to medical purposes, is likely to 
serve a useful purpose. The small book before us fulfils 
most of these requirements ; it is well written, abundantly 
and clearly illustrated, and is of convenient size. Though 
not a medical practitioner, the author has a general acquaint¬ 
ance with the anatomical and physiological facts necessary 
for a proper appreciation of the principles underlying the 
therapeutic application of massage and muscular exercises. 
Indeed, he strongly emphasises the necessity for adequate and 
sufficient training in the theory and practice of these 
methods, and declaims against the harmfulness likely to 
result from the application of them by those with but a few 
weeks or moDtbs of training. He points out that in Sweden 
a course of three years at the Royal Institute of Massage is 
necessary before a diploma is granted. He insists on the 
importance of the application of these therapeutic methods 
under medical supervision by skilled persons and refers to 
various injurious effects which may be induced by their 
injudicious application. 

The first section of the book opens with a chapter on the 
history of massage and of its recent developments and 
applications; another follows on general considerations 
relating to the uses and applications of massage and 
muscular exercises. The second part of the book deals 
with the technique of massage. The various processes of 
efflevrace, fcrasement, pltrissage, tapotement, ondvlatitms , 
and vibrations are outlined and very clear figures are 
given in illustration. Various mechanical vibrators are 
described, including one devised by the author. The appli¬ 
cation of massage to the body generally and to the various 
organs is next discussed and the position of the patient and 
the operator is clearly defined. In this section it seems to ns 
that unnecessary importance has been given to massage in 
gynsecological conditions. 

The third section of the book is devoted to medical 
gymnastics and in it the passive and active movements 
applied to the various muscular groups are described 
and illustrated by figures or diagrams. In connexion with 
the active movements the various respiratory exercises are 
given. In this section certain resistance movements are 
noted such as those recommended in the treatment of 
some forms of cardiac disease. The exercises used in the 
treatment of scolii sis are also described and figured. 

The fourth and concluding section of the work deals with 
the physiological actions of massage and of muscular move¬ 
ments and with the indications for their use in practice. 
This would have been more suitably written by a medical 
author or in collaboration with one. It includes supposed 
indications for the application of these methods in a very 
great variety of conditions. None the less, as we have said 
at the outset, this is a practical and handy little book on the 
subject of which it treats. 


LIBRARY TABLE. 

Eneyclopcedia a/nd Dictionary of Medicine and Surgery. 
Vol. VI., Lumbar Region to Nephrotomy. London and 
Edinburgh: William Green and Sons. Fp. 562. 1907. Price 
15*. net.—The sixth volume of this valuable encyclopaedia o 1 
medicine and surgery contains more subject headings than any 
previous volume with the exception of the second. The subject 


most extensively dealt with is that on Diseases of the Lungs, 
but besides this long article there are 48 others of more than 
1000 words in length, as well as 82 of less than 1000 words 
and more than ten lines in length. The rest of the volume is 
made up of 1100 short paragraphs or definitions. Amongst 
the Various subjects dealt with we find an able article on 
Lunacy by Dr. J. F. Sutherland, In which the practitioner 
will find information on all the ohief points of the 
affections included under this term. Dr. R. W. Philip, 
Dr. S. H. Habersbon, and Dr. R. A. Fleming contribute 
the excellent section on the Lungs. The historical aspect 
of tuberculosis is well drawn. This is followed by 
the section on the etiology, pathological anatomy, and 
symptoms. Then we come to an excellent exposition of 
the physical signs of the various stages. The clinical 
varieties and complications are detailed and are followed 
by the diagnosis, prognosis, and treatment. Much 
information is given about the sanatorium treatment. The 
remaining diseases of the lungs are dealt with in an 
equally explicit manner. Dr. Norman Walker contributes 
an excellent article on Lupus Erythematosus. In his opinion 
we note that internal medication is rarely of much value. 
This is not, however, by any means universally held, as the 
salicylates have been found by other authorities to confer 
much benefit on the sufferer from this affection. Dr. 
G. Lovell Gulland gives a valuable contribution on the 
Physiology and Pathology of the Lymphatic System. The 
tabular statement of the glands showing the source of their 
afferent vessels and the destination of their efferent vessels 
is concise and complete. This is followed by a description 
of the different diseases of the lymphatic glands and their 
treatment. The article on Malaria, perhaps the best in the 
volume, is contributed by Mr. D. C. Rees. This writer gives a 
succinct accouut of the various steps whereby the mosquito 
theory was finally established. He then describes the 
biology of the malarial organism and the life-history of this 
parasite, which is illustrated by some excellent plates; the 
different species of the mosquito receive attention together 
with the development of the malarial organism in these 
hosts. The student is taught how to demonstrate the 
parasite, after which the clinical features of malaria are 
described with the various sequelae that may ensue. The 
sections on the morbid anatomy, the etiology, and the treat¬ 
ment, both curative and prophylactic, complete the article. 
Mr. T. D. Patmore writes exhaustively on the subject of 
malingering and gives many amusing instances of the 
manner in which malingerer were detected. Mr. H. J. Stiles 
discusses the Diseases of the Mammary Gland in an article 
which will well repay perusal ; this also is illustrated by 
some excellent plates. Dr. F. de Havilland Hall contributes 
a lucid article on the Diseases of the Mediastinum, whilst 
Dr. A. Mackintosh, Dr. G. F. Still, and Professor W. Osier 
deal with the matters connected with the meninges, describ¬ 
ing the anatomy, physiology, and vascular disorders of these 
membranes, and tuberculous, posterior basic, and epidemic 
cerebro-spinal meningitis. Amongst the other sections in 
the volume may be mentioned that on the Injuries and 
Diseases of the Mouth and Jaws, by Mr. H. P. Dean ; a very 
good article on Mycetoma, by Lieu tenant-Colonel W. Keith 
Hatch ; and lastly, an excellent contribution on Nephritis, 
by Dr. Nestor Tirard. This volume fully sustains the 
reputation of its predecessors. 

Manual of Praatical Anatomy. By D. J. Cunningham, 
M D. Dab. and Kdin., D.Sc., LL.D., D.C.L., F R 8.. Professor 
of Anatomy in the University of E linburgh. Vols. I. and II. 
Fourth edition. London and Edinburgh : Young J. 
Pentland. 1907. Vol. I., pp. 621 ; Vol. 11. pp 600. Price 
10* 6 d per volume.—The appearance of a fourth edition of 
Professor Cunningham's well known “Manual of Practical 
Anatomy,” besides affording conclusive proof of its 
popularity also points to the characteristic thoroughness 




80 The Lancet,] 


REVIEWS AND NOTICES OF BOOKS, 


[Jan 4, L90S.' 


of the author in having once again brought his book up to 
date. The general plan of the work, which like its pre¬ 
decessors is still published in two volumes, remains un¬ 
altered but the text has been carefully revised and several 
parts, chiefly in the chapters relating to the abdomen and 
thorax, have been rewritten. A large number of new illustra¬ 
tions have likewise been added to both volumes. The figures 
depicting the right and left pleural chambers, as seen from 
the side after removal of the lungs and a portion of the 
chest wall, are particularly instructive and should be of great 
assistance to the student. In the section devoted to the 
heart the text is amplified by many excellent illustrations, 
one of which depicts the auriculo-ventricular bundle in the 
heart of a calf. The chapters on the head, neck, and brain 
are particularly good and leave nothing to be desired. No 
less than 30 new illustrations have been added to the second 
volume which deals with the limbs and abdomen, whilst the 
text in the latter section has been rewritten in many places. 
The account of the stomach, pyloric canal, and pyloric 
vestibule is very clearly given and is liberally illustrated. 
Though several pages are still devoted to the pelvic fascia we 
fear that the average student very seldom sees the many 
layers and ligaments which are so aptly described. 
Professor Cunningham’s “ Manual of Practical Anatomy ” is 
undoubtedly the beet work of its kind in the English 
language and thoroughly deserves all the success which it 
has gained. 

The “ Ideal ” Medical Diary and Visiting List. London : 
Langley and Sons. Price 7s. 6 d. in morocco cover ; visiting 
list refills, 3s 6d. ; duplicate prescription refills (50), 6ii.. or 
5s. 6 d. a dozen. Wellcome's Medical Diary and Visiting List , 
190ft .—We noticed the editions for 1907 of both these diaries 
fully in The Lancet of Jan. 26ob, 1907, p. 236. Similar 
diaries for 1908 have reached us in which the main features 
are repeated. The “Ideal” Diary is a neat and handy pocket- 
book and the removeable visiting list and blank prescrip¬ 
tion forms are distinctly serviceable. Messrs. Borroughs, 
Wellcome, and Co.’s Medical Diary and Visiting List is 
widely known and appreciated. 

Walker's Diaries. London : John Walker and Co., Limited.— 
We have received a selection of pocket diaries from Messrs. 
Walker and Co. which are of the accustomed quality of their 
annual publications. Those before us are in various bindings 
and of different prices, from an “ American Russian ” one 
page at an opening at 3i. 6<f., to a tiny “quarterly” waist¬ 
coat-pocket diary with refills at 1». Those with pigskin 
bindings are especially serviceable but all are well and 
neatly bound. 

The Poetical Works of Thomas Campbell. Pp. 400. Price 2s. 
The Poetical Works of Shelley. Pp. 928. Price 2s. The Ox’ord 
Edition. Oxford : Henry Frowde. 1907.—The above-men¬ 
tioned works are two more volumes of the admirable Oxford 
Edition of Poets, one volume of which—namely, the Keats— 
we reviewed recently. For one parson who knows the works 
of Campbell probibly 50 know those of Shelley, and although 
the former was not to be compared with the latter as a poet, 
yet some of his lyrics are among the finest things in the 
English language. The volume opens with “The Pleasures 
of Hope,” a poem which is quite up to the standard of the 
average Newdigate, but which, like all eighteenth-oentury 
didactic poems, irresistibly reminds one who has read the 
poetry of the Anti-Jacobin of the famous “ Loves of the 
Triangles.” This, however, was a youthful flight. Campbell’s 
real poetic genius is shown in “The Battle of the Baltic,” in 
“ Hohenlinden,” in his songs, and above all in that mag¬ 
nificent poem, “ The Last Man,” with that wonderful 
couplet,— 

“ And ships wore drifting with the dead 
To shores where all was dumb/' 

Much may be forgiven to a man who could write like that, 
even 

" The sunset sheds a horizontal smile," 


as he wrote elsewhere. Mr. J. Logie Robertson supplies an 
introduction and notes. As regards the “ Shelley,” which is 
edited by Mr. Thomas Hutchinson, who writes an introduc¬ 
tion, the reader finds here a complete collection of all the 
works of Shelley which have ’ appeared in print hitherto, 
including fragments. The Oxford University Press deserves 
great credit for making it possible for those whose purse 
is not deep to possess well-printed, well-edited copies of 
imperishable literature. 

The Explorer. By W. S. Maugham. London : W. H. 
Heinemann. 1908. Pp. 297. Price 6s.—When we reviewed 
Mr. Maugham's first book, namely, “ Liz * of Lambeth,” while 
giving him full credit for a clever book full of observation 
we ventured to hope that in future works he would choose a 
less sordid subject. This hope was fulfilled in a later book— 
“Mrs. Craddock”—and in the book now before ns he has 
risen to a greater height still. “The Explorer” is a fine 
study of two fine characters and, as is always the case, they 
are refined by suffering. Alec MacKenzie is by no means 
perfect, he makes mistakes and profits by them, but his course 
is ever upward, and at the end we leave him strong in the 
love of the woman who is everything to him and happy in 
the consciousness that he will return from an expedition full 
of danger. The minor characters are well drawn ar d no one 
in the book bores the reader. Altogether, “ The Explorer ” is 
a book to be read and epjoyed. 


JOURNALS AND MAGAZINES. 

The Journal of Balneology and Climatology , October, 
1907 the official quarterly of the British Balneological 
and Climatological Society). This number contains Dr. 
Norman Moore’s address on “Air, Water, and Sanita¬ 
tion,” which has appeared in our columns ; some notes 
on the Shropshire Highlands and the Wentnor Saline 
Water, by Mr. Norman Hay Forbes; a piper on the 
Relation of Temperature, Humidity, and Winds to Chronic 
Nephritis, by Dr. W. R. F. Phillips ; and a communication 
by Professor Victor Schmieden on Bier's Method of Treating 
Inflammations by Stasis and Hyperaemia. translated by Mr. 
Charles G. Levison of San Francisco. This is a very clear 
and able summary of the technique of applying Bier’s treat¬ 
ment by bandaging or suction or heat to the various parts 
of the body. It is entirely practical and does not touch on 
the principle underlying a method which is proving in¬ 
creasingly useful. The translation is able but we must 
protest against the term “stased limb” used throughout 
for a limb undergoing venous stasis. 

Proceedings of the Royal Society of Medicine , Vol. I., 
No. 1.—We have previously alluded to the format of the 
official journal of the Royal Society of Medicine, 1 which is 
edited by Dr. John Nachbar under the direction of an 
editorial committee representing the various sections of the 
society. The first number contains reports of the opening 
meetings of the various sections, including presidential 
addresses by Sir Thomas Barlow in the Clinical Section, a 
most interesting and stimulating review of the past work of 
the Clinical Society; by Dr. H. RadcUfife Crocker in the 
Dermatological Section ; by Mr. W. Deane Butcher in the 
Electro-Therapeutical Section on the Future of Electricity in 
Medicine, a fascinating forecast which has already appeared 
in these columns; by Dr. A. Newsholme in the Epidemio¬ 
logical Section on Poverty and Disease as illnstrated by 
the Course of Typhus Fever and Phthisis in Ireland, 
which is a very painstaking and exhaustive study; by 
Dr. Samuel J. Gee in the Medical Section; by Mr. 
J. Howard Mummery in the Odontologioal Section ; by Mr. 
S G. Sbattock in the Pathological Section ; and by Dr. T. E. 
Burton Brown in the Therapeutical and Pharmacological 
Section. The most noteworthy of the papers printed in the 

1 Thf. Laxcet, Dec. 7th, p. 1633. 




Tir* Lancet,] 


REPORTS AND ANALYTICAL RECORDS.—NEW INVENTIONS. 


[Jan. 4, 1908. 31 


present '‘Proceedings” is probably that read by Professor 
E. Goldmann before the Surgical Section on “The Growth 
of Malignant Disease in Man and Lower Animals, with 
special reference to the Vascular System.” 3 There is a large 
number of interesting cases recorded, with abstracts of dis¬ 
cussions held on some of them, to which we need not further 
allude, as many of these cases have been recorded in our 
columns. 


spurts and Jnalgtiral JUrords 

FROM 

THE LANCET LABORATORY. 


SACK BIN. 

(Allen and Haniu rvs, Limit ed, 37, Lo.uuard-strekt, London, E.C.) 

“ Sauerin ’’ is described as a pure culture of a vigorous 
strain of bacillus acidi lactici prepared in tablet form for 
internal use and for the production of soured or curdled 
milk. We owe to Metchnikoff and others the discovery that 
an active strain of lactic acid producing bacteria inhibits the 
growth of the bacillus ooli communis and other intestinal 
bacteria in the colon by producing lactic acid. The 
suggestion, therefore, is that the active lactic acid pro¬ 
ducing bacillus might be given to act as a general intestinal 
disinfectant and might prove useful in disorders arising from 
a toxic process in which excessive intestinal putrefaction 
is involved. Already some evidence has been obtained that 
lactic acid is valuable in the direction indicated. We have 
submitted the sauerin tablets to experiment and have found 
that they are active in producing lactic acid readily when 
cultivated in milk kept at a blood temperature. The 
organisms, of course, attack the milk sugar, converting it 
into lactic acid. The milk so treated appears to present the 
lactic acid in a most active form for administration. The 
curdled milk can be Savoured with cinnamon, nutmeg, or 
other substance according to taste. The method suggested 
appears to be worthy of trial. 

MARMITE (SAVOY BRAND). 

(The Marmite Food Extract Co., Limited, Mincing-lane House, 
59, Eastcheap, London, K.C.) 

We have already submitted ordinary Marmite Food Ex¬ 
tract to analysis, but we have recently received a sample 
known as the Savoy Brand which is stated to be obtained by 
submitting the ordinary marmite to an additional process 
whereby it becomes more highly refined and also retaios 
the flavour of the fresh vegetables which are used in the 
process. The flavour, in our opinion, is certainly good and 
is barely distinguishable from good beef extract, yet marmite 
is entirely of vegetable origin. Our analysis, which prac¬ 
tically agrees with an analysis a copy of which has been 
Bent to us, gave the following results : moisture, 23 ■ 84 per 
cent. ; mineral matters, 19 • 78 per cent. ; and extractives, 
56'38 per cent. The extractives include over 2 per cent, of 
peptones and albumose, but for the most part the nitro¬ 
genous matters consist of bases, while the non-nitrogenous 
matters include lactic acid. The total nitrogen was 6*82 
per cent. The preparation serves the purpose of a stimulant 
in much the same way as does meat extract, while it also 
contains a definite proportion of real nutritives. 

COGNAC BRANDIES. 

(Dk Laaoe Fils and Co., Coonac. London AgencT: Noakes and 
Co., Limited, White's Grounds, Bermondset, S.K) 

Of the two samples of brandy submitted to ns one was 
described as “three stars ” and the other as 25 years old. 
Our analysis, especially In regard to secondary products, gave 
results identical with those given by genuine Cognac brandy. 
The ethers in both instances amounted to 100 parts per 
hectolitre, the furfural amounted to 1 part, and the bigtier 
alcohols to just short of 200 parts. The 25 year old brandy 

» The Lancet, Nov. 2ud, 1907, p. 1236. 


was more elegant In regard to taste and bouquet than was 
the “three stars.” It was, however, somewhat sweet to the 
taste. There is no evidence on analytical premisses that 
these brandies are not the genuine products of the Cognac 
district. They contain a notable amount of extractives and 
resinons matters derived probably from storage in wood. 

SARDINES (CROSSED FISH BRAND). 

(Stavanger Prkserving Company, Norway, and Coronation 

House, 4, Lloyd’s Avenue, London, E.C.) 

Tbe sardine preserved in olive oil fills an important place 
in the dietary, since not only is it appetising but decidedly 
nutritious also. The Norwegian sardine is further submitted 
to a process of smoking which. In the view of many, adds con¬ 
siderably to its palatable qualities. The sardines at any rate 
of the above company are very agreeable to the palate and, 
so far as we can see, are prepared with care. We could find 
no evidence of metallic contamination either in the olive oil 
or in the fish. There was just a slight indication that the 
sardines prepared with tomato pur6e contained a trace of 
metal. This could be avoided by using varnished or lacquered 
metal when it is intended to pack the fish with an acid- 
containing substance such as is the pulp of the tomato. 

JAMAICA TRA. 

(The Colonial Planters, 154, Church-road, Hove, Sussex.) 

In our recent articles on Jamaica as a Health Resort we 
have alluded to the production of tea in that colony. We 
have since had the opportunity of submitting a sample to 
analysis, with the following results : moisture, 7 • 50 per cent.; 
mineral matter, 5 50 per cent. ; tannin, 8 22 percent.; and 
theine, 1 * 60 per cent. According to this analysis it is worthy 
of note that the tannin is decidedly less than that contained 
in either China or Indian tea, the average amount being 10 
per cent. The theine, however, occurs also in smaller quantity 
in Jamaica tea but this m-iy not be a disadvantage. The 
flavour of the tea is decidedly delicate, being free from the 
roughness of coarse teas ; it is, however, not so attractive 
to the palate as that of line oriental teas. 

PATENT COVERED COOKED HAM. 

(Walter Mitchell and Sons, Ayr.) 

We have received a cooked ham from which the bones 
have been removed, contained in a stout gelatin corton. 
The meat proved to be quite sound and it is said that this 
method of packing keeps it sound for months. The hams, 
we understand, have been supplied to the Royal Navy. We 
quite admit that this cover is an improvement on the tinning 
method provided that it protects the meat from undesirable 
changes. We found that the gelatin corton was impregnated 
with boric acid. The corton is known as the gelantiseptic 
cover. 

SOLOID BLACK MERCURIAL LOTION. 

(Bubroughs, Wellcome, and Co., Snow Hill Buildings, 
London, E.C.) 

This soloid is convenient for readily obtaining the black 
mercurial wash of the pharmacopoeia. One soloid powdered 
and shaken with one fluid ounce of water gives a lotion con¬ 
taining tbe same mercurial equivalent as the lotio hydrargyri 
nigra. By adding 24 minims of glycerine to the fluid ounoe 
the official preparation is more nearly represented, glycerine 
serving to prevent the black suboxide of mercury produced 
by the inter action of the lime and calomel from oxidising to 
yellow mercuric oxide. 


Jjtefo Indentions. 


MELVIN’S PORTABLE “SANATORIUM.” 

The illustration depicts a portable hut designed and 
patented by Mr. Melvin of Glasgow. The floor, sides, ends, 
and roof are made of a strong wooden framework, the floor 
beiog covered with match boarding. All the parts are 
hiDg'ed in the centre, so that they can be folded and thus 
rendered easy to transport. The sides, ends, and roof a^e 




32 The Lanoet,] 


NEW INVENTIONS.—LOOKING BACK. 


[Jan. 4, 1908. 


covered with a specially prepared waterproof canvas. The 
sides and ends are attached to the floor and to each 
other at the four comers by thumb-screws and sockets. 
The thnmb-screws can be unscrewed sufficiently far to 
release them from the sockets but cannot be entirely 
removed, thus obviating the danger of loss. The 
door and the two windows are hung on loose pin 
hinges and may be lifted off and hung, opened, and 
closed at will. The means for ventilation are good. The 
beds nsed in these huts are fixed somewhat after the 
manner of those in a ship's cabin and can be easily placed 



in position and taken down. The table, the hat and coat 
hooks, and other furniture are also designed so that they can 
be removed without difficulty. The sanatorium whioh we 
saw was 8 feet 6 inches in length and 6 feet 3 inches in 
width. When packed it occupied a space of 50 cubic feet 
and weighed three hundredweights. The advantages claimed 
for these huts over the ordinary huts or tents are that they 
are comfortable, they can be placed in position and taken down 
in a few minutes, and they are storm proof and well lighted 
and ventilated. The uses to which such buildings could be 
put are many and medical men will hardly require to have 
them pointed out. The London and export agents are 
Messrs. Stracban, Turner, and Oo, 37, Lime-street, London, 
Bf.C., from whom all particulars may be obtained. 


Xookino Back* 


FROM 

THE LANCET, SATURDAY, Jan. 2nd, 1830. 


I received some of my medical education at Guy's 
Hospital ; 1 and at the time I was a pupil there, Dr James 
Curry, knowing the important share the liver had in disease, 
and the great use of mercury, rendered me an essential 
service by much that be taught; though for the liver, I now 
know that we ought to substitute the whole order of hepatic, 
gastric, and intestinal organs ; yet, to so absurd a pitch 
would he carry his views of the importance of the liver, 
that he would have had one believe that, in all diseases, the 
liver was importantly affected, and that the chief attention 
ought to be paid to it. I once saw a case of urethral 
stricture relieved by the warm-bath ; and in which, he said, 
the relief was obtained through the warm-bitti relaxing the 
biliary ducts, and that the stricture in the urethra became 
relaxed, merely by sympathy with their relaxation. The 
practice now so strongly recommended by Broussais in 
France, of withdrawing blood from the abdomen in fever, 
was always strongly inculcated by him; to me, Bioussais’s 
practice offers nothing new; it is what, owing to the 
instructions of Dr. Curry, I have all my life adopted ; that 
is to say, I always looked out for abdominal tenderness, and 
remedied it by local bleeding. Dr. Curry's error was, in 
contending that the liver was so peculiarly affected in fever, 
that the tenderness all around the region of the liver, was 
to be attributed entirely to disease of that organ ; whereas, 
it is the stomach and intestines, at least as much as the liver, 
that suffer. On his absurdity in mercurialising for every 
disease, as he positively did, I need not dwell. A surgeon, 


i Excerpt from Clinical Lecture by Dr. Blllotson, delivered at 
SW Thomas's Hospital. Fever.” 


now retired from practice, Baw, better than his surgical 
brethren, the utility of blue pill, and the importance of 
attending to the stomach and bowels ; but he was not content 
with exhibiting it where it was improperly neglec'ed by 
other surgeons; he gave it indiscriminately in any case, 
medicsl or surgical, and would generally not take the trouble 
to investigate a case, or even to look at a local affection, but 
at once called out, " The stomach, the bowels, are in fault, 
and blue pill must be taken so that with him, I have no 
hesitation in saying, as Dr. Macculloch does, at p. 55. that 
this was "an abuse, convenient to indolence, by superseding 
the necessity of thought or investigation, and by reducing 
the whole practice of physic to an empiricism to which 1 
know not that its entire history can pro lace a parallel 
example ” “ If the united ignorance and presumption,” 

Dr. Macculloch goes on to say, at page 163, “of self em¬ 
pirics could ever find an excnse, they might, indeed, claim it 
in this case, when they see practitioners of high fame, if 
notoriety be fame, following similar universal systems of cure, 
applying salts, or the blue piil, to every disorder or symptom 
in the nosologv, and without inquiry; and thus, while saving 
themselves all the trouble of thinking, rendering physic 
an art, which may be practised by any one without previous 
study, or present ob-ervation.” So great has been this 
influence upon the pnblic, this infatuation, that in England, 
few persons are now contented, when requiring a plain 
laxative, with the mild vegetable aperients, which we have 
in abundance, nd which produce no constitutional effects, 
but merely open the bowels ; every one mu-t take a portion 
of blue pill, of a metal which does more than is required for 
habitual use ; which weakens the stomach and whole frame, 
and gives a susceptibility of cold. Zimmerman, in his work 
on experience, page 140, notices this tendency in our 
profession to patronUe particular organs, or diseases, 
or remedies. "I know,” says he, "several physicians 
who see only certain diseases : one of these, who 
is a celebrated practitioner, and who has an obstructed 
liver, fancies he discovers a similar complaint in all 
his patients, and it is one particular remedy he con¬ 
stantly prescribes, because he finds it useful to himself; 
another is in love with his theriaca, probably because it con¬ 
fines him to his bed, sometimes for three months ; without 
this same theriaca, if we are to believe him, he would long 
ago have been overcome by bis complaints ; bat with this, 
sajs he, I can master them. I know a third, who is confined 
three or four months every year with the gout, and yet he 
constantly denies that he has anything gouty about him, and 
contends upon all occasions that he never bad so mnch as 
the rheumatism. This physician, and all his patients about 
him, if we are to believe him, are subject to an affection 
of the nervous system, and be employs narcotics upon all 
occasions " The very same things are said in rhyme by our 
own poet Crabbe :— 

“ One to the gout contract* all human pain. 

He views It raging In the frantic brain ; 

Finds it. in fevers, all his effort* mar. 

And sees it lurking In the cold catarrh. 

Bilious by some, by others nervous seen, 

It age the fantastic demons of the spleen ; 

And every symptom of the strange disease. 

With every system of the sage agrees. ” 

Moliere, in bis Malade Tmaginaire, in the person of a 
sham physician, who patnmUei the lungs, ridicules this 
propensit y, and as each sy m ptom is mentioned by the u n happy 
patient, nods his head and says, " Le poumnn 1 justement 
le poumon 1 ” and when the patient has finisher), exclaims 
" Le poumon 1 le ponmon ! 1 ” Some, struck with the fact, 
that inflammation attends so many cases of so many 
diseases, consider every disease an inflammation, as though 
this explained the phenomena of tubercles, cysts, cancer, 
melanosis, dyspepsia, diabetes, and every thing else. 
The occurrence of inflammation in so maty aff ctions, is 
sometimes the disease itself; sometimes an exciting cause, 
sometimes a concomitant, sometimes a part only of the 
disease, sometimes absolutely an effect, and, in a large 
number, it is really absent. No one is more aware than 
myself, of the Importance of looking ont for inflammation in 
every case, and of treating it if found ; but this supposition 
of its universal existence, and of its universa lty as a cause 
of disease, is a mere assumption. My convictions from close, 

I may »av prinfui ob-ervation and reflection, ere the same as 
those of Dr. Andral, in his Tecent work on morbid anatomy ; 
a work which shows full information, and a solid and dis¬ 
passionate judgment, and is the production of a man who 
one day or other, I am sure, will be the first physician » 
France. 











The Lancet,] 


THE DIFFUSION OF MEDICAL KNOWLEDGE. 


fJAN. 4, 1908. 33 


THE LANCET. 


LONDON: SATURDAY , JANUARY 4, 190S. 


The Diffusion of Medical 
Knowledge. 

During 1908 The Lancet will enter upon the eighty-sixth 
year of its existence, 1 and while the beginning of every new 
year is naturally made a season for moralising we hope 
that we may claim indulgence for a few words of self- 
congratulation. We are not blind to the need for moralising 
or unaware that during our career we must have made 
errors, but at any rate we can claim that we have never 
faltered in our long endeavour to maintain the dignity of 
medicine and the rights of the medical practitioner. This 
was the object with which The Lancet was founded, and 
the purpose of the founder has been carried out steadily by 
his descendants, the eldest of whom death removed from the 
editorial chair during the year which has just ceased. We 
shall deeply miss his counsel and the lessons of his experi¬ 
ence, but we commence the new year with confidence, for we 
possess the reassuring knowledge that we shall have ex¬ 
tended to us by our professional brethren the same steady 
support that we have received without intermission from the 
inception of the jonrnal. We have come to perceive that 
the work of The Lancet is considered by the medical pro¬ 
fession to be in its nature cooperative, and year by year we 
are confirmed in this flattering view. We can only give to 
our readers the latest medical learning and the most 
practical professional information if we in our turn are 
helped by our readers. Our editorial efforts would have 
no practical result if we did not find among our 
public many who are anxious to communicate through us 
with their professional brethren, thus rendering our pages a 
central bureau for the collection and redistribution of know¬ 
ledge. The responsibilities which are thus placed upon us 
grow no lighter with experience in the attempt to meet 
them. On the contrary the progress of scientific medicine 
brings with it every day fresh problems ; something new 
occurs incessantly which may or may not be significant of 
an important development. Fortunately it does not depend 
upon ourselves alone to decide in all instances what move¬ 
ments make for truth and what are based upon error. Our 
duty is to hear all sides and by submitting them to the 
judgment of our readers to obtain the assistance of their 
criticism before making any pronouncement. We trust also 
that we shall not be found afraid to lead when initiative is 
required. 

It seems to us that the feature which has most pro¬ 
minently marked our columns during the past five years is 

1 The first number of The Lancet was issued on Sunday, Oct. 5th. 
1823. Consequently on Oct. 4th. 1907. it completed the eisht.v-fouri h 
year of its ■ xistence, and upon Saturday, Oct. 5'b, 1907, entered upon 
Its eighty-fifth. It is obvious that it ia not possible to make the age of 
The Lancet tally with the calendar year. For purposes of con¬ 
venience it Is found to be most suitable to give upon itie title page of 
each volume of The Lancet the year of existence entered upon in the 
course of that particular calendar year. 


the desire of medical men in all parts of the world to com¬ 
municate with their fellows. It is a truism, which may 
be found in our columns as well as in those of every 
scientific newspaper in every language, that science has 
no geographical limits any more than it has political 
bearings. It is, or should be, as absurd to talk of a French 
school of medicine or a British school of gynaecology as it 
would be to talk of a Home Rule system of dentistry. 
There is scientific medicine, scientific gynaecology, and 
scientific dentistry, and in each case the essential doctrines 
must be dictated by knov.'edge of the truth, by adapta¬ 
tion of accepted principles to circumstances, and by 
examination and sifting of scattered facts so as to form 
them, through collation and comparison, into the founda¬ 
tions of a theory. When, however, we pass from the theory 
to the practice of medicine it is obvious that the environ¬ 
ments of practice will have much to say in respect to the 
measures employed as well as to the conditions observed. 
The climate, the health and the manners of the people, 
the extent to which they are as a whole liberally educated 
or the reverse, the industries on which the population 
is employed, the ease or difficulty with which money is 
gained at those industries, and all the other circumstances 
which make up the sociology of a race will, of course, 
determine the classes of disease and of injury which are 
likely to be prevalent, as well as the facility or difficulty 
with which remedial actions may be taken. But the 
methods of diagnosis must be universal and those of treat¬ 
ment must be based upon identical and ascertained truths. 
When the world was small and the interchange of ideas 
between distant nations was restricted owing to the 
rigorous limitations of the means of transport, althongh 
the scientific practice of medicine was bound to have the 
game foundations all the world over, the conditions were 
such that in different places different procedures were 
pursued, for opportunities were wanting by which schools 
of thought could compare and test their theories and their 
results. But of recent years the association between 
the peoples of the earth has become vastly more inti¬ 
mate, and nothing so marks the progress of civilisation as 
this opening up of rapid channels of intercommuni¬ 
cation. Great Britain and her colonies have gained a 
knowledge of each other during the short period which 
the twentieth century has yet run which is surprisingly 
large and general, considering that in the Victorian era 
most of those at home knew nothing of the life of our 
dependencies, while oar colonial brethren knew but little 
more of us This is a situation which has recently undergone 
satisfactory change. The United States of America in 
circumstances which have not been entirely cheerful for them 
have also improved their acquaintance with the rest of the 
world; they have learned something of the burdens which 
must be taken up by great civilising powers. On the con¬ 
tinent the commercial industry of Germany has compelled 
all European powers to consider their fiscal position, with 
tbe result that there is a great increase on all sides of 
national knowledge of the trade-manners and trade- 
customs of foreign neighbours. Russia and Japan under¬ 
stand each other far better than they did before their 
terrific struggle and have learned lessons from each 
other which neither can ever forget. In a happier 



34 The Lancet,] 


HEROES OF THOUGHT. 


[Jan. 4,1908. 


way the personal influence of our King has been used to 
secure a better comprehension of English aims by the world 
at large. The outcome of all this must be the placing of 
our profession upon a securer basis, for as the different 
nations rise in the scale of civilisation and obtain a more 
just acquaintance with their neighbours they must come to 
perceive how universal are the laws of scientific medicine. 
They find themselves confronted with the same problems, 
sanitary or pathological, as their friends abroad, and they 
learn to appreciate the labours of medical men by applying 
to their own use the fruit of these labours. 

We have endeavoured, particularly during the last three or 
four years, to illustrate the truth of this movement by placing 
before our readers regular correspondence from all parts of 
the world. The mere sire of such a programme makes it in¬ 
evitable that the communications should be brief, but we are 
happy to know that they prove of considerable service to 
our readers, while it is interesting to observe how the same 
scientific and professional difficulties present themselves 
in every quarter. We hope and believe that in the newer 
countries scientific medicine will be able to develop faster 
than it has done in Europe in bygone days, for these 
countries will be unhampered by traditions having their 
origin in restricted knowledge and sociological mis¬ 
conception. In particular their authorities and important 
persons, both medical and lay, are able to work at 
once from a position to which we in this country 
are now only beginning to attain. They follow 
the reasons for scientific proceedings in a way which 
they could not possibly have done had it not been 
for the past labours of the medical profession, and 
the medical profession will be invited to call upon 
the assistance of laymen for the advancement of scientific 
medicine, a fact which is of great importance now 
that medicine touches the borders or passes over into the 
territory of so many other sciences. Great advances in 
medical knowledge are inevitably coming of the growing 
recognition of medicine by the world as a science com¬ 
pounded of sciences; while the disappearance from the 
popular mind of the conception of the practitioner as a sort 
of magician is being replaced in every direction by a 
more reasonable estimate of his services. We know 
—none better—that the practitioner has many draw¬ 
backs in his hard and anxious life, and we grieve to 
think that many of these could easily be set right in our 
own country by a more complete understanding of profes¬ 
sional aims and responsibilities than yet exists, but despite 
this the story of medicine is one of progress. The public 
sympathy with medicine increases, and it will continue to do 
so in proportion to the advancement of education and of 
that wide spread of sound medical doctrine to which we are 
proud to be able in some measure to contribute. 


Heroes of Thought. 

“ Hellenists, professors of Roman law, and enthusiasts of 
Romantic or Christian mediaevalism are not to be easily con¬ 
vinced that an intelligible stream of progress can be shown 
in the long, brokeD, stormy course of evolution from Solon 
and Thales to the nineteenth century of Cavour and 
Darwin. Rut a true philosophy of history can trace a real 


and consistent sequence.” Thus writes Mr. Frederic 

Harrison in an introduction to a volume of “ Essays and 
Addresses” by the late John Henry Bridges. 1 The first 
half of this book is devoted to essays in Positivist 
doctrine, of which, as is well known, Dr. Bridges 
was one of the most distinguished exponents in this 
country. One of these essays, entitled “The Philo¬ 

sophy of History,” might well serve as a text for 
the whole book, for in it an attempt is made to 

sustain one of the central tenets of the Positivist school— 
that of the principle of historical growth or of continuity 
in progress. 

In tracing the oonrse of Western civilisation during 
the 25 centuries since its dawn in the times of the 

great Greek thinkers, it is claimed that the state of the 
speculative faculties of mankind is the prime agent in social 
advance and progress, and further that the social change 
of each successive period resulted not from the praotical life 
of that period but from the previous stato of belief and 
thought, and that therefore the order of human progression 
depends mainly, or at any rate largely, upon the order of 
progression in the intellectual convictions of mankind. When 
we remember the importance assigned by Comte to mathe¬ 
matics as the basis of systematic thought, it is not surprising 
to find that Dr. Bridges maintained that the most original 
achievement of Greece was neither her poetry nor her 
metaphysical philosophy but her separation of mathematics, 
the humblest and yet the most fundamental of the abstract 
sciences, from the confused collection or inchoate maee of 
empirical knowledge which mankind bad previonsly accumu¬ 
lated. Dr. Bridges complained that history as commonly 
taught does not include the history of science and that even 
now the sociological importance of its great disooveries ie 
only just beginning to be recognised. In illustration of the law 
of continuity he shows bow tbe discoveries in geometry and 
mathematical astronomy made by tbe Greeks were adopted 
and extended by the Arab schools of Bagdad and Oordova, 
to be continued by the Western thinkers of the thirteenth 
century, men such as Grosseteste and Roger Bacon, ho 
bis opinion there was. no dark age, even in the apparent 
retrogression of mediteval Europe before the Renaissance, 
for he maintained that whereas in ancient Greece there wa» 
a great development of tbe intellectual aspects of human 
faculties and in ancient Rome great practical activity in 
political and warlike spheres, tbe third or spiritual part of 
man's threefold nature was but little advanced till these so- 
called dark ages. In these times learning began to extend 
from the favoured few to the many through the medium of 
the monastic teachers, while the great social revolution 
from servile to free labour began. Dr. Bridges illustrated 
his views in some commemorative addresses which form the 
second part of this book. These lectures were delivered on 
certain days in the “Positivist Calendar of Great Men.” 
Among these, he treats of Thales, Roger Bacon, and 
Harvey as heroes of thought; Dante, Calderon, 
Corneille, and Diderot as heroes of literature. 

The account given of the importance to mankind of the 

1 Essays and Addresses, by tbe late John Ilenry Bridges, M.B. r 
F.R.C.P.*. sometime Fellow of Oriel College, Oxford; late Medical 
Metropolitan Inspector to tbe Local Government Board. With an 
introduction by Frederic Harrison. London; Chapman and Hall, 
Limited. 1907. Pp. 307. Price 12s. 6d. net. 




The Lancet,] 


HEROES OF THOUGHT. 


[Jan. 4,1908. 35 


elementary mathematical abstractions of Thales and the 
ether Greek geometers is exceedingly interesting. Starting 
from the practical problems involved in land measurement 
they laid the foundations of physicB and astronomy and evolved 
certain fundamental laws—indeed, the tirst laws of nature 
to be grasped by man. It is hard for us now to conceive 
without oareful thought of the great advance made in the 
two apparently simple abstractions of the line and the angle, 
and yet they form the basis of all measurement and without 
them no calculation or accurate mensuration would be 
possible. The further conception of the triangle, the 
simplest possible figure, was the one in connexion with which 
Thales made his greatest discoveries, among whioh the law 
that the three angles of any triangle were equal together to 
two right angles is one of the most familiar. Another great 
law discovered by this master mind was that of the similarity 
of two figures of unequal sides and equal angles by means of 
which he taught the Egyptians how to measure the height 
of their pyramids. This was done by measuring the length 
of the shadow cast when the sun was halfway between the 
zenith and the horizon, since at that moment the shadow 
of a stick placed upright in the ground was found to be equal 
to the length of the stick itself. Without these great 
fundamental conceptions and the laws deduced therefrom 
there could have been no astronomy, no mechanics, no 
navigation, and no true conception of order which is in turn 
the basis to which science endeavours to reduce the complex 
problems met with in biological and sociological studies. 

It is a long step from Thales to Roger Bacon, from the 
ancient to the medimval, but Bacon stands out from the 
schoolmen as a great philosopher and a practical man of 
science, and Dr. Bridces’s long study and special knowledge 
of the great Franciscan friar are here summarised in a most 
illuminating essay. The influence upon his career of his 
early association with Grosseteste at Oxford, who probably 
directed his attention towards science, the importance of 
his introduction to the Arabian adaptations of Greek dis¬ 
coveries through the agency of Michael Scott, and the 
effect of his whole-hearted attachment to the Franciscan 
order are all clearly indicated. It is only in recent times 
that we have realised what we owe to Arabian philosophers 
and men of science who preserved what the Greeks had 
discovered in arithmetic, geometry, astronomy, natural 
history, and hnman anatomy. Moreover, the Arabian and 
Moorish schools in many instances made great advances, 
since their instruments of observation were more accurate 
than those of the Greeks. They laid the foundations of 
algebra and of optics. They adopted, if they did not dis¬ 
cover, the decimal system, and they promoted the study of 
trigonometry, while their advances in chemistry and in 
medical sciences were truly remarkable. Roger Bacon was 
one of the first to render this great store of Eastern know¬ 
ledge accessible to Western thinkers, his object being to 
show the West superior to the East and to advance learning 
through religious agencies with a view to the reform of 
education and the promotion of knowledge. His “Opus 
Majus ” is one of the most remarkable surveys of knowledge 
extant and shows him to be greatly in advance of 
his contemporaries; indeed, he has been desoribed as 
a man born some three centuries before his time. He 
devotee the earlier sections of his work to the four great 


obstacles to wisdom—namely, undue deference to authority, 
custom, popular prejudice, and unwillingness to confess 
ignorance. His instruments for advancing the studies of 
Western Europe were philology, mathematics, and experi¬ 
mental research, and to these the second, third, fourth, and 
fifth sections of the “ Opus Majus ” were devoted. To mathe¬ 
matics he attached the greatest possible importance, de¬ 
scribing it as the key and entrance-gate of science. His 
application of mathematics to geography led him to a careful 
study of geography and to the compilation of a treatise 
thereon. He pointed out the necessity for a reform of the 
Julian Calendar which was delayed for three centuries after 
his death before it was carried out. The seventh section of 
the “Opus Majus,” of whioh only part is preserved, dealt 
with practical reason and ethics and is the crowning of his 
work. This essay of Dr. Bridges is the most interesting 
short study that we have read on this great philosopher, and 
as Mr. Harrison writes in bis introduction, makes one 
wonder “if we are right in putting Francis Bacon on a 
pedestal higher than that occupied by Roger." 

The third of these commemorative addresses, entitled 
“Harvey and his Successors,” was delivered as the Harveian 
Oration before the Royal College of Physicians of London, in 
1892. Here again the importance of mathematics in rela¬ 
tion to science is emphasised. Harvey was born at the 
time when England gave birth to her greatest men in 
literature, philosophy, and science, to quote Dr. Bridges, 
“the greatest period of English history.” At Padua he 
studied under F abricius and may well have come under the 
influence of Galileo, who was then attracting students from 
all partB to Padua, and although there is no record of personal 
acquaintance between the two men there can be little 
doubt that the influence of Galileo's physical advances 
was felt by Harvey, who, as Dr. Bridges wrote, “came 
back from Padua with the sense that Nature was not merely 
to be observed but measured.” Harvey’s great work was the 
application of scientific methods to the study of living 
organisms, and by this means the complex aichemistic or 
humoral explanations of vital processes were at once dis¬ 
proved. Dr. Bridges traced in this address the influence of 
Harvey’s work upon his contemporaries and successors. 
The appreciation of his work by Descartes and the com¬ 
bined influence of his discoveries and the Cartesian philo¬ 
sophy in leading to the foundation of scientific medicine are 
discussed. The origin of the iatro-matbematical or iatro- 
physical and the chemiatric schools is traced and the subse¬ 
quent foundation of an animist school by Stahl at the end 
of the seventeenth century is outlined. It was not, however, 
nntil the eighteenth oentury that biology became recognised 
as a distinct science with special methods, but the great 
discoveries of Harvey were the direct outcome of the 
mathematical and physical discoveries made in his time. 
It has been said that science is measurement and Dr. 
Bridges’s interesting addresses afford a striking illustra¬ 
tion in support of the trite generalisation. The three 
great men whom he has studied were all heroes of thought 
who in face of obstacles applied accurate methods to the 
practical study of the problems which they investigated. It 
is highly instructive to follow the work of three such 
striking philosophers as the Greek geometer, the medimval 
physicist, and the first scientific biologist. We oan 



36 The Lancet,] 


THE COORDINATION OF MEDICAL STUDIES. 


[Jan. 4,1908. 


cordially commend this interesting collection of thoughtful 
essays to onr readers as a stimulating and suggestive study. 


The Coordination of Medical 
Studies. 

To consider the beginnings of medical study at the 
beginning of the year seems to us appropriate, and we 
therefore publish in this issue two interesting contributions 
on the study of anatomy and embryology contributed by 
well-known teachers in different schools, feeling sure that 
they will afford abundant food for thought to the man who 
is at all concerned about the future of medical education 
in this country. Dr. Arthur Keith in his address to the 
students of the London Hospital very clearly setB forth a 
convincing case against the fashion of entirely divorcing 
the study of anatomy from that of physiology with the 
result that the average student starts on his profes¬ 
sional career with his knowledge of the structure and 
the function of the human body stored away in two 
watertight compartments in his mind. It is a useful cor¬ 
rective to over sanguine ideas as to the complete efficiency 
of the present state of medical education to be told by 
Dr. Keith how recently we have fallen away from 
higher standards in our systematic teaching of anatomy. 
“Up to the end of the eighteenth century,” he says, 
“ there was a strong school of British anatomists who 
regarded dissecting as a means for obtaining not a 
description but an understanding of the human body ; ” and 
surely this was the ideal of the great anatomists of all past 
ages as witness Herophilus and Galen amongst the 
ancients, Eustachius, Fallopius, Steno, and Sylvius 
in succeeding centuries after the mediaeval revival of the 
neglected science, and, greatest of all, William Harvey 
and the two Hunters at whose handiwork of dissection 
we may still look with our own eyes. What would John 
Hunter have thought, what would he have said, could 
he have looked forward to see his methods of thinking and 
teaching entirely superseded by the brilliant categorical and 
purely descriptive anatomy which the schools of Paris even 
in Hunter's lifetime were setting up? 

The British student sought Paris a hundred years ago 
because the difficulty of obtaining subjects for dissection 
hampered his teachers at home and not because he had any 
fault to find with their teaching. But Dr. Keith is right in 
pointing out that the method of anatomical instruction thus 
started soon became established in England as a custom, and 
even the old concession made by authors to the cause of 
the solidarity of medicine in writing on “Anatomy, 
Descriptive and Surgical,” is lacking in many more modern 
treatises, excellent indeed after their sort, but composed 
of des ;riptive anatomy pure and simple. There is no doubt 
that this divorce of structure from function is an 
error. Save for the very rare student with an 
inherent genius for one or other of these studies the 
sole aim of teaching a medical student anatomy and phy¬ 
siology is that he may become a scientific physician or a 
rationil surgeon who has built his professional house on the 
solid rock of well-ascertained fact. What is required by 
medical students is instruction in theory and detail alike 
of the kind which will make the pathological processes 


which they are afterwards to study comprehensible 
to them. Teachers are wanted who can clothe the 
dry bones of their lectures on anatomy with the living 
tissues of physiology and morphology and render them yet 
more vital to the medical student by pressing into service 
illustrations from medicine and surgery, so that the warp 
of structure and the woof of funotion may be woven into 
a stout garment of knowledge to clothe the student’s mind 
in the place of the patchwoik cloak in which it must now too 
often go forth, shivering on a stormy journey. Instances 
arise of the need of teaching of this sort in the con¬ 
sideration of every system in the body, for the circulation, 
the respiration, the digestion, and the functions of the brain 
can be much better grasped by the simultaneous teaching 
of their anatomy and physiology. The physiological teacher 
is occasionally obliged to sketch the rough outline of 
the coarse anatomy of the subjects with which he deals, for 
often, as in dealing with the brain, he must do so 
to make himself understood at all, and he also either 
in propria persona or through an assistant in histology 
devotes much care to teaching the microscopical structure 
of the various tissues ; but it is to a much fuller extent that 
we would have the physiologist invoke his anatomy ; might 
not he, for instance, occasionally direct more attention to 
the ordinary functions of muscles illustrated from gToss 
anatomy instead of spending nearly all the time that be can 
give to them in the demonstration of their chemical and 
electrical niceties ? Still more often does the anatomical 
teacher appear to ns to miss the true reasons of the lessons 
which he is giving by avoiding the very mention of any¬ 
thing that savours of physiology, referring such subjects 
to the other department of the medical school. We 
would even suggest that examiners might rest content 
with a little less minute knowledge of ultimate divisions of 
small nerves and arteries and markings on bones when 
the time saved might be employed by students in gain¬ 
ing a good working idea of the human machine. How 
many men on first entering on clinical work can look at 
a patient and form a clear mental picture of his organs 
as they lie inside him and at the same time even faintly 
realise the ceaseless and multiple activities of their vital 
functions 1 The average student sitting for an examination in 
surgery knows the anatomy of hernia thoroughly, for he was 
brought up on it, but there are many more anatomical 
points the vital surgical importance of which might with 
equal advantage be impressed on the student of anatomy 
when he first learns it; whilst the physiological teacher 
could take many more illustrations than is his wont from 
the field of medicine. And in neither case need the student 
be taken into the wards; the pathological deviation from 
the normal could be explained by consideration of the 
normal. 

Professor Peter Thompson’s lecture on the Study of 
Embryology bears testimony to the truth of the contention 
that medical studies are not well coordinated despite the 
ceaseless care that has been exercised in arranging the 
numerous systems. Embryology is a study the importance 
of which has been appreciated Bince the days of William 
Harvey at least; a great deal is now known about 
it which might profitably be the common knowledge 
tf every medical student, and yet how often doee it 




ThbLanobt,] SUGAR.—PRIVATE PRACTIOE BY GOVERNMENT SERVANTS IN INDIA. [Jan. 4, 1908. 37 


fall between the two stools of anatom; and physio¬ 
logy, each granting it bat half-hearted support and 
relegating it to one or two scrambled lectures which are 
neither complete in themselves nor complementary to each 
other. The teaching of the development of the foetus in 
utero is indeed often largely handed on to a lecturer in 
midwifery who has only just enough hours at his disposal to 
summarise the bare facts of obstetrics and might reasonably 
suppose his bearers to come equipped with the physiology of 
foetal development and even of the normal processes of 
birth so far as they fall under the headings of anatomical 
and physiological functions. The present medical curriculum 
is allowed on all hands to require lightening. The average 
student has to learn a large quantity of things that will 
be of no use to him and has to spend an extravagant 
amount of time in acquiring the knowledge. One method 
at least of economising time and labour would be to teach 
anatomy and physiology for the compulsory courses far 
more directly in relation to the professional career. 


Jmtfftalnms. 

"Ne quid 
SUGAR. 

Sugar is often given a bad name from a physiological 
standpoint but in many instances it is questionable whether 
it is deserved. It seems inconceivable that the bountifulness 
with which the world is supplied with sugar should mean 
anything else than that it is designed for human food. 
Sugar is one of the most powerful foods which we possess as 
it is the cheapest, or, at any rate, one of the cheapest. 
In muscular labour no food appears to be able to 
give the same powers of endurance as sugar; and com¬ 
parative practical experiments have shown without the least 
doubt that the hard physical worker, the athlete, or the 
soldier on the march is much more equal to the physical 
strain placed upon him when he has had included in his diet 
a liberal allowance of sugar than when sugar is denied to 
him. Trophies, prizes, and cups have undoubtedly been won on 
a diet in which sugar was intentionally a notable constituent. 
It has even been said that sugar may decide a battle and 
that jam after all is something more than a mere sweetmeat 
to the soldier. The fact that sugar is a powerful “muscle 
food ” accounts probably for the disfavour into which it falls, 
for a comparatively small quantity amounts to an excess, and 
excess is always inimical to the easy working of the digestive 
processes. A strong solution of sugar is irritating to the 
tissues, will set up superficial inflammation, and may produce 
a form of eczema. It is well known that an excessive diet of 
sugar irritates the mucous membrane of the stomach and 
encourages the production of mucus and of a highly acid 
gastric juice. The ingestion of much sugar spoils the 
appetite. Children who have been tempted to over-indulge 
in “lollipops” between regular eating times do not want 
their ordinary meal. The schoolboy spoils his dinner by 
eating too many sweet things before that meal. An over- 
indulgence in sweet liqueurs, in sweet ices, and in 
“ crystallised ” fruits after dinner retards the digestion of 
the meal. Sugar satiates ; it is a concentrated food. Where 
sugar does harm, therefore, it is invariably due to excess. 
Taken in Bmall quantities and distributed over the daily 
food intakes sugar contributes most usefully in health to the 
supply of energy required by the body. In certain diseases, 
of course, the presence of sugar in the diet is plainly 


undesirable. Generally speaking, however, there is a pre¬ 
judice against sugar which is not justified by physiological 
reasoning—at all events, when it is eaten in moderation ; 
and it is a curious fact that the man who practically abstains 
from sugar, or reduces his diet to one almost free from carbo¬ 
hydrates in favour of protein foods such as meat, often shows 
feeble muscular energy and an indifferent capacity for 
physical endurance. _ 


PRIVATE PRACTICE BY GOVERNMENT SERVANTS 
IN INDIA. 

The question of remuneration for private work performed 
by Indian medical officers in their spare time has again risen 
to the surface, the motive power that caused the resurrection 
being, as usual, jealousy. In a long and bitter letter to the 
Pioneer, signed “Pro Bono Publico,” the writer either begs 
the question or else relies upon assertion. 11 1 know of many 
cases," he says, but instances none, “in which Indian chiefs 
have appealed to their political agents against the fees which 
the agency surgeons were charging, and everyone with any 
knowledge of the eutycct must be aware how the present 
legislation restricting fees has been brought about chiefly 
through the enormous fees which certain members of 
the I.M.S. charged to Indian chiefs.” The italics are 
ours. When an anonymous writer makes unsupported 
statements they have no importance. We need not 
accordingly occupy more space with this portion of 
the attack. Proceeding with his diatribe, “ Pro Bono 
Publico ” asserts that “ the ordinary Indian doctor has no 
more knowledge, except of special tropical diseases, than the 
usual English country practitioner who charges 7». 6 d. or 
10s. per visit, and in respect of his knowledge of women's 
diseases he is generally partly inferior, yet he demands the 
fees of a first-class London specialist (who only charges a 
guinea per visit after the first visit) in addition to drawing 
his Government salary. Safe in the knowledge that he hag 
his Government pay and that he is entirely free from com¬ 
petition, the Indian civil Burgeon has no incentive to keep up 
his professional knowledge, and the medical fossils which 
could be dug out of many of the smaller stations in India 
would fairly startle their brethren at home.” The only use 
served by vituperation of this calibre consists in the exposure 
of the writer’s animus. That the members of the Indian 
Medical Service are second to none either in professional 
knowledge or in general intelligence is shown by the marks 
and places which they obtain in competitive examinations. 
There is not a session of the London School of Tropical Medi¬ 
cine where the class fails to include several Indian medical 
officers, ranking from colonel to lieutenant, the time thus 
devoted being deducted from private leave. The animus 
alluded to above assumes a very unpleasant form in the 
remarks which "Pro Bono Pablico ” sees fit to make regard¬ 
ing the losses recently sustained by the Indian Medical 
Service through devotion to duty. “ How many men in all 
other branches of the Indian services die at their posts,” 
he exclaims, “and lose their lives in the execution of 
their duty! Why should such deaths constitute a 
special claim in the case of the I.M.S. and not in 
the case of the other services?” To what is “Pro 
Bono Pablico” referring? He further asserts that the 
right to accept private practice which is enjoyed by officers 
of the Indian Medical Service is due to long-established 
custom, and graciously adds that it may be admitted as 
“a concession which is granted to no other profession.” 
It may have surprised him to learn that the right in 
question was granted by Act of Parliament which has never 
been repealed (13 George III., c. 63). In its editorial 
columns the Pioneer fully exposes the inexactitudes with 
which the letter of its correspondent abounds. “In the 
case of the law,” says the Pioneer, “which approximates 




38 Thu Lancet,] 


THE FINANCIAL CRISIS IN RELATION TO SUICIDE. 


[Jan. 4, 1908. 


most nearly to medicine, the principle of private practice is 
fully admitted. If the State had to maintain a corps of 
whole time Government advocates and public prosecutors all 
over the country it would either have to pay a prohibitive 
sum or put up with very indifferent agents.” Precisely so : 
the two cases are accurately on all fours; and moreover no 
Government, save for income-tax purposes, would venture to 
order its legal servants to furnish the details of their private 
incomes. Iu the ca.-e of medical cilicers the Government 
does make this inquisitorial demand, and, strange to say, 
Indian Engineering , usually so enlightened, contends that 
it is justified in so doing. Engineers in India are not allowed 
to engage in private practice but that is no reason 
for denying a reasonable privilege to another body of 
men. Our contemporary says that when it comes to a 
civil surgeon getting a lakh or two for any service the 
Government is wise to interfere. Perhaps so, but do such 
cases occur in real life ? We do not believe it. It is but 
another instance of question-begging. We can assure the 
writer of the article entitled “ Professional Fees ” in Indian 
Engineering, dated Nov. 13th, that the virtual extortion of 
fabulous sums from rajahs (or from anybody else for that 
matter) by the Indian Medical Service does not occur, and 
the moral odium cast on an honourable service by such loose 
accusations is bitterly resented. 


THE FINANCIAL CRISIS IN RELATION TO 
SUICIDE, 

THERE Is little doubt that the present financial stress in 
America has been coincident with a large number of suicides 
and it is of more than passing interest to consider whether 
the one is a natural accompaniment of the other and whether 
self-destruction must be considered as a common corollary to 
severe monetary losses. It must be borne in mind that the 
successful man of business is commonly a highly neurotic 
subject—in truth, he frequently owes his very success to his 
keen sensibility and his deftness in foreseeing the trend 
of coming events. Now men are prone to forget, or 
maybe they are ignorant of the fact, that the type of nervous 
system whioh endows them with so many advantages is a 
highly unstable mechanism and renders them more liable 
to sudden fatigue or mental aberration than the less sensitive 
system of their more lethargic neighbour. Sudden stresses are 
more likely to lead to impulsive acts than are adverse circum¬ 
stances of gradual onset. Periods of monetary stringency 
caused by trade depression have not uncommonly been noted 
as cycles during which the incidence of insanity has fallen. 
Times of difficulty undoubtedly weigh heavily on some indi¬ 
viduals but given a few weeks the man soon gets used to his 
altered circumstances and hardships alone seldom produce 
mental disorder. But this is not so with sudden calamity. 
The millionaire of yesterday who is faced with ruin 
to-day has received a severe mental shock, and a profound 
emotional disturbance such as this paralyses judgment. Now 
uncontrolled emotion is a common precursor of rash acts. 
The once prosperous man who is suddenly confronted with 
bankruptcy is liable to lose the very attribute by which he 
attained bis success ; judgment is replaced by impulse and 
he not uncommonly plunges deeper and deeper into the 
morass and his affairs become increasingly involved ; nights 
are spent in vain attempts to disentangle himself from the 
impending disaster and he has no proper time for meals or 
sleep; he soon becomes physically weakened and tills ac¬ 
centuates his mental distraction, symptoms of fatigue appear, 
and the mind becomes confused and in consequence irrational 
acts may be performed. It must further be borne in mind 
that suicidal acts are more common in the earlier periods 
of a mental illness than during the later phases, and this fact 
alone accounts for an appreciable number of deaths of 
persons who succeed in destroying themselves before their 


disorder is recognised. So far we have only referred to the 
class of financier who is not necessarily a speculator but 
frequently a man whose business is sound and legitimate, 
notwithstanding the fact that he is dealing in large sums of 
money. But there is another type of person whom we may 
designate as a common gambler, for his vocation is 
speculating with money that he does not possess, and his 
success or ruin is more dependent upon the caprice of 
fortune. Now gambling appeals very forcibly to a certain 
degenerate class or ne'er-do-wells. The life of such a person 
is a lottery ; he plays to win but if he loses he has already 
thought out the remedy and suicide to him will appear to- 
be little more than a move in the game. We do Dot 
believe that there are many such men, but a certain 
number do exist and their self-destruction goes to 
swell the total number of tragic deaths which are 
inseparable from every great financial crisis. Suicide may 
be the termination of a life spent in gambling or it may 
follow the downfall of the man who, either from pride or 
lack of moral courage, is unable to face comparative poverty 
or to see his family, who were once surrounded with luxury, 
driven to earn their living. In this way a sudden financial 
collapse must be held responsible for the wave of suicide 
which so commonly follows in its train, but the majority of 
deaths by self-destruction are brought about by far more 
complicated stresses which undermine both the physical and 
the mental health of the individual, and the culminating act, 
is only done when the mind of the distracted person becomes 
so confused that impulse replaces judgment and voluntary 
attention. 


THE NEW BUTTER AND MARGARINE AC T. 

By this Act, which came into force on Jan. 1st, a statutory 
maximum limit of 16 per cent, of water is imposed in the oase 
of all butters, with the exception of “ milk-blended butter,” 
which is to be allowed to have as much as 24 per cent. Be¬ 
long as it is sold by a name which is approved by the- 
Board of Agriculture and one which is not “ suggestive of 
butter or anything connected with the dairy interest. ” The 
names under which margarine is sold are to be subject to the 
same restrictions. It is, perhaps, open to question whether 
the new statutory limits for moisture in butter and margarine 
will very much benefit the consumer ; a large proportion of 
both articles has certainly contained considerably less than 
16 per cent, in the past. The principal advantage of the 
Act, however, is the substitution of a system of control! 
at the port of importation (through the Customs autho¬ 
rities and the Government laboratory) and in this 
country at the place of manufacture for the present 
methods which are based almost wholly on analysis 
of purchased samples. These methods have constantly 
broken down in cases where small quantities of foreign oils 
and fats have been “blended” or worked in with natural 
butter with considerable profit to the blender. Places where 
butter is blended “by way of trade” will now have to be 
registered and no foreign fats are to be kept on such 
premises. Wholesale “blending” of butter and margarine 
making are not to be carried out on the same premises, 
although exceptions may be made for existing factories. 
Another considerable advantage of the Act is that it empowers 
the Local Government Board to schedule and to regulate 
the use of preservatives in butter, milk-blended butter, and 
margarine, and it may be hoped that this will speedily be 
done. A circular has now been issued by the Board of 
Agriculture as to the action which looal authorities are 
recommended to take under the new Act. Apparently 
the principal duty required of them is to see that 
butter-blending, milk-blending, and margarine-making 
premises are all duly registered and to report to the 
Board of Agriculture cases where in course of ordinary 



The Lancet,] 


PNEUMOCOCCIC INFECTION OF SEROUS MEMBRANES. 


[Jan. 4, 1908. 39- 


sampling it is fonnd that the permitted limits of moisture 
have been exceeded. It maybe gathered from the circular 
that routine inspection of the registered factories will be 
made by officers of the Board of Agriculture. The circular 
points out, however, that under Section 2 of the new Act 
local authorities have powers to authorise any officer who is 
authorised to procure samples under the Sale of Food and 
Drugs Acts to enter any registered butter factory for the 
purpose of inspection of processes and taking samples. These 
powers may be found useful by medical officers of health in 
cases where there is reason to question the wboleBomeness of 
the methods of manufacture carried on in the premises 
registered with their authorities ; and it would probably be 
advantageous to all medical officers of health in the districts 
covered to arrange to be supplied with information as to the 
registered premises and with the necessary authorisation to 
inspect any of them. 

PNEUMOCOCCIC INFECTION OF SEROUS 
MEMBRANES. 

IN the British Journal of Children's Diseases for November, 
1907, Mr. H. S. Clogg has reported the following case of pnen. 
mococcic infection of serous membranes which presents 
several points of interest. A girl, aged four and a half years, 
was admitted into hospital on Sept. 2nd, 1907. She became ill 
on July 28tb with doable pneumonia. The crisis occurred on 
the fifth day but though the temperature remained normal, 
or nearly so, improvement was not satisfactory. The dulness 
at the bases of the lungs persisted and moist sounds 
were heard all over the chest, except at the right 
apex where the breathing was markedly blowing. 
Towards the end of the second week the abdomen was 
somewhat swollen. The ohild lost flesh, the pulmonary 
signs did not clear up, the breathing became gradually 
more embarrassed, and the abdomen continued to swell, but 
the temperature remained practically normal. On admission 
she was thin and pale, there were considerable dyspnoea and 
cyanosis of the lips, the temperature was 100 • 2° F., and the 
pulse was 140. The apex beat of the heart could be neither 
seen nor felt. The heart sounds were best heard over the 
left edge of the sternum, about the level of the fourth costal 
cartilage. The breath sounds were distinct anteriorly as low 
as the third rib; below this they were faint and there wa 8 
dnlness to percussion. On the left side was marked 
dnlness to percussion and the breath sounds were very 
faint. Posteriorly as high as the mid-scapular region 
there was dulness over both lungs, vocal fremitus was 
absent, and the breath sonnds were faint. The abdomen 
was much distended with fluid. Both sides of the chest 
were explored. The result on the right side was negative ; 
from the left chest pus was withdrawn. Two hours later 
under chloroform a needle was again inserted in the left 
seventh intercostal space and a fen drops of pus were with¬ 
drawn ; a rib was resected and the parietal pleura was 
incised. The latter was much thickened. The surface 
of the lung beneath showed a small area of lymph. By 
inserting a finger into the pleural cavity and gently sweeping 
it in all directions pus was found. Evidently when the chest 
was explored a small abscess had been entered and evacuated. 
The exposed lung appeared to be pneumonic. A small gauze 
drain was inserted and the greater part of the wound was 
sewn up. The child stood the operation badly ; she became 
collapsed, the cyanosis increased, and the pulse was 
hardly peroeptible. Under the belief that the dyspnoei 
was partly due to the pressure of the abdominal fluid 
on the lungs, paracentesis abdominis was performed 
about 24 hours after the operation and 13 ounces of 
pus were withdrawn. The respiration improved and 
a few hours later the abdomen was opened in the middle 
line below the umbilicus and three or four pints of very 


thick, yellowish green pns were removed. Further incisions 
were made in each loin and drainage-tabes were inserted in 
each wound. Drainage of the abdomen was satisfactory 
but the cyanosis persisted and the dyspnrea was un¬ 
diminished. The temperature did not range above 99'6°. 
Two days later death occurred suddenly. At the necropsy 
the brain and meninges were found to be normal. The peri¬ 
cardium was distended with 16 ounces of thick greenish 
pus. Both the parietal and visceral layers were thickened 
and covered with thick layers of lymph. There was 
generalised double pleurisy with numerous recent adhesions. 
In the left pleural cavity at the level of the ninth rib 
were about two drachms of pus inclosed by recent 
adhesions. On tbe right side, about the level of the seventh 
rib, in the posterior scapular line was a similar col¬ 
lection. The upper lobe of the right lung showed some 
redema, the middle and lower lobes considerable cedema. 
The upper lobe of the left lung showed some oedema ; the 
lower lobe was very congested. The intestines were covered 
by a layer of lymph and bound together by recent adhesions 
which here and there formed pockets inclosing pns. The 
intestines showed inflammatory changes. The pelvic peri¬ 
toneum was severely affected but the pelvic organs were 
normal. Cultures from the pleurae, pericardium, and peri¬ 
toneum showed the pneumococcus in pure culture. The case 
seemed to have been an example of primary pneumonia with 
secondary infection of the pleurae, pericardium, and peri¬ 
toneum. There was no evidence that the abdomen had been 
infected by extension from the pleura or from the ailmentary 
canal. The pericarditis was entirely overlooked. On admis¬ 
sion the dyspnoea was thonght to be due to an empyema, a» 
pns had been found in the chest, but when exploration showed 
only a few drops of pus the dy6pDoca was thought to be due 
to the pulmonary disease and possibly to be increased by the 
pressure of the abdominal fluid. 


DELIRIUM TREMENS AND THE SUDDEN 
DEPRIVATION OF ALCOHOLIC DRINK. 

In tbe medical section of the recently published volume 
of Prison Statistics (1906) for England and Wales some 
pertinent comments are made as to the alleged onset of an 
attack of delirium tremens as the result of a heavy drinker 
being suddenly and completely deprived of alcoholic drink. 
212,000 persons were incarcerated faring last year in local 
prisons and of these 132 died ; three of this number had 
“ delirium tremens ” certified as a cause of, or as a condition 
at, death. 63,000 persons, exactly one-third of whom were 
females, were sent to prison for drunkenness; very many 
more prisoners were of course notorious drinkers, although 
they had committed other definite offences. 246 cases o* 
delirium tremens were recorded, exactly one-quarter of this 
number being females ; of these, four men and one woman 
were certified as insane and sent to asylums, 159 men and 
59 women had recovered at the expiration of their sentences, 
and 16 men and six women were discharged at the end of 
their term. Another interesting fact is that epileptiform 
convulsions are stated rarely to be seen among alcoholic 
prisoners. There appears therefore to be little support for 
the old theory and practice of giving a man verging on 
delirium tremens “a hair of the dog that bit him.” 


THE PHYSIOLOGICAL ACTION OF COLLINSONIA 
CANADENSIS. 

In the Repertoire de 1‘harmaeie M Abal has dealt with the 
physiological action of collinsonia Canadensis. This plant 
contains a glucoside of the saponin type and a resin. The 
alcoholic extract of the root when given to animals in small 
doses produces hyper-excitability. In large doses this is 
followed by depression, leading to paralysis of central origin, 
with circulatory disturbances and irritation of the glandular 



40 The Lancet,] 


DEATH OF SIR JAMES HECTOR.—NICKEL POISONING. 


[Jan. 4, 1906. 


system. The glacoeide in mild doses eats as a feeble cardiac 
tonic, and in larger doses the irritant effects preponderate, 
giving rise in cold-blooded animals to asystole alternating 
with an increase of systolic energy. In warm-blooded 
animals there is a rapid lowering of arterial pressnre with 
increased force of the heart beat. Though the resin acts less 
energetically it augments the action of the heart. It excites 
the secretions of the gastro-intestinal tract and provokes 
marked diuresis, probably owing to its action on the circula¬ 
tion as well as on the renal epithelium. The diuretic action 
is accompanied by an increased output of all the urinary 
constituents. The drug is chiefly used as a diuretic. 


DEATH OF SIR JAMES HECTOR. 

New Zealand has through the demise of Sir James Hector 
M.D. Edin., F.R S., K.C.M G., the director of the Geologica 
Survey Department, lost one of the most brilliant all-round 
men of science she has ever had. For nearly half a century he 
was the most conspicuous man of science in New Zealand, 
while his persistent journeyings into every nook and corner 
of the land brought him more or less personally into contact 
with every inhabitant of the colony who had any stake in its 
welfare and any share in its publio life and progress. His 
multifarious activities were pursued until between four and 
five years ago, at which date he resigned from the public 
service. At that time he proposed to make a tour with the 
view of exploring the scenes of his Canadian explorations of 
50 years ago—for he was employed on the Palliser Expedi¬ 
tion from 1857 to 1860—but the scheme was abandoned owirg 
to the death of his son and the brief remnant of his life was 
spent in retirement. It is not likely that in the future 
any man will be able to take so commanding a place in the 
scientific life of his country as Sir James Hector did in 
New Zealand, and we cannot do better than quote an appre¬ 
ciation of his many-sided genius from the Wellington Pott 
which has been forwarded to us by our special correspondent 
in the colony. The fact is well brought out in our con¬ 
temporary's sympathetic words that the all-round man of 
science must new be dying out—Sir James Hector was one 
of the last. “ Science was not specialised in the days of Sir 
James Hector's youth as at present and with a vast faculty 
of observation and assimilation, fine reasoning powers, and 
exceptional executive ability, his almost encyclopedic know¬ 
ledge was always at the disposal of his adopted country. 
It may seem paradoxic, but in Sir James Hector's case a list 
of scientific subjects on which he was not a recognised 
authority would be difficult to compile, they were so few. 
At the Philosophical Society he usually left the discussion of 
subjects in the higher mathematics, modern chemistry, or 
optics to others—in practically every other sphere he was on 
even terms with the leading men, and in many supreme. 
His acquaintance with animal and vegetable comparative 
physiology, and biology generally, was marvellous. A bone, 
a wing, a shell—an exceptional structure in any natural 
specimen under discussion—would be the text for 
an extempore discourse scintillating with wit ard 
wisdom, illuminating, fascinating as a fairy tale, and 
invariably supported by original observation. He was a 
thorough meteorologist. His geological attainments were 
world-famous. He knew the physical geography of New 
Zealand and its outlying islands, the contours of its ocean 
deeps, its seismic and thermal lines, ‘ almost as he knew his 
alphabet.’ On the native products of the colony and their 
practical uses he was the leading authority, and he was the 
author, among many other works, of a standard treatise on 
the phormium industry.” Sir James Hector, as might be 
anticipated from such a record, was also prominent in the 
public advancement of science in New Zealand; it was 
always his particular aim to bring home to the people that 
in scientific knowledge, properly organised, must lie social 


salvation. He was one of the founders of the Philosophical 
Institute, which has just issued its thirty-ninth annual 
volume, and he held a prominent position on its council up 
to about five years ago. The Colonial Museum was established 
and built under his care. He organised the New Zealand 
Exhibition of 1865, which was a great success even when 
compared with much later exhibitions having the same object. 
Naturally he was ready to work in any useful directions for 
the development of education, and he became prominent in 
the executive work of the New Zealand University from its 
start. Such is the brief record of a man of most varied 
attainments who served his adopted country so well in many 
ways. His position was always thoroughly recognised by 
his brethren in science. He was associated by friendship 
and correspondence with the leading scientific men of the 
age and honoured by learned societies all the world over. 
In private life his high character, his kindly nature, and his 
genial disposition endeared him to a large circle of friends 
and the gap that he has left will never be exactly filled. 
There is a movement on foot to establish a medal in con¬ 
nexion with the university in commemoration of the great 
work which Sir James Hector did as Chancellor. 


ROYAL COLLEGE OF SURGEONS OF ENGLAND: 

PRESENTATION TO MR. C. R. HEWITT. 

On Dec. 23rd, 1907, an interesting presentation took place 
at the Riyal College of Surgeons of England. Mr. C. R. 
Hewitt, who was recently appointed a librarian at the Royal 
Society of Medicine, being the recipient of a piece of plate 
suitably inscribed and a cheque for 55 guineas in recognition 
of his 22 years’ service in the library of the College. The 
gifts were subscribed for by some 75 friends as a token of 
esteem and good wishes for success in his new appoint¬ 
ment. Professor William Osier made the presenta¬ 
tion ou behalf of the subscribers and in the course of a 
few well-chosen words recalled the valuable help which 
he had received from Mr. Hewitt many years ago 
in the College library. Professor Osier further said how 
pleased he was to see Mrs. Hewitt present on the occasion, 
as the piece of plate—a tea-caddy—would certainly be more 
appreciated by her than by her husband, and he therefore 
felt that he ought to present that to her. Mr. Henry T. 
Butlin, besides thanking Mr. Hewitt personally for the help 
which he had received on many occasions in the library, 
also thanked him on behalf of the Council of the College 
for his valuable assistance and genial manner to the 
readers generally. Mr. Butlin said that the Council 
felt that they had lost an official whose place would he 
difficult to fill. Mr. Hewitt’s new appointment would, how¬ 
ever, give him wider scope in which to show biB ability as a 
library bibliographer. Mr. Hewitt returned thanks for the 
kind words spoken by Professor Osier and Mr. Butlin and 
recorded his appreciation of the sound advice and kind 
assistance that he had received whilst in the service of the 
College from the librarian, Mr. Victor G. Plarr. 


NICKEL POISONING. 

In the Journal of the American Medical Annexation of 
Nov. 9th, 1907, Dr. George Richter has recorded a case of » 
very rare condition—nickel poisoning. The patient was a 
man, aged 24 years, a polisher of aluminium, copper, and 
brass, but mostly of nickel. In the process considerable dust 
was evolved which was only partly removed by “sucking 
blowers.” He consulted Dr. Richter on account of great 
prostration, a sense of pressure on the stomach, and slight 
headache, which he attributed to influenza. His skin was 
pale and bis complexion was sallow. The tongue was 
slightly coated and on its left margin and the corresponding 
buccal surface was extensive leuooplakia. In the evening 



ThiLanobt,] DRUID POKTRY AND MEDICINE.—'TOTENTIZATION ” AGAINST SMALL POX. [Jan.4,1908. 41 


severs pain occurred in the loner abdomen which was not 
increased by pressure. Repeated doses of a third of a grain 
of morphine gave little relief. Magnesium sulphate pro¬ 
duced large evacuations and on the next day there was some 
improvement and the pain was located around the navel 
The urine contained neither albumin nor sugar but was of a 
peculiar light green colour. Fresh urine gave no reaction 
for nickel. 400 cubic centimetres were evaporated and 
incinerated. The ash was treated with hot concentrated 
nitric acid. After the removal of iron the filtrate gave 

with oxalic acid a faint greenish-white sediment, with 
caustic soda a slight greenish sediment, and with 
ammonium Bulphide a brown colour. Blood examination 
showed : haemoglobin 70 per cent., normal erythrocytes, u 
striking number of platelets in aggregation, and normal 
lymphocytes. Under symptomatic treatment and purgation 
recovery took place in ten days. The symptoms thus con¬ 
sisted of cachexia and anaemia followed by severe colic. 
Possibly nickel dust accumulated in the intestines and 
irritated them, and some was converted into a salt and 
absorbed into the blood where it produced the anaemia and 
blood platelets. Possibly also some of the other metallic 
dusts evolved in the patient's work exercised an adverse 
influence. He stated that many of his fellow workers 
frequently complained of ailments which they attributed to 
inhalation of aluminium dust. In the case related above it 
is noteworthy that although the dust was presumably inhaled 
there were no pulmonary symptoms. 


DRUID POETRY AND MEDICINE. 

AN ancient folk-song, “The Twelve Apostles,” still sung 
at Chri-tmas and on festive occasions by English rustics, has 
been found on examination to be a variant of the rhythmic 
chant in which the Droids, or medicine-men of the ancient 
Britons, recorded their wisdom. “ The Twelve Apostles ” in 
its Hampshire form is sometimes cited by its first line— 
“ What la your one 0 ? a question that has with its answer 
puzzled whole generations of people curious in such matters. 
In foreign variants of the song, whether Armorican, Slavonic, 
Sonthern German, or even Hebrew, the answer to the open¬ 
ing question is generally a statement of the Unity of the 
Godhead, but the English song differs from all its continental 
parallels in that it retains traces of pre-Christian mysticism, 
quite meaningless at first sight but partially explainable on 
reference to a Celtic version quoted by Aur61ien de Courson 
in hie “ Histoire des Peoples Bretons." “What is yonr one 
O f ”—the Ei glish query—receives the answer, from whioh 
rhyme and reason seem alike to have departed, “ When the 
one is left alone, No more he can be seen 0.” We turn 
to de Courson's version, which must not be confounded 
with the Armorican Church Latin with its “ Unus est 
Deus," and we find a Druid instructor telling his disciple 
that the One is Death. “There is no division for the number 
One, the unique necessity, Death, father of sorrow, nothing 
before, nothing after.” “ Two ” is explained as “ two oxen 
harnessed to an egg-shell. They drag it and they die. 
Behold the marvel.” Then come the “ three beginnings and 
the three endings, for man as for the oak, three celestial 
realms of Merlin, golden fruits, bright flowers, little children 
that laugh” Under these poetic symbols the Druids of the 
pre-Christian period doubtless veiled their teachings, astro¬ 
logical, physical, or medical. Some light is thrown on the 
nature of their medical apothegms by the Hebrew version 
above mentioned, where Nine is the nine months of a 
woman’s gestation (in the English song it is “the triple 
trine,” a mystic reference possibly to the same period). 
What the Druid medicine actually amounted to it is hard 
to say, though the modern Welsh bards still profess to know 
something about it through a kind of MasoDic tradition. The 
Druids’ wives, the Alraunes, are said to have had the care of 


warriors wounded in battle and of women in child-bed. The 
Druids themselves were probably dealers in Bimples and 
astrologers of a rough-and-ready kind, like “ the wise 
women” of our own primitive country-sides. Some Celtic 
herbalist remedies linger, as we know, in the Scottish and 
Irish Highlands and among the descendants of the Cymri on 
both Bides of the Channel. _ 

THE AUSTRALASIAN MEDICAL CONGRESS 
FOR 1908. 

We are asked to remind our readers that the eighth 
session of the Australasian Medical Congress will be 
held in Melbourne this year under the presidency of 
Professor H. B. Allen, the session commencing on Monday, 
Oct. 19th, and terminating on Saturday, Oct. 24th. The 
subscription is I guinea and will entitle every member te 
a copy of the Transactions of the Congress ; this should be 
sent to the general secretary of the Congress. The railway 
departments of Australasia will issue concession tickets to 
members for the return journey at special rates, par¬ 
ticulars of which will be supplied to intending mem¬ 
bers by the State secretaries. It is anticipated tbat 
reductions in fares, similar to those granted in previous 
years, will be made by the Interstate Steamship Companies. 
The council of the University of Melbourne has granted the 
use of the buildings and the Government of Victoria has 
undertaken the printing of the Transactions. Addresses will 
be given in plenary congress by the presidents of the 
sections of medicine, surgery, pathology and bacteriology, 
and public health, whilst special meetings of the congrees 
will be devoted to the consideration of (a) tbe relations of 
the medical profession to hospitals; and (A) syphilis. Any 
medical man resident in Great Britain desirous of attending 
the Congress or of becoming a member should write to Dr. 
H. C. Maudsley, at 8, Collins-street, Melbourne, who is 
aoting as general secretary._ 

“ POTENTIZATION " AGAINST SMALL-POX. 

A statement contained in the Bulletin of the Chicago 
School of Sanitary Instruction to the effect that attempts 
are made to introduce children into the public schools on tbe 
strength of their being furnished with certificates from 
medical practitioners stating that the children have been 
" potentized ” reads almost like ancient history. It carries 
us back, indeed, to the days of Lady Mary Wortley Montagu 
who first introduced the system of small-pox inocula¬ 
tion into this country from Constantinople. Apparently, 
however, “ potentization ” Is usually induced by adminis¬ 
tering “ variolinum ” internally, this substance being pre¬ 
pared by triturating “ matter ” from a ripe small pox vesicle 
with sugar of milk. Sometimes, however, tbe “ varioliuum ” 
is rubbed on the arm. It is stated that, unlike inoculation, 
“ potentization ” has no protective influence over small-pox 
and that children thus treated may be easily vaccinated. But 
although we are told that this “ potentization ” is not re¬ 
cognised by health authorities no mention is made as te 
whether or not this custom has led to the spread of small¬ 
pox or why, as with inoculation in this country, the operation 
is not forbidden by law. Perhaps later issues of tbe Chicago 
Bulletin will contain additional data relative to this “potenti¬ 
zation ’’ and as to its historical relationship to the practice 
adopted by the Chinese of inserting small-pox crusts into the 
nostrils of the patients in order apparently that they might 
contract tbe disease by inhalation. It is difficult to ascertain 
whether there were amongst the Chinese any conscientious 
objectors to this crusting process but in so far as inoculation 
or eDgralting is concerned it would appear from the writings 
of Madame Sevigi.6 in 1718 tbat in Adrianople “every 
year thousands undergo the operation, and the French 
Ambassador says pleasantly tbat they take the small-pox 




42 The Lancet,] 


THE MEDICAL DIRECTORY FOR 1908, 


[Jan. 4, 1908. 


here by way of diversion as they take the waters in other 
countries. There is no example of anyone who has died in 
it, and you may believe I am well satisfied of the safety of 
this experiment since I intend to try it on my dear little 
son.” As to the practice of inoculation in this country, 
there are probably persons still alive who underwent the 
operation, although none are likely to remember that the 
charge for the operation amoDgst medical practitioners was 
about half a guinea. But in those days there were no 
public vaccinators and hence no opportunities for boards of 
.guardians to accord them the minimum fees. 


THE MEDICAL DIRECTORY FOR 1908. 

Thb issue of this work for 1908 appeared with commend¬ 
able promptitude in the third week of December, 1907. 
Comparing the edition for the current year with that for the 
year just past we see that the total number of names for 
1903 is 39,703, as against 39,365 for last year, being an 
increase of 338. As regards the several regions into which 
the Directory is divided the number of names in the London 
list for 1908 is 6550, as against 6512 in 1907. The pro¬ 
vincial list for England for 1908 contains 17,211 names, 
as against 17,080 in 1907 ; Wales for 1908 has 1256 
names, as against 1232 for 1907; Scotland for 1908 
has 3829 names, as against 3815 for 1907. The 
Irish list for 1908 contains 2660 names, as against 2672 for 
the past year. The list of practitioners resident abroad 
contains 4927 names, as against 4822 in 1907. The Naval, 
Military, and Indian Medical Services for 1908 number 3259 
names, as against 3223 in 1907. It will tans be seen that 
there is a recorded increase in the cnmbers of the profession 
in every part of the kingdom except Ireland. The "Too 
Late” list for this year contains 11 names, two more than 
in 1907. The introductory chapter on the legal relations of 
medicine has become an acknowledged authority for refer¬ 
ence, and as is universally known in the medical profession 
Messrs. J. and A. Courchili are the publishers of this 
indispensable work of reference. 

THE DETECTION OF COCOANUT OIL IN 
BUTTER. 

One of the most subtle forms of adulteration in the 
present day is the admixture of cocoanut oil with butter fat, 
the product being sold as genuine batter. Indeed, it has 
been asserted that almost pure cocoanut oil has been palmed 
off as pure butter. Hitherto the analyst has been balllad in 
his attempts at devising a method for the certain detection 
cf cocoanut oil in butter, the sophistication being so 
cleverly accomplished that the mixture on examination is 
found to yield certain analytical factors which are consistent 
with those yielded by genuine butter itself. It is singularly 
opportune in view of the new measure for the control of the 
sale of butter which comes into force this year that a method 
has been projected which promises to place in the hands 
of the analyst a means of detecting this sophistication. In 
a note contributed to the Chemical A’emt of Dec. 20th, 
1907, Mr. T. R. Hodgson, B.A., A.I.O., of the analytical 
department of the University of Birmingham, shows that the 
oxygen equivalent of cocoanut oil is considerably less than 
that of pure butter fat. The oxygen equivalent is found by 
submitting the pure fats to the action of a standard 
solution of potassium permanganate for a time and 
afterwards determining the amount of permanganate left 
unreduced. One gramme of the filtered fat is weighed 
out into a flask and 25 cubic centimetres of a half normal 
alcoholio solution of caustic potash are added. The whole 
is heated under a reflux condenser for 30 minutes. After the 
saponification is complete the flask is detached from the con¬ 
denser and the solution is evaporated to dryness. Distilled 
water is added to the residue and the whole is evaporated 


once more to dryness. The process is repeated until the 
whole of the alcohol has been dissipated. The residue is next 
dissolved in water and made up to 1000 cubic centimetres. 
20 cubic centimetres are measured out and placed in a 
beaker and 50 cubic centimetres of a tenth normal solution 
of potassium permanganate are added and finally 50 cubic 
centimetres of a 50 per cent, solution of sulphuric acid. 
The beaker is then placed on the water bath (100° C.) for 
half an hour and the excess of permanganate is then deter¬ 
mined by means of a standard solution of ferrous ammonium 
sulphate. The number of cubic centimetres of permanganate 
solution used multiplied by 4 gives the “oxygen equivalent,” 
or the number of grammes of oxygen required to oxidise 100 
grammes of the oil or fat. Pure butter fat gives an oxygen 
equivalent of 167 • 2. With 10 per cent, of cocoanut oil 
present the equivalent is 160'8, with 20 per cent. 152, with 
30 per cent. 142 1 4, with 40 per cent. 136 1 0. with 50 per 
cent. 127 • 2, with 60 per oent. 118 • 4. with 70 per cent. 
110 • 4, with 80 per cent. 103 2, with 90 per cent. 95 ■ 2, 
until pure cocoanut oil itself gives 87 • 2 as the “oxygen 
equivalent.” It is to be hoped that this method will prove 
on continued trials to give trustworthy results and so to 
supply at last to the analyst a means of bringing to light 
a very subtle form of adulteration. 


PROPOSED LOCAL GOVERNMENT BOARD 
INQUIRY INTO THE CAUSE OF 
SCARLET FEVER. 

At a meeting of the Metropolitan Asylums Board on 
Saturday, Dec. 7th, it was unanimously decided, on the 
motion of Dr. W. R. Smith, 

That, in view of the continued prevalence of scarlet fever, notwith¬ 
standing the extensive isolation accommodation which has been pro¬ 
vided, the Local Government Board !»o asked to cause an inquiry to he 
instituted into the cause of this disease; and whether any, and if so 
what, further means can l>e adopted for ita prevention. 

Dr. Smith submitted a table of figures which showed that in 
1890 there were 15.330 cases of scarlet fever notified, ora 
ratio per 1000 of population of 3 7; in 1906 the cases 
notified numbered 20.329 or a ratio per 1000 of population 
of 4 3. In the acquisition of sites the Board had expended 
£234.104 and the cost of buildings and equipment amounted 
to £2,905.659. For that expenditure they had provided 
8166 beds and they were in no way better off from the poiDt 
of view of the spread of infectious disease by reason of that 
vast expenditure. _ 

“CRUELTY TO CHILDREN” PRISONERS. 

In The Lancet of August 20th, 1904, we commented 
favourably upon some lectures given by Miss Charlotte 
Smith Kosaie to women prisoners in Portsmouth jail. The 
lectures were upon the subjects of hygiene and the care of 
children. An article by Miss Rossle appears in the current 
number of The Semday at Home in which she gives an 
account of some lectures which she delivered to sundry 
women prisoners who were undergoing punishment for 
cruelty to children. This offence, disgraceful as it is 
to have to say so, iB by no means confined to the 
injutta » overoa, who has throughout the ages gained an 
evil reputation, bat in many cases mothers are as hideously 
cruel as it is possible to conceive. Miss Rossie claims 
to have influenced these prisoners for good and she makes 
one suggestion which seems to us worthy of notice by experts 
in prison sociology. It is that “ cruelty ” prisoners should 
not be put in a “star" class, for that means a privileged 
class, but that they should be placed in a separate class from 
the ordinary criminal, ‘‘as for the most part they are 
respectable married women ” and an attempt should be made 
to teach them home duties. This, we think, is a good 
suggestion, for the average modern woman is singnlarly 
ignorant of home duties and of the commonest laws of 





The Lancet,] 


PUBLIC HEALTH AND POOR LAW. 


[Jan. 4,1908. 43 


health. Hence nearly every woman’s paper contains a column 
generally headed “ Health and Beauty ” or some similar title, 
in which correspondents ask idiotic questions and in many 
instances get equally idiotic answers. IF Miss Rossis would 
add to her labours in the instruction of prisoners by instruct¬ 
ing those outside prisons as well, avoiding, of course, medical 
questions, she would be deserving of the gratitude of many. 


THE EXHUMATION OF THE BODY OF MR. 

T. C. DRUCE. 

The opening of the grave of the late Mr. T. C. Druce at 
Highgate has set at rest the doubt which apparently existed 
in some minds as to whether the coffin bearing his name and 
placed in his family vault in 1864 might contain nothing 
more than rolls of lead used for purposes of deception at 
a mock funeral. It is difficult to understand such doubts 
affecting anyone who heard or read the evidence given 
at the hearing in the Probate Division in December, 
1901, 1 unless he believed that the grave might have 
been tampered with since the incidents then deposed to 
by the medical witnesses took place. It is not too much 
to say that if no human remains had been found in the coffin 
opened on Dec. 30th last the only alternative to a theory 
of interference subsequent to the funeral would have been 
the supposition that not only Mr. Herbert Druce but Dr. 
Edmund Shaw and his partner, Mr. W. Blasson, as well as 
the housekeeper, Catherine Ann Bayley, committed deliberate 
perjury in the suit tried before Mr. Justice Gorell 
Barnes. Their evidence was perfectly clear that a 
gentleman well known to them as Thomas Charles Druce, 
who had been ill for some time and who had been 
operated upon by Sir William Fergusson, died and was by 
them placed in his coffin, which they, or some of them, 
followed to the grave. At the same trial a statement, since 
frequently repeated, to the effect that there was an irregularity 
in the certificate of the cause of death in that it did not bear 
the signature of any medical man, was fully explained, the 
simple explanation being that in 1864 the law did not require 
death certificates to be signed. The effect of the recent 
exhumation has been to corroborate the evidence of two 
medical practitioners of unimpeachable integrity, inde¬ 
pendent witnesses whose testimony was in no way shaken 
when it was originally given, and which consequently 
required nothing to confirm it, but at the same time 
the popular interest in the matter and the unwilling¬ 
ness of the public to be undeceived rendered the 
opening of the coffin, with the resulting ocular demonstra¬ 
tion that it contained a dead body, desirable. What this 
result may be upon the litigation which in various forms 
is still pending, and upon public opinion with regard to it, 
we do not, of course, discuss. 


TnE second annual dinner of the past and present students 
of the Royal London Ophthalmic Hospital will take place at 
the Trocau (ro Restaurant, Shaftesbury-avenue, W., on 
Wednesday, Jan. 29th, at 7.45 for 8 p.m., with Sir John 
Tweedy, consulting surgeon to the hospital, in the chair. 
Each student is entitled to introduce two guests and 
tickets (price 10». 6 d. each, exclusive of wine) may be had on 
application to either of the honorary secretaries, Mr. Arnold 
Lawson, 12, Harley-street, London, W., and Mr. J. Herbert 
Parsons, 27, Wimpole-street, London, W. 


The opening lecture of the Mount Vernon Hospital post¬ 
graduate course will be given by Sir Thomas Clifford All butt, 
F.R.8., consulting physician to the hospital, in the lecture 
room at the central out-patient department. 7, Fitzroy-sqnare, 
Loudon, W... on Thursday, Jan 9th, at 5 P.M. The subject 


of the lectnre, to which medical practitioners are invited, 
will be Angina Pectoris. _ 

A telegram from the Governor of the Mauritius received 
at the Colonial Office on Dec. 27th, 1907, states that for the 
week ending Dec. 26th there were one case of plague and 
one death from the disease._ 

Mr. C. A. Ballance has been elected an honorary fellow of 
the American Laryngological, Rhinological, and Otological 
Society. _ 

Mr. Malcolm A. Morris, F.R.C.S. Edin., has been appointed 
a Knight Commander of the Royal Victorian Order. 


Jnlrlic pealt|j aitb ^aor fafo. 


LOCAL GOVERNMENT BOARD. 

REPORTS OF INSPECTORS OF THE MEDICAL DEPARTMENT OF 
THE LOCAL GOVERNMENT BOARD. 


On the Sanitary Circumstances and Administration of the 
Urban District of Whitby , by Dr. R A. Farrar. 1 — Whitby, 
already described in 1538 as “a great fischar towne,” had 
become a prosperous seaport in the reign of Queen Elizabeth, 
when it did a good trade in the manufacture of alum. In 
1753 the town entered on a new era, as ships began to sail 
from Whitby to the Greenland seas for whale fishing. 
Following on the whale fishing came a period of wooden 
ship-building which gave place to an iron ship-building 
industry which has only ceased within the last few years 
owing to the insufficiency of the harbour. The decay 
in ship-building was for a time more than compen¬ 
sated by the development of the jet trade. In the 
early days of Queen Victoria’s reign, particularly after the 
death of the Prince Consort, jet ornaments had an extra¬ 
ordinary vogue and at one time as many as 1400 hands 
were employed in their manufacture. “Line” and herring 
fishing brought some prosperity to the town until a few years 
ago, but the silting of the harbour has rendered the passage 
of the harbour bar so unsafe that the port has practically 
been abandoned by all but a few local fishing cobles. At the 
present day Whitby’s only source of prosperity is its annual 
influx of summer visitors and excursionists. All these 
vicissitudes have left their mark, as Dr. Farrar shows, on the 
housing conditions of the town. As the whale fishing and 
ship-building industries increased the good and substantial 
houses on the East Cliff were surrounded or superseded by an 
abundance of jerry-built houses and narrow courts. When 
the jet industry flourished jet factories and warehouses were 
crowded into every corner which could be made available. 
The “slums” of Whitby, about which there has lately been 
much local agitation, are in consequence of these conditions 
slums in a very real sense. Not only is the crowding on 
area excessive, and greatly aggravated by the presence of 
derelict jet factories, but the courts and dwellings themselves 
are in many cases beyond repair and though occupied are 
quite unfit for human habitation. The entries into the 
courts are seldom more than three feet wide and the passages 
dividing the blocks of houses have generally a like width. 
The lower rooms are in consequence almost invariably dark. 
Many of the houses are damp owing to the walls being built 
against the hillside. The bedrooms are often mere cup¬ 
boards contrived in the living room, containing less than 
ZOO cubic feet air space and kept closed in the daytime. Dr. 
Farrar has no doubt that the health of the inhabitants of 
these slum areas in Whitby suffers from the conditions of 
living which result from the character of these dwellings. 
In examining the school children he found that the physical 
condition of those on the east side of the town was markedly 
inferior to that of children on the west, and, in particular, 
children from one of the collections of “slum” courts could 
by their physical deterioration be as a rule picked out at a 
glance from the other scholars. The report points out that 


1 London: Wyman and Sons, Fetter-lane; Edinburgh: Oliver and 
Boyd; Dublin: E. Ponsonby. No. 287. Price 4cl. 


1 The Lancet, Dec. 14tb, 1901. 





44 The Lancet,] 


PUBLIC HEALTH AND POOR LAW.—VITAL STATISTICS. 


[Jan. 4,1908. 


the first proceeding necessary is to treat derelict tenement 
blocks, jet factories, and warehouses as obstructive buildings 
under the Housing of the Working Classes Act, with a view 
to letting in light and air to the remaining blocks. This 
could be done, Dr Farrar notes, “without seriously impair¬ 
ing the effect of the huddle of red roofs which is one of the 
aesthetic charms of Old Whitby.” The space thus gained 
could be utilised as open space in a variety of useful ways, 
and the authorities concerned should then use their powers 
to secure that the remaining bi cks are put into habitable 
repair. Along with these measures it is desirable that a certain 
number of modern working-class dwellings should be erected. 
Action by the district council on these lines has been success¬ 
fully taken at Alnwick and other old towns presenting 
similar problems. The district council, in the hope of re¬ 
habilitating the ship building and filing industry of Whitby, 
is proposing to spend no less than £95 000 on harbour 
extensions and improvements and on the rebuilding of 
Whitbv bridge. If the anticipation of increased prosperity 
is just,ifind it will be essential to provide for increase in, and 
improvement of, the house accommodation which is avail¬ 
able for the working-class population. If the anticipation is 
unlikely to be justified (and in view of recent extensions of 
competing ports the proposal seems open to some doubt) the 
Whitby council would probably be serving its town better by 
abandoning grandiose schemes and by spending a much more 
moderate sara on housing improvements which at least may 
be relied upon to yield a return in the form of the better 
health and physical conditions of the population. 

On the Solitary Circumstances and Administration of the 
T/iingoe Rural District , by Dr. F. ->t George Mivart 3 — 
Many interesting matters are dealt with in this report which 
relates to a large rural district with some 14 000 inhabitants 
surrounding the borough of Bury St. Edmunds Among 
these are the insanitary conditions of dairy farms, many of 
which supply London dairy companies, and the unsatisfactory 
conditions of housing which prevail. The want of more 
cot ages is “ bitterly felt” in this district, and this is little 
to be wondered at in view of the character of many of those 
which now exist. Dr. Mivart reports that often houses were 
in a ruinous condition, the holes in the plaster walls being 
plugged with old sacks and rags within or blocked with a 
piece of plank and odds and ends of timber without. Such 
houses were also leaky in other places—e.g., round the door 
and window frames, and occupiers resort to all sorts of 
expedients to prevent the entrance of cold air in winter 
Riin-water pipes when present are commonly broken and 
while allowing the water to stream down the house walls 
deliver it also upon the ground in proximity to founda¬ 
tions, t* e surface about the house being only in a 
few instances furnished with paving. As to cottage 
bedrooms the report points out that sometimes the first- 
floor sptee comprises two or three rooms, of which the back 
one has no direct supply of light and air at all. The 
following account of a cottage in Sicklesmere is given aR an 
instance of the use to which first-floor space may be put 
without bringing about prosecution for overcrowding :— 
“Total first floor spac*, about 13 X 15 X 7 feet = about 
1365 cubic feet of space. A corner of this, sufficient to 
hold a bed. is screened off by a dwarf partition about 4 feet 
6 inches high. The entire first-floor space is shared by six 
persons, viz . a widow, aged 40; two sons, aged 16 and 14 ; two 
daughters. at?ed 13 and 6 ; and, as a logger, a brother-in law, 
aged about 50 No fireplace or back window. Ventilation 
only by front window 2 feet square and by the opening in 
the floor for the ladder staircase.” In the living rooms the 
fireplaces are often so poor that “cooking of any useful 
kind would be almost impossible even if inmates had 
sufficient knowledge for this.” Many cottage dwellings 
are going steadily to ruin There is special difficulty in 
getting repairs in “ tied ” cottages—ie., those rented by the 
farmers for their labourers. It is some iroes said that 
stringency of building by-lawg prevents building in rural 
areas, hut in this district no by-laws as to new buildings are 
in force. It should be said, however, that the di*.r,rict 
council m ide an attempt some years ago to utilise the 
Housing of the Working C asses Act. Eight good semi 
detached cottages in fonr blocks, with sufficient land, were 
erected at Ixworth in 1893 at a cost of £1700, obtained by 
loan reptyaole in 30 years. The innovation was suhje ted to 
much local criticism and ridicule under the name of the 
“Tbingoe Folly.” But Dr Mivart found the houses all 


* Ibid., No. 286. Price 4 d. 


occupied ; he gives the profit and loss account in connexion 
with them, and shows that when the loan is extinguished 
the council is likely to find itself well on the right side of the 
account. The experiment suggests that subject to some altera¬ 
tions, such as lengthening the borrowing period, it would 
be practicable to do much good by similar “follies” in 
other villages and hamlets. Too much stress must not 
be laid on the argument that properly built cottages of this 
kind must be let at a higher rent than the labourer can 
afford. Those who can afford the rent and go into these 
cottages in most cases vacate a better kind of cottage for the 
labourer to move into, and advantage can be taken of the 
process of “ moving up ” to compel demolition or satisfactory 
repair of the worst kinds of dwellings. 

On the Prevalence of Diphtheria at Ringmer , by Dr. R. J. 
Reece 8 —This report relates to a persistent prevalence of 
diphtheria in a little village in Su-sex which appears to 
have beeD sp-^ad through the agency of the village school 
and to ha\e continued notwithstanding frequent but short 
periods of school closure. The account given by Dr. Reece 
affords one more illustration of the danger of concluding that 
children are no longer capable of carrying infection because 
a single examination of a “ swab ” from the throat has given 
a negative result as regards the presence of the bacillus diph¬ 
theria;. It also affords a good instance of the way in which 
apparently healthy children may harbour the diphtheria 
bacillus in the throat or nose. At the end of September, 
when the disease had been prevalent in the school for 
some nine months, Mr. A. G. R Foulerton made a bacterial 
examination of swabs from 48 children in Standard I., with 
the result that the diphtheria bacillus was found to be 
present in the throat or nasal cavity of 14 of these children. 
Dr. Reece gives the text of a series of recommendations made 
to the local authority with a view to check the further 
spread of the disease: these include the isolation of 
“infected” and “suspected” cases until they are proved 
bacfceriologically to be free from infection, and the provision 
of temporary accommodation for the isolation of suspected 
cases. 


VITAL STATISTICS. 


HEALTH OF ENGLI8H TOWNS. 

In 76 of the largest English towns 8435 births and 5160 
deaths were registered during the week ending Dec 21st, 1907, 
The annual rate of mortality in these towns, which had been 
16 0 and 16 1 per 1000 in the two preceding weeks, 
further rose to 16 8 per 1000 in the week under notice. 
During the first 12 weeks of the quarter the death-rate 
averaged 15 7 per 1000, the rate during the same period 
being 14'9 in London. The lowest death-rates in the 
76 towns were 6 0 in Bournemouth, 8 0 in East Ham. 
8 7 in H-indsworth (Staffs), 9 3 in Hornsey, and 9 9 
in Great Yarmouth ; the highest rates were 24 1 in 
Sunderland, 24 ‘2 in Rotherham, 25 • 6 in Bootle, 25*7 in 
Tynemmi'h, 26 0 in Merthyr Tydfil, and 28 9 in Preston. 
The 5160 deaths in these towns exceeded by 206 the 
number in the preceding week, and included 398 which 
w^re referred to the principal epidemic disea^-es, against 
388 and 374 in the two preceding weeks; of these, 
124 resulted from measles, 94 from whooping-cough, 
62 from diphtheria, 50 from scarlet fever, 48 from diar¬ 
rhoea, and 20 from “fever” (principally enteric), but not 
any from small-pox. No deaths from any of these epidemic 
diseases were registered in Leicester, Blackburn, Brighton. 
Plymouth, Leyton, Stockport, or in nine other of the 76 
towns ; the annual rates from these diseases, however, ranged 
upwards to 3 1 in Aston Manor, 3’3 in Salford, 3'8 in 
Tynemouth, 4 8 in Rhondda, 5*1 in Barrow-in Furness, and 
6 2 in Bootle. The deaths from measles, which had been 111 
and 107 in the two preceding weeks, rose again to 124 in 
the week under notice, the highest rates being 1*7 in Gates¬ 
head. 1 8 in Salford, 1 • 9 in Leeds, 2 * 1 in Willesden 3 • 6 in 
Rhondda, 3 8 in Tynemouth, and 5*1 in Barrow-in-Furness. 
The fatal cases of whooping-cough, which had been 107 and 95 
in the two preceding weeks, declined to 94. and caused death- 
rates ranging upwards to l'l in Northampton, 12 in 
Rochdale, 13 in Sunderland, 1*4 in Ipswich and in Kings 
Norton, 2 • 5 in Aston Manor, and 4 ■ 7 in Bootle. The deaths 
from diphtheria, which had been 60 and 67 in the two pre¬ 
vious weeks, rose again to 62, the greatest proportional 

* Ibid., No. 290. Price 3d. 




Tub Lancet,] 


VITAL STATISTICS 


[Jan. 4,1908. 45 


mortality being recorded in H-mdley and in Bootle, where 
the rate was I ■ 6 per 1000. The 50 fatal cases of scarlet 
fever exceeded the numbers registered in any of the seven 
preceding weeks ; the highest death-rate from this disease 
was 1 0 per 1000 in Burnley. The deaths from diarrhoea, 
which had been 89, 50, and 47 in the three preceding weeks, 
were 48 in the week under notice, and caused death-rates 
ranging upwards to 1 • 1 in Walsall and 1 1 4 in Merthyr 
Tydfil. “ Fever ” was not excessively fatal in any of the 76 
towns. The number of scarlet fever cases under treatment in 
the Metropolitan Asylums Hospitals and the London Fever 
Hospital, which had been 5676, 5581, and 5352 at the end 
ot the three preceding weeks, had further decreased to 
6035 on Saturday, Dec. 21st.; 447 new cases were admitted 
daring the week, against 623, 554, and 500 in the three 
preceding weeks. The deaths in London referred to 
pneumonia and other diseases of the respiratory organs, 
which had been 388, 355, and 348 in the three preceding 
weeks, were 347 in the week under notice, and were 94 below 
the corrected average number in the corresponding periods of 
the five years 1902-06 The causes of 36, or 07 percent., 
of the deaths in the 76 towns were not certified either by a 
registered medical practitioner or by a coroner. All the 
causes of death were duly certified in Leeds, Bristol, West 
Ham, Bradford, Newcastle-on Tyne, and in 56 other towns ; 
six uncertified deaths were registered in London, six in 
Sheffield five in Birmingham, five in Liverpool, and two 
each iD Preston, Gateshead, and Khondda. 

During the week ending Dec. 28th, 5860 births and 4527 
deaths were registered in 76 of the largest English towns. 
The annual rate of mortality in these towns, which had been 
16 0, 16 1, and 16'8 per 1000 in the three preceding weeks, 
declined again last week to 14 7 per 1000. During the 13 
weeks of the quarter the death-rate averaged 15 5 per 1000, 
the rate in London during the same period being 14 9 The 
death-rates in the 76 towns last week ranged from 6 9 in 
King’s Norton, 7 0 in Hastings 7'4 in Southampton, and 
7'6 in Eist Ham to 22 8 in Rhondda, 23 6 in Wigan. 23 6 
in Ipswich, and 24'4 in South Shields. The 4627 deaths 
registered in the 76 towns last week were 633 fewer than the 
number in the previons week, and included 373 which were 
referred to the principal epidemic diseases, against 374 and 
398 in the two previous weeks; of these 373 deaths 105 
resulted from measles, 89 from whooping-cough, 71 from 
diphtheria, 44 from diarrhoea, 41 from scarlet fever, 
and 23 from “fever” (principally enteric), but Dot any 
from small-pox. No deaths from any of these epidemic 
diseases were registered last week in Hastings, Bournemouth, 
Reading, Handsworth (Staffs), Smethwick, Coventry, 
Wallasey, or West Hartlepool ; among the other towns the 
death rates from these diseases ranged upwards to 3 6 in 
Rhondda, 3 9 in Burton-on-Trent, 4 8 in Tynemouth, and 
9'3 in Ipswich. The fatal cases of measles, which had been 
107 and 124 in the two preceding weeks, declined again to 
105 last week, and caused death-rates ranging upwards to 
1 ■ 3 in Salford, 1'6 in Bootle, 1 • 7 in Barrow-in-Furness and 
in Leeds, 2'7 in Swansea, 2 9 in Burton-on-Trent, 3 8 in 
Tynemonth, and 7 2 in Ipswich The deaths from whooping- 
cough, which had been 107, 95, and 94 in the three preceding 
weeks, further fell to 89 in the week nDder notice, the highest 
death-rates from this disease beiDg 1 ■ 1 in Northampton, 1 3 
in Devunport, in Aston Manor, in Sunderland, and in New¬ 
castle on-Tyne, 1-4 in Ipswich, and 1 ■ 6 in Hanley and in 
Bootle. The fatal cases of diphtheria, which had beeD 57 and 
62 in the two previous weeks, further rose last week to 
71; this disease was proportionally most fatal in Norwich, 
where it caused a death-rate of 1 ■ 3 per 1000. The deaths 
from diarrhoea, which had been 47 and 48 in the two pre¬ 
ceding weeks, deolined again to 44 in the week under 
notice ; the mortality from this disease was not excessive in 
any of the large towns. The fatal cases of scarlet fever, 
which had been 38, 40, and 50 in the three preceding weeks, 
fell to 41 last week, and caused death-rates ranging upwards 
to 1 1 1 in Walsall, 2' 1 in Newport (Mon,), and 2 ‘3 in West 
Bromwich. The 23 deaths referred to “fever ” were three in 
excess of the number iD the previous week, the highest death- 
rate from this cause being 1 1 in Northampton. There were 
4999 scarlet fever patients under treatment in the Metro¬ 
politan Asylums Hospitals and the London Fever Hospital at 
the end of last week, against 5581. 5352, and 5035 at the end 
of the three preceding weeks ; 353 new cases were admitted 
during the week, against 554, 500, and 447 in the three pre¬ 
ceding weeks. The deaths in London referred to pneumonia 
and other diseases of the respiratory organs, which had been 


365, 348, and 347 in the three preceding weeks, further 
declined to 317 in the week under notice and were 145 below 
the corrected average number in the corresponding periods 
of the five preceding years, 1902-06. The causes of 56, or 
1 2 per cent., of the deaths registered in the 76 towns were 
not certified, either by a registered medical practitioner or 
by a coroner. AH the causes of death were duly certified in 
Bristol, West Ham, Bradford, Newcastle-on-Tyne, and in 42 
other towns; seven uncertified deaths were registered in 
Liverpool, six in Birmingham, five in WarriDgton, three in 
Manchester, and two in each of nine other towns. 


HBAI/TH OF SCOTCH TOWNS. 

The annual rate of mortality in eight of the principal 
Scotch towns, which had been 19 ■ 3, 20'6, and 20 0 per 1000 
in the three preceding weeks, increased to 20 ■ 8 per 1000 
during the week ending Dec. 21st, 1907, and was 4 0 per 
1000 above the mean rate during the same period in 
the 76 large English towns. The rates in the eight Scotch 
towns ranged from 13'7 in Aberdeen and 18 0 in Edin¬ 
burgh to 27'4 in Leith and 30 1 5 in Dundee. The 724 
deaths in these towns were 28 more than the number in 
the previous week, and included 126 which were referred 
to the principal epidemic diseases, against 111, 132, aDd 
127 in the three preceding weeks ; of these, 53 resulted 
from measles, 26 from whooing-cough, 14 from diarrhcea, 
11 from diphtheria, seven from cerebro-spinal menirgitis, 
three from scarlet fever, and two from enteric iever. 
These 1 -6 deaths were equal to an annual rate of 3 • 3 
per 1000, which was 2 0 per 1000 above the mean rate 
during the same period in the 76 large English towns. The 
fatal cases of measles, which had been 79 and 71 in the two 
previous weeks, fnr; her declined to 53 in the week under 
notice, and included 35 iD Glasgow, 10 in Dundee, and five 
in Greenock. The deaths from whooping cough, which had 
been 13 and 24 in the two preceding weeks, farther rose to 
26 of which 11 occurred in Glasgow, four in Edinbnrgh, 
four in Aberdeen, three in Perth, aDd two in Greenock. The 
fatal oases of diarrhcea, which bad been 36, 21, and 18 in the 
three preceding weeks, farther declined to 14 in the week 
under notice, and included eight in Glasgow and four in 
Edinbnrgh. The deaths from diphtheria, which had been 
nine and eight in the two previous weeks, increased again to 
11, of which three occurred in Glasgow, three in Paisley, 
and two in Leith. Of the seven deaths from cerebro-spinal 
meningitis three were registered in Glasgow, two in Pai-ley. 
and one each in Edinbnrgh and Leith. The deaths referred 
to diseases of the respiratory organs, including pneumonia, 
which had been 167 and 161 in the two preceding weeks, 
further declined to 157 in the week under notice, but were 
38 above the number in the corresponding week of last year. 
The canses of 25, or 3’5 per cent., of the deaths in the 
eight Scotch towns were not certified or not stated ; in 
the 76 English towns the proportion of uncertified deaths 
registered during the same week did not exceed 0'7 
per cent. 

Daring the week ending Saturday last, Dec. 28th, the 
annual rate of mortality io the eight Scotch towns was 18 ■ 2 
per 1000. against 20.' 6, 20 0, and 20 8 per 1000 in the three 
preceding weeks, and was 3‘5 per 1000 above the mean rate 
last week in the 76 large English towns. Among the Scotch 
towns the death-rates ranged from 12 • 5 in Leith and 13'2 
in Aberdeen to 24 2 in Greenock and 25 4 in Perth. The 
632 deaths registered in these towns last week were 92 fewer 
than the number in the preceding week, and included 109 
which were referred to the principal epidemic diseases, 
against 132. 127, and 126 in the three precedir g weeks ; of 
these 53 resulted from measles, 24 from whooping-cough, 14 
from diarrhoea, seven from diphtheria, five from scarlet 
fever, three from enteric fever, aDd three from cerebro¬ 
spinal meningitis, but not any from small-pox. These 
109 deaths were equal to an annual rate of 3 1 per 
1000, which was 1 ■ 9 per 1000 above the mean rate last 
week from the principal epidemic diseases in the 76 large 
English towns The fatal cases of measles, which had 
been 79, 71. and 53 in the three preceding we. ks, were again 
53 last week, and included 38 in Glasgow, eight in Dundee, 
lour in Greenock, and two in Aberdeen. The deaths from 
whooping-cough, which had been 13 24, and 26 in the three 
preceding weeks, declined again last week to 24. of which 
six occurred in Glasgow, six in Perth, three in Edinbnrgh, 
three in Dundee, three in Leith, and two in Greenock. The 
fatal cases of diarrhoea, which had been 21, 18, and 14 in the 



46 Tbs Lancet,] 


VITAL STATISTICS—THE SERVICES. 


[Jan. 4, 1906. 


three preceding weeks, were again 14 in the week under 
notice, and included five in Glasgow, three in Aberdeen, two 
in Edinburgh, two in Dundee, and two in Paisley. The 
deaths from diphtheria, which bad been eight and 11 in the 
two preceding weeks, declined last week to seven, of 
which four were registered in Glasgow. The fatal 
cases of scarlet fever, which had been three in each of 
the two previous weeks, rose last week to five, and included 
three in Glasgow, where the three deaths from cerebro¬ 
spinal meningitis also were registered. The deaths referred 
to diseases of the respiratory organs in these eight towns, 
which had been 167, 161, and 157 in the three preceding 
weeks, further fell to 127 in the week under notice and were 
40 below the nnmber in the corresponding period of last year. 
The causes of 26, or 4 1 per cent., of the deaths in these 
towns were not certified or not stated ; in the 76 English 
towns the proportion ot uncertified deaths was 1 2 per cent. 


HEALTH OF DUBLIN. 

The annual rate of mortality in Dublin, which had been 
26 ■ 7 and 22 ■ 3 per 1000 in the two preceding weeks, rose again 
to 25'0 per 1000 in the week ending Dec. 21st, 1907. During 
the first 12 weeks of the current quarter the death-rate 
averaged 21 7 per 1000, the rate during the same period 
being 14 ■ 9 in London and 14 • 4 in Edinburgh. The 187 
deaths of Dublin residents registered during the week under 
notioe were 20 in excess of the number in the previous 
week, and inoluded ten which were referred to the 
principal epidemic diseases, against four, nine, and six in 
the three preceding weeks ; of these, four resulted from 
diarrhoea, three from diphtheria, two from whooping-cough, 
and one from scarlet fever, but not any from small pox, from 
measles, or from “fever.” These ten deaths were equal 
to an annual rate of 1'3 per 1000, the death-rates 
during the same week from the principal epidemic 
diseases being 1 0 in London and H in Elinburgh 
The four fatal cases of diarrhoea exceeded the numbers in 
the three preceding weeks; the three deaths from diphtheria 
corresponded with the number in the previous week. The 
187 deaths from all causes in Dublin during the week 
under notice included 40 of children under one year 
of age and 53 of persons aged upwards of 60 years ; there 
numbers were respectively 13 and five in excess of the 
corresponding numbers in the previous week. Eight inquest 
cases and six deaths from violence were registered ; and 
78, or 41'7 per cent., of the deaths occurred in public 
institutions. The causes of four, or 2 ■ 1 per cent., of the 
deaths registered in Dublin during the week were not certified ; 
in London the proportion of uncertified deaths was 0'4 per 
cent,, while in Edinburgh the proportion was not less than 
9 • 2 per cent, of the total deaths. 

In the week ending Dec. 28th the annual rate of mortality 
in Dublin was 19 8 per 1000, against 22 • 3 and 25 • 0 per 
1000 in the two preceding weeks. Daring the past 13 
weeks the death rate has averaged 21 * 5 per 1000. the rates 
during the same period being 14 • 9 in London and 14 • 6 in 
Edinburgh. The 148 deaths of Dublin residents registered last 
week were 39 fewer than the nnmber in the three preceding 
week, and included five which were referred to the principal 
epidemic diseases, against nine, six, and ten in the three pre- 
cedingweeks ; of these, two resulted from whooping-cough, one 
from scarlet fever, one from diphtheria, and one from “ fever,” 
but not any from small-pox, measles, or diarrhoea. These five 
deaths ware equal to an annual rate of 0 ■ 7 per 10-0, the 
death-rates last week from the principal epidemic diseases 
being 0 9 in London and 1 ■ 1 in Edinburgh. The 148 
deaths from all causes in Dublin included 25 of children 
under one year of age and 38 oE persons aged upwards of 60 
years ; the deaths both of infants and of elderly persons 
showed a decline of 15 from the respective numbers recorded 
in the previous week. One inquest case and two deaths 
from vi lence were registered, and 54, or 36 5 per cent., of 
the death- occurred in public institutions The causes of 
three, or 2 0 per cent., of the deaths in Dublin la»t week 
were not certified ; in London only two of the 1326 deaths 
were uncertified, while in Edinburgh the proportion was 4 5 
per cent, of the total deaths. 


West London Post-Graduate College.—T he 

next ses-ion of th-s College will commence on Monday, 
Jan. 13th, and will last for 12 weeks. 


THE SERVICES. 


Royal Navy Medical Service. 

In accordance with the provisions of Her late Majesty’s 
Order in Conncil of April 1st, 1881, Fleet-Surgeon William 
Gordon Stott has been placed on the Retired List at his own 
request (dated Dec. 29th, 1907). Inspector General of 
Hospitals and Fleets John Cassilis Birkmyre Maclean has 
been placed on the Retired List at his own request (dated 
Dec. 31st, 1907). 

The following promotions have been made : Deputy In¬ 
spector-General of Hospitals and Fleets William Edward 
Breton to be Inspector-General of Hospitals and Fleets in 
His Majesty's Fleet, and Fleet-Surgeon Frederick John Lilly 
to be Deputy Inspector General of Hospitals and Fleets in 
His Majesty's Fleet (dated Dec. 31st, 1907). 

The tollowing appointments are notified : Fleet Surgeon : 
H. F. Iliewicz to the President, additional, for three months’ 
course at the London and West London Hospitals. Staff 
Surgeon : M. Cameron to the Indefatigable, additional, and 
on recommissioning. Surgeon: J. N. Robertson, to the 
President , additional, for three months at West London 
Hospital. 

Royal Army Medical Corps. 

Captain it. A. Bransbury lias been appointed to the London 
District. Captain A. C Outturn, from Agra, has been trans¬ 
ferred to the Burmah Division for dnty. 

Army Medical Reserve of Officers. 

Surgeon-Major Robert B. Graham to be Surgeon- 
Lieutenant Colonel (dated Dec. 17th, 1907). 

Royal Army Medical Corps (Volunteers). 

Eastern Command: Woolwich Companies: Lieutenant- 
Colonel and Honorary Colonel Francis Lawrence Stephenson, 
C.B., retired (lately Commanding), is appointed to the 
Honorary Colonelcy of the Companies, vioe Surgeon- 
Lieutenant-Colonel W. Collingridge, retired (late Militia 
Medical Staff Corps), who vacates that appointment (dated 
Oct. 16th, 1907). 

The Health of the United States Navy. 

The statistical report of the health of the Navy and 
Marine Corps for the year 1906 shows that the average 
strength of the active list during the year was 42 529, an 
increase of 1316 over the previous year, the average strength 
of 1905 being 41,313. The total number of admissions to 
hospital for all causes was 32,517, the ratio per 1000 of 
strength being 787 23. as compared with a ratio of 714 • 81 
for the previous year and 788 ’18 for the ten preceding years. 
There were 27,452 admissions for disease and 5065 for 
injuries, giving ratios of 658 47 and 121-49 respectively. 
The corresponding ratios for 1905 were 594-82 and 
106-67, from which it will be seen that the admissions 
for diseases and injuries were greater than in 1905. 
The number of persons invalided from the service during the 
year for disease and injury was 1117, giving a ratio of 26 26 
per 1000 of strength. The corresponding figures for the 
previous year were 1201 and 29'07 respectively. The ratio 
for 1906 is lower than that for last year and of the ten 
preceding years. The discharges for disability include 908 
for disease and 209 for injury, with ratios per 1000 of strength 
of 21 35 and 4 91 respectively. The corresponding figures 
for 1905 were 1023 and 4 • 38, with ratios per 1000 ot strength 
of 24 76 and 4 38 respectively. There were 241 deaths 
during the year, giving a ratio of 5 66, which is con¬ 
siderably less than that of the previous year (6 • 48) and 
less than the average of the ten preceding years (6 • 63). 
The diseases causing the largest number of admissions to the 
Bick list stand in the following order: gonorrheet, 2640; 
malarial diseases, 1854; tonsillitis, 1375; bronchial affec¬ 
tions, 1211 ; wounds, 1211; syphilis, 1147; epidemic 
catarrh, 1076; and rheumatio affections, 980. Venereal 
diseases caused a decided loss of efficiency, with 7273 
admissions, which is an increase of 1119 over the admissions 
for 1905 The admissions for these diseases show only 
approximately the prevalence of venereal infection in the 
navy, owing to the fact that a large number of cases of 
chancroid, and especially of gonorrhoea, are not admitted to 
the sick list, and hence are not included in the statistical 
reports. Venereal diseases give a total of 140,352 Bick days. 






The Lancet,] 


LORD KELVIN AND PUBLIC HEALTH.—THE MICROSCOPE IN WAR. [Jan. 4, 1908. 47 


which is equal to the entire loss of the service of 384 men for 
the year. 

New Year Indian Honours. 

Major John Norman Macleod, I.M.S., Civil Surgeon at 
Quetta, has been made a Companion of the Most Eminent 
Order of the Indian Empire, and Major Robert Charles 
Macwatt, I M S , Residency Surgeon at Jodhpur. Rajputana. 
has been awarded for public service the Kaisar i-Hind Medal 
of the First Class. 


Ccmspoitbcnre. 


“Audi alteram partem.” 


LORD KELVIN AND PUBLIC HEALTH. 

To the Editor of The LANCET. 

Sir,— A service which Lord Kelvin rendered to publio 
health a few years ago perhaps deserves reference at a time 
when much is being written about his many activities. When 
it was decided to appoint a Royal Commission after the 
occurrence of poisoning on a large scale by arsenic in beer 
in Manchester in 1900 Lord Kelvin was asked bv Mr. Walter 
Long, then President of the Local Government Board, to be 
its chairman. The inquiry was certain to be—as it proved — 
lengthy and in several respects tedious. The subject, save 
that it called for ability to master a variety of com¬ 
plicated scientific and technical considerations, was far 
out of Lord Kelvin’s ordinary lines, and at the age of 
nearly 80 he might well have hesitated to burden him¬ 
self with it. But the request of the Government was 
sufficient; he acceded to the proposal, if I remember 
right, by return of post, and during 1901 and 1902 
he presided over nearly all of some 35 sittings (many of 
which occupied the greater part of a day) in London and 
Manchester. It is generally recognised that the work done 
by the Commission under his guidance has had valuable 
results. Its final report has become the recognised authority 
for the various manufacturing and brewing industries and 
also for the administrative bodies which are concerned with 
the question of arsenical poisoning through food, while its 
more general recommendations have had an important share 
in determining recent Government action to secure improved 
methods of coutrol in regard to impurities and deleterious 
substances in foodstuffs, as exemplified by Mr. Burns’s 
Kegnlations as to Food Act of last session. 

Many of those who were concerned with the work of the 
Commission will retain pleasant recollections of Lord Kelvin'B 
interest and active assistance and a vivid memory of the 
mental alertness and power of concentration which in him 
was so strong a characteristic. 

I am, Bir, yours faithfully, 

London. Dec. 21«t, 1907. G. S. BUCHANAN. 


ON A SYMPTOM WHICH OCCASIONALLY 
MAY THROW LIGHT ON THE DIA¬ 
GNOSIS OP MOVEABLE 
KIDNEY. 

To the Editor of The Lancet. 

Sib,—T he interesting communication of Dr. Hector 
Mackenzie on Mobility of the Kidneys which appeared in 
The Lancet of Oct. 26th, 1907, takes in all that is 
known on the subject, in my opinion. As regards the 
symptomatology, the statement of the author, when he 
says, referring to the greater part (411 in 515) of the cases 
which have come under his observation, that they ‘-had no 
symptoms which with any reasonableness could be attributed 
to the condition of the kidneys," expresses exactly the truth 
contained in the words of Professor Osier therein quoted, 
namely," that in the majority of the cases (‘in a vast majority,’ 
says Dr. Mackenzie) there are no symptoms whatever.” 

As a matter of fact, the epigastric pain mentioned by 
Edebobls as characteristic, the different manifest itions of 
dyspepsia, the vomiting crises described by Dietl, and the 
different neurotic affections, such as migraine, vertigo, 
leuralgia, hypochondriasis, epilepsy, neurasthenia, &c , have 
lot been established in cases of mobility of the kidneys 
vith the frequency necessary to prove clearly a connexion 
>et ween such phenomena and the anatomical derangement 


in question. Even a certain amount of irritability of the 
bladder with an irresistible desire to pass urine, which I have 
observed sometimes, and which is pointed out in Dr. 
Mackenzie s communication, I have been led to recognise 
by the further development of the case as a manifesta¬ 
tion of cirrhotic interstitial derangements of the gland 
concomitant with the relaxation of the organs which sustain 
it rather than being symptomatic of moveable kidney. 
The sensation of a lump in the lower part of the abdomen 
near the hip, so long as the nature of the tumour be not 
defined, is without any pathognomonic significance. 1 have 
seen patients who have complained that something is try¬ 
ing to escape from the belly through the groin when they 
run, cough, or lift htavy objects, and one was already wear¬ 
ing a truss when be came to consult me. 

It has been in such cases that I have been able to observe 
a symptom which I consider to be of real use in the dia¬ 
gnosis. It is the followirg. In persons habitually consti¬ 
pated, or who have to make great exertion at the time of 
defalcation, it happens that when they are emptying or 
beginning to empty the bladder they experience a sharp 
cruel pain which stops the flow of the urine and runs 
through the urinary passages with all the characteristics of 
nephritic colic. Instinctively the patient changes Ids position, 
rises from his seat, and puts his hand on the lower part of the 
belly, pressing or rubbii g the side affected ; by doing which 
the pain disappears with the same suddenness as that with 
which it came on, urination goes on, and everything proceeds 
in due course. The mechanism of the phenomenon seems to 
be explained either by a compression of the kidney caused 
by the effort to evacuate or by a sudden obstruction of the 
ureter by excessive twisting or distension and its r isappear- 
ance by the cessation of the circumstances mentioned, due 
to the movements of the patient. Having regard to an affec¬ 
tion which may easily pass unperceived from w»nt of sub¬ 
jective phenomena, I think that it is of use to point out any 
which, even occasionally, may serve to make it recognisable. 

On this understanding I have ventured to take up a small 
space in your columns, adding, in conclusion, that the pain 
to which I refer must have, in order to be regarded as a 
symptom of moveable kidney, the following feature : (1) a 
sudden appearance at the time of great exertion, chiefly 
during defecation and while the patient is passing urine ; 
(2) that the pain should be felt along the urinary passages as 
in nephritic co ic and with suffic ent intensity to interrupt 
urination ; and (3) instantaneous disappearance on change of 
position of the patient or light massage on the side of the 
abdomen affected. It is, of course, clearly understood that 
renal lithiasis may make itself felt in the act of defalcation, 
but the differentiation between such lithiasis and moveable 
kidney would be so easy that I do not think it necessary to 
point it out. I am. Sir, yours faithfully, 

Zacatecas, Mexico. JUAN BrKNA, M.D. 


THE MICROSCOPE IN WAR. 

To the Editor of The LANCET. 

Sir.—I have read with mnch interest the chairman's 
address to the Swansea division of the British Medical 
Association 1 but, while sympathising with Dr. J. Arnallt 
Jones’s desire to popularise the study of bacteriology 
amongst general practitioners, I venture to join issue with 
his opinion as to the role of the microscope in war. Dr Jones 
says that “Major Seaman of the U.S Army in his report 
pointed out that the Japanese medical offic er was invariably 
found in the first screen of scouts with his microscope and 
chemical reagents testing and labelling wells so that the 
army following should drink no contaminated water.” This 
might be accepted by an audience unacquainted with the 
conditions of military service but I do not think that the 
members of the medical department of any army will agree 
with the medical officer of health of Aberavon that it is “a 
brilliant practical illustration ” of “ what science can do in 
the way of preventing disease in war.” 

If Dr. Jones will refer to the Parkes Memorial Prize 
Essay for 1904 he will find that Lieutenant-Colonel Robert 
Caldwell, R.A M.C., who has had great experience, writes 
as follows : “ It does not appear likely that the introduction 
of a chemical laboratory into the field is likely to be fol¬ 
lowed by any particular benefit. An incomplete analysis is 
valueless ; it tells of danger but cannot tell of safety, and it 
iB impossible to carry out any analysis but an incomplete 

* Brit. Med. Jour., Dec. 21st, 1907, p. 1764. 





48 The Lancet,] 


ACUTE PULMONARY (EDEMA. 


[Jan. 4. 1908. 


one under the conditions of active service, and for this 
reason any such attempt should be abandoned. Water 
(water being naturally the main subject for analysis) 
might, for instance, give excellent results when examined 
chemically and might at the same time be swarmiDg with 
an extensive variety of disease producing germs. These 
latter could not possibly be detected without recourse to 
appropriate bacteriological methods and such methods could 
only liad practical application within the walls of a properly 
equipped laboratory.” a 

During the recent autumn manoeuvres in Wiltshire the 
writer of the foregoing, in his capacity as sanitary officer of 
the Northern Army, took samples of water from the River 
Wyley both before and after it bad passed through the new 
army water-cart. The samples reached the District Labora¬ 
tory, Devonport, the day following their despatch. I was 
in temporary charge of the laboratory during Colonel 
Caldwell’s absence and examined them for the presence of 
bacillus coli communis according to the method recorded by 
Dr. Thresh in his admirable work on “Water and Water- 
supplies ” (p 361). The river water gave unmistakeable evi¬ 
dence of bacillus coli in so low a dilution as one cubic centi¬ 
metre, whereas 20 cubic centimetres of the water which had 
passed through the service cart showed no evidence of coli- 
form organisms. The chemi ai constituents of both samples 
were within the limit prescribed for “a good potable water." 
This bears out Colonel Caldwell’s opinion, as expressed above, 
that incomplete or chemical examinations of water are value¬ 
less and shows, I think, that if the Japanese medical officer 
was actually “ with the first screen of scouts analysing water 
and labelling wells ” his labours were sad waste of energy 
and his ‘ labels ” not worth the paper they were written on. 

In conclusion, I venture to predict that the microscope 
will perform an important idle in the wars that are to oome 
but it will be neither “ with the first line of scouts " nor in 
the stress of the fighting line, but in the properly equipped 
laboratories which the sanitaiy section of the expeditionary 
forces of the future will establish at their base and on their 
lines of communication. 

I am, Sir, yours faithfully, 

R J. Blackham, 

Devonport, Dec. 23rd, 1907. Major, Royal Army Medical Corps. 


A PLEA FOR THE SIMPLE METHOD OF 
DKAINING THE BLADDER AFTER 
SUPRAPUBIC CYSTOTOMY. 

To the Editor of The Lancet. 

Sir,—I n the large mass of recent literature on the subject 
of tbe most satisfactory method of draining the bladder after 
snprapnbio cystotomy the simplest and best method of all, 
by what may be called natural syphon action, appears to 
have been temporarily forgotten. The method 1 have been 
in the habit of ui-iDg in such cases for some time past has 
the merit of simplicity and efficiency and is briefly as follows. 
The incision in the bladder wall is reduced in size by a series 
of strong catgut sutures, introduced on the Lembert principle, 
until only a sufficient opening is left to take a large drainage- 
tube. Two boles are cut on opposite sides of the lower end of 
this tube which is placed well down on to tbe trigone or into 
the cavity from which a prostate has been removed. The 
long end projects from the wound and the tube is fixed in the 
opening in tbe anterior wall of the bladder by a purse-striog 
catgut suture, one portion of which transfixes the tube to 
still further secure it in position. The skin inci-ion is left 
widely open and the connective tissue space around the 
bladder, which has been opened up in the course of the 
operation, is carefully but lightly packed with sterilised 
gauze. When the patient has been put back to bed a long 
narrower rubber tube is attached to the tube in the bladder, 
and then runs over the side of the bed into a bottle or ot> er 
vessel containing dilute lysol solution, the end of the tube 
naturally beiDg below the level of the fluid. The syphon 
thus formed starts to work of itself and in my experience 
answers admirably. It is important to take care that the 
purse-string suture produces a good funnel-shaped pro¬ 
jection of bladder wall round tbe tube and to test the 
efficacy of the closure of the bladder by distending 
the cavity with fluid, passed into the bladder by means 
of a soft catheter by the urethra, before the operation 
is completed. The bladder may be washed out in the 

2 Prevention of Disease in Armies in the Field, p. 149. 


same way after the operation if necessary, bnt usually 
tbe drainage is so perfect that it is only in advanced cases of 
bilharziosis, or cystitis from any other cause, that this will 
be required. The tube is left in from four to eight days and 
on its removal the bladder is washed out from time to time by 
the urethra. A few days later the bladder has dropped back 
well into its place and the wound in it is firmly healed. It 
is a great mistake, in my opinion, to attempt to suture tbe 
bladder wall to the skiu or deeper tissues, as this procedure 
is so often followed by a very intractable sinus. Once the 
tube has been removed the patient should be allowed to sit 
up and two days later to walk, as both these actions tend 
to drive the urine, so to speak, out of the bladder by its 
natural channel. The rather special opportunities one has 
in the practice of bladder surgery in Egypt must be my 
apology for venturing to trespass on your space to this 
extent and the feeling that, perfect as some of the more 
complicated methods appear to be, they are rather un¬ 
necessary in view of the simpler measures which are at our 
disposal. I am. Sir, yours faithfully, 

Cairo, Deo. 3rd, 1907. FRANK C. MaDDEN. 


ACUTE PULMONARY (EDEMA. 

To the Editor of The Lancet. 

Sir,—T he interesting communications under this title 
have drawn attention to a condition which, though familiar, 
is not often described. It should, however, be kept distinct 
from acute suffocative catarrh, a condition well described by 
Laennec, but not, it would seem, generally recognised now 
any more than it was at the time he wrote. To the description 
Laennec gave, little, if anything, can be added. Dyspncea 
comes on suddenly, rapidly becomes intense, and in a few 
hours the patient may die from suffocation. If life be pro¬ 
longed the condition becomes one of ordinary bronchial 
catarrh. Laennec’s suffocative catarrh has to be distinguished 
from capillary bronchitis and disseminated post-bron- 
chitic broncho pneumonia, for in these cases the suffo¬ 
cative symptoms are secondary. More closely resembling 
it are primary broncho pneumonia—i.e., disseminated 
pneumococcal broncho pneumonia and possibly an acute 
pneumococcal or other bacterial bronchitis In associa¬ 
tion with it may be placed : 1. Cases of acute pulmonary 
oedema which develop in the course of chronic heart 
obstruction or of acute heart failure, such as most of those 
are which have been recently described. 2. Cases of col¬ 
lateral fluxion or pulmonary failure such as are familiar in the 
course of acute pneumonia in tbe non-coneolidative parts of 
the lung. 3. An interesting but not common group of cases 
in which acute pneumonia commences with widespread pul¬ 
monary congestion, the general congestion disappearing as 
the local lesion develops. 

I write this as a preliminary note, for I propose to.briog 
the whole subject shortly before one of the medical societies. 
It has been stated that no account of these conditions appears 
in the ordinary text books. The various conditions I have 
referred to are, however, all discussed in my book on 
“Diseases of the Respiratory Organs,” and I daresay else¬ 
where too. I am, Sir, yours faithfully, 

Dec. 30th, 1907. _ Samuel West. 

To the Editor of The Lancet. 

Sir. —Tbe clear clinical picture of “Acute Pulmonary 
(Elema.” drawn by Dr. Leonard Williams in The Lancet 
of Dec. 7th, 1907 has left an impression on my mind which 
will never be effaced. Although the condition is one of 
great rarity, doubtless its occurrence is much more frequent 
than is generally supposed, being overlooked by the fact 
that no description of it is to be found in any of 
our English text-books, and hence students have not 
been made familiar with the symptoms. I can cer¬ 
tainly recall a case in which, although a fatal issue was 
not unlooked for, I was yet unable to account for the long 
stream of foam issning from the month and nose, and have 
now no doubt that tbe actual cause of death was acute 
oedema of the lungs. The omission of such an important 
mode of death from our English text-books, and also I notice 
from the 1 Nomenclature of Diseases” issued by the Royal 
College of Physicians of London, is much to be regretted, and 
one can only hope that it will be repaired at an early date. 

I am, 8ir, yonrs faithfully, 

Alexander Bryce, M D. Glasg., D.P.H. Cantab. 

Moseley, Birmingham, Dec. 26th, 1907. 




The Lancet,] 


THE GENERAL HOSPITALS AND THE TRAINING OF MIDWIVES. [Jan. 4. 1908. 49 


I THE GENERAL HOSPITALS AND THE 
TRAINING OF MIDWIVES. 

To the Editor of Thb Lancet. 

Sir,—I n commenting on the report of a meeting recently 
convened by the Association for Promoting the Training and 
Supply of llidwives, the Times in a leading article expressed 
regret that none of the speakers, beyond urging the necessity 
for increased support of the Association, gave any indication 
as to the means by which the serious difficulty is to be met 
which may arise in 1910 when the clauses in the Act 
forbidding the practice of midwifery by unqualified persons 
come into operation. The opinion was also expressed that 
"a very definite organisation with definite and clearly stated 
aims is a necessary condition of any extended support from 
the public.” A subsequent letter from the Council of the 
Association makes the issue clear—viz., which is to come 
first, the plan or the money i 

1 am writing in the hope that the suggestions contained 
in this letter may help the Association to a decision upon 
this point. I cannot claim to speak with any authority on 
the general question, but I have been led during the past two 
years to take an interest in it owing to my appointment as 
a visitor of some of the lying-in hospitals of London by the 
Conncil of King Edward’s Hospital Fund. No one can enter 
the wards of one of these hospitals without being struck 
with the enormous advantage which any poor woman whose 
labour is conducted there enjoyB over her less fortunate 
Bister who is confined in her own home, often amidst 
surroundings which can only be realised by those who have 
actually witnessed them. It is gratifying to learn that by 
the adoption of a rigidly aseptic and antiseptic method 
maternal mortality has in these institutions been practically 
abolished. It is equally saddening to reflect that whilst the 
lying-in ward has been transformed from a death-trap to a 
place of the greatest attainable safety, there has been little 
or no diminution in the mortality from child-birth through¬ 
out the country generally. 

The Faculty of Medicine of the University of London was 
recently asked by the Senate to advise as to the action to 
be taken by the University upon the proposed regulation of 
the General Medical Council that every student shall be re¬ 
quired to have received instruction and gained his practical 
knowledge of midwifery by attending the requisite number 
of labours, either in a lying-in hospital or in the lying-in 
ward of a general hospital. I am glad to say that a resolu¬ 
tion was passed that in the opinion of those present “ teach¬ 
ing in practical midwifery in the wards of a lying-in hospital 
or in the lying-in ward of a general hospital should be made 
compulsory as soon as practicable." 

I lately suggested to the Weekly Board of the Middlesex 
Hospital that a lying-in ward should be established, so that 
our students may learn this most important branch of their 
profession under the best possible conditions and not, as 
hitherto, by attendance upon the poor living in the area 
supplied by the hospital. The suggestion received the 
approval of the board and of the medical staff and a 
committee is about to report upon the changes necessary 
to carry it into effect. The existence of such a ward is no 
new thing, as in 1747 it was enacted that “a third part of 
the beds used in the hospital from time to time be appro¬ 
priated to the use of lying-in women.” The total number of 
beds in the hospital at that date was either 18 or 22. In 1749 
a rule was established that “ whenever there shall be an 
increase of beds for sick and lame the same number be also 
added for lying-in women.” In 1783, owing to lack of funds, 
retrenchments became necessary and these were continued at 
intervals until 1807, when the lying-in ward was abolished. 

Such a ward in a general hospital to which a medical 
icbool is attached would serve a fourfold purpose: 1. It 
would insure that a certain number of poor women were 
ielivered under conditions involving in a normal pregnancy 
he minimum risk to life. 2. The offspring would be free 
rom the danger of contracting purulent ophthalmia, which 
wo of the speakers at the meeting referred to stated to be 
re cause of fully one-fourth of the cases of blindness in the 
immunity to-day. 3. It would afford the students an 
-iportunity of learning thoroughly the aseptic and antiseptic 
chnique of modern midwifery, knowledge which must in 
leir future practice be of the greatest service to them and 
erefore to the public. 4. It would allow the hospital to 
come a. centre for the training of nurses skilled and 
rti floated in midwifery and thus increase its claims to 


public support. Some of these nurses might be available for 
attendance upon the poor living in the neighbourhood of 
the hospital, thus replacing the services of the students. 

I would therefore suggest to the Association that it should 
forthwith institute a campaign throughout the country to 
urge: 1. That every general hospital should as soon as 
possible provide a lying-in ward. 2. That the general 
hospitals in each county should become centres for the 
instruction of midwives, who would obtain there the 
certificates necessary to secure admission to the Roll. 
3. That one or more branches of the association should be 
established in each county in connexion with the general 
hospitals in order to ascertain and provide for the wants of 
the county as regards midwives and to organise and to super¬ 
vise their work. 4. That the county councils and local 
authorities should exercise the powers given to them by the 
Act of making grants towards the cost of the education 
given to midwives in the hospitals; thus the whole community 
would bear a part of the expense to which the hospitals 
would be put in carrying this proposal into effect and not only 
those members of it who recognise their duties to the poor. 

I venture to submit these suggestions as the basis of a 
scheme which may provide “ the definite organisation with 
clearly stated aims” necessary to secure increased public 
support of the Association. I have not referred to the good 
work which I know Queen Charlotte’s Lying in Hospital is 
doing in increasing the provision for the instruction of 
students, as the need is for a scheme applicable to the 
country as a whole. 

I am, Sir, yours faithfully, 

J. K. Fowler, 

Dean of the Faculty of Medicine, University of London. 

Clarges-street, W., Dec. 28th, 1907. 


THE COEFFICIENT OF DISINFECTANTS 
AS REGARDS THE PLAGUE 
BACILLUS. 

To the Editor of Thb Lancet. 

Sir, —The statements made with reference to the 
coefficient of various disinfectants against the bacillus 
pestis indicate that this organism is particularly susceptible 
to the influence of the various preparations used for 
disinfecting purposes, but I gravely doubt whether all these 
statements are absolutely reliable. My reason for saying 
this is based upon the results of a series of experi¬ 
ments made when examining a well-known disinfectant. 
I found that using broth for cultivating purposes, with 
and without the addition of a little butter, the results 
were sometimes doubtful. I therefore made from all the 
tubes giving no definite indications of growth agar slope 
cultures and was not surprised to find after several days that 
a distinct growth of the bacillus pestis made its appearance. 
The result was that the disinfectant under trial gave a 
coefficient about the same as that obtained when the bacillus 
typhosus was used, whereas judging from the broth cultures 
alone it was nearly twice as high. An attempt was made to 
use agar slopes in the first instance instead of the broth, but 
the results then differed widely from those obtained either 
with broth alone or with broth followed by agar. Probably 
other bacteriologists interested in this subject may care to 
repeat my experiments and confirm or disprove my results. 
This is my excuse for troubling you with this letter. 

I am. Sir, yours faithfully, 

John C. Thresh. M.D. Viet., Ac. 

London Hospital Medical College, Dec. 23rd, 1907. 


TWINS: A CURIOUS INCIDENT. 

To the Editor of The Lancet. 

Sir, —At Stoke Newington recently inquests were held 
upon the bodies of twin boys, aged 18 months, who were 
found dead at the same time in the same bed on a Friday 
afternoon about 6 P.M. One child had been brought up by 
the bottle on cow’s milk and barley water and the other had 
been suckled. Both had seemed well until the Sunday 
before, when both became poorly with colds in the head and 
coughs. The mother treated the children with castor-oil and 
embrocations of camphorated oil. She did not think either 
was seriously ill until the Friday, when one was taken to a 
doctor who prescribed for it at noon; the other had no 
medical attendance. The parents declared that both had 




50 The Lancet,] LONDON’S MILK-SUPPLY.-MEDICAL PRACTICE IN TURKEY. 


[Jan. 4, 1908. 


been seen alive by them about 5.30 P.H. ; half an hour after 
both were dead, lying on their sides, faces not covered up, 
some distance apart Post-mortem examinations showed a 
similar state of broncho pneumonia; there were no injuries 
and no suspicion of foul play. 

I am. Sir, yours faithfully. 

W. W. Westcott, 

Dec. 28th, 1907. Coroner. 

LONDON’S MILK-SUPPLY. 

To the Editor of The Lancet. 

Sib, —I notice in The Lancet of Dec. 21st. 1907, p. 1778, 
that a reference is made to the adoption of new regulations 
by the Hailsham rural district council under the Dairies, 
Cowsheds, and Milksbops Orders 1885, 1836, and 1899. In 
the same article you imply that the Hailsham council has 
had no Dairy, Cowshed, and Milkshnp Regulations for the 
past 20 years. You have evidently been misinformed. Asa 
fact the Hailsham rural district council was one of the 
first councils to make regulations under the Dairies, 
Cowsheds, and Milkshops Orders 1885, 1886, and the old 
regulations were more strict than the new regulations. 
The Hailsham council, acting on the advice of its medical 
officer of health, has recently brought the above regulations 
up to date and these remodelled regulations will come into 
force on Jan. 1st, 1908 It is no doubt these revised regula¬ 
tions that your correspondent has mistaken for the Order. 
I would point out that the Dairies, Cowsheds, and, Milkshops 
Order is not adoptive as described in your article under 
London’s Milk-supply. 

I would also draw your attention to the fact that the Order 
does not compel local authorities to make regulations, 
but, unfortunately, merely empowers them to do so, and 
the Legislature should doubtless have made the making 
regulations under the Order compulsory instead of permissive. 
It is a matter for deep regret that your usually accurate 
journal should be blemished by a contribution the author 
of which shows want of knowledge, both as to his legal 
principles and facts. 

I am, Sir, your obedient servant, 

Hugh Stott, 

Medical Officer of Health, Hast Sussex Combined 

Dec. 26th, 1907. Sanitary District. 

*** We are sorry to find that our correspondent has made 
a mistake.—E d. L. 


MEDICAL PRACTICE IN TURKEY. 

To the Editor of The Lancet. 

Sib,—P erhaps it may interest a few of your readers to 
know how the licence to practise medicine in the Turkish 
Empire is to be obtained. Perhaps this licence is not 
absolutely necessary for an English practitioner whose work 
lies solely in an English institution, yet it is strongly recom¬ 
mended to be obtained as without it one has no legal right to 
practise. 

First from the Consulate (fee 10s.), or from some friend 
who can write a formal Turkish letter, a “ petition ” is 
obtained stating that X, a British subject, graduate of 
such a University, desires the licence of the Ottoman 
Government. This letter addressed to the Director-General of 
Medical Affairs (Nazir Mekteb Tibbiye SI aha' e) you take to 
the Haidar Pasha new military medical school near Skutari, 
to a room called evraq odasy. There a clerk gives you a form 
bearing a number (fee 20 paras = Id.), and you are 
probably told to call in a week’s time. Meanwhile, the 
petition goes before some authority and on your next visit 
you pay in an adjoining office (Bureau de Comptabilitf) 
£T 20 + 20 paras ; no receipt is given yet. Five days later, 
probably, on visiting the original office and displaying the 
number, the clerk, turning up his register, writes “council” 
on your form, and after waiting an hour or so you enter to 
see the council which examines your university diploma and 
medioal registration certificate The former it retains, all 
things being satisfactory, and you enter an adjoining room for 
a v'va-voee examination by the professor of anatomy, of 
surgery, and of medicine. This examination is a perfectly 
fair gentlemanly one. If you display a reasonable know¬ 
ledge of your profession you are immediately afterwards 
invited to the council room where the chairman declares 
your acceptance. 

The examination must be taken in French or Turkish. An 
interpreter is allowable. Then comes a wait of some ten 


days during which your diploma and the result of the test. 
Sec., pass to the Director-General and are finally returned to 
the school. It is necessary in the meantime to pay a visit to 
the Sublime Porte to have your passport legalised (fee half 
Turkish pound 4- 2 piastres). The return of your papers 
is announced in Turkish on a notice board in the ball in 
which you do so much waiting. Your university diploma is 
now returned to you and also a receipt for the fee, and after 
a period varying according to whether there are others 
ready with you or not, you are led before the Director- 
General to swear the oath not to procure abortion, 
not to treat hardly the poor, to call your professional 
brethren in consultation when necessary, &c., aDd after paying 
21 piastres (3s. 6 d.) for a stamp, your licence is handed to 
you. The examination and council, kc., are held three 
times weekly—Mondays, Thursdays, and Saturdays, and it 
is advisable to call regularly on each of these days when 
waiting, as the clerk’s instruction to come in a week's time 
is but a way of speaking. In the first office and the fee¬ 
paying office there is no one who speaks French. The whole 
affair takes three weeks if very fortunate, five weeks usually, 
and seven weeks if unfortunate. In Egypt the same affair 
takes from four to five days and there is no examination 
and a nominal fee of 3>. 6 d. or so to pay. 

I am. Sir, yours faithfully, 

Baghdad. P. A. H. RADCLIFFE, M.B. Viet., D.T.M. 

THE TREATMENT OF PUERPERAL 
SEPSIS. 

To the Editor of The Lancet. 

Sir,—I n a letter in The Lancet of Dec. 2lst, 1907, p. 1785, 
Dr. Amand Ronth says, “ I cannot recall any acute sentic 
condition of the endometrium where curettage with a sharp 
curette has done good.” I should like to bring forward 
some statistical evidence on this point. In the Journal of 
Obstetrics for January, 1907, in a paper dealing with 
the treatment of puerperal sepsis, I wrote: “Out of 79 
cases (of my own) treated by general means, with or without 
intra-uterine douches, 37 died—a mortality of 46 per 
cent. In 86 cases where the method I have described 
was employed the mortality was 23 per cent, only.” I can 
now add to the latter serits 43 more cases with 11 deaths. 
The method referred to consists in the removal of the endo¬ 
metrium as completely as possible with a large sharp curette 
followed by swabbing of the resulting raw surface with 
undiluted izal. I should add that all the patients were 
intensely ill when I first saw them and that the large 
majority had been treated previously by intra-uterine and 
vaginal douches for several days, the average day of admis¬ 
sion to hospital being, in fact, the fifth of the pyrexial 
period or, in other words, the stage which is certainly not 
the most favourable for the use of the Bharp curette. I do 
not see mild or early cases at all. 

I am well aware of the fallacies which attend the use of 
the statistical method in such a complex disease as puerperal 
sepsis, but I think it is evident that these figures do not 
justify the inference that the use of the sharp curette is per 
se either dangerous or inadvisable and that the number of 
cases, 208 in all, is sufficiently great to be worth quoting in 
this connexion. I am, Sir, yours faithfully, 

A. Knyvbtt Gordon. 

Monsall Hospital, Newton Heath, Manchester, Dec. 22nd, 19-7. 


NOTIFICATION OF BIRTHS ACT. 

To the Editor of The Lancet. 

Sir, —The town council here has adopted the above Act 
and I shall be compelled under a penalty to notify all my 
confinement cases without receiving any compensation 
therefor, which is not quite just. However, the spirit of the 
Act is a step in the right direction and one must not com¬ 
plain. It seems a pity that the scope of the Act did not 
enable the local authorities to take an interest in both the 
mother and the child at parturition. Obstetricians who have 
the true spirit of their office must have felt unhappy and 
uncomfortable after refusing to get out of bed to attend a 
woman in labour who had been so improvident as not to have 
engaged anyone to attend her, knowing well from past 
experience that the only recompense that these improvident 
people afford is the approving conscience of haying 
done your duty, which is very satisfying at the time, 
but of no avail in paying the bills of the butcher. 



The Lancet,] 


THE POWER OF LOCAL AUTHORITIES TO PROVIDE HOSPITALS. 


[Jan. a, 1908. 51 


the biker, the dressmaker, the draper, the landlord, 
the tailor, and other tradesmen. The objects of the 
Act would have been more tally accomplished had it 
empowered local authorities to grant a moderate fee to any 
licensed practitioner who attended a case of confinement 
in circumstances precluding any hope of any other re¬ 
compense. The present Government seems inclined to pass 
enactments to ameliorate the condition of the masses, and 
if any of its measures would make it impossible for anyone 
to spend in drinking, betting, and smoking the money that 
should be spent in supplying himself or herself and 
dependents with the necessaries of life the above Act and 
many others would never have been required. Until restric¬ 
tions are put on these three bad habits, so that no one could 
spend more than a certain amount on either of them—the 
amount allowed to be limited to income and obligations— 
all other ameliorative measures will be comparatively useless. 
Slavery has been abolished in the British dominions, but there 
are still a great many people who would be better to be still 
in slavery under a kind master. They are quite unworthy 
of their freedom and cannot enjoy it properly, and if the 
present Government passes rest icti e measures to prevent 
these unworthy people from injuring them elves, thdr de¬ 
pendents, or the community generally, then others who need 
no such restrictions should cheerfully acquiesce in the new 
arrangements for the sake of their we iker brethren. It is 
hoped and expected that Parliament, so >n to as emble, will 
put restrictions on these three great evils. 

I am, Sir. yours faithfully, 

John B. Hunter, M.D., O.M. Glisg. 

Paisley, Dec. 28th, 1907. 

PS.—It is certainly an outrage on humanity and a dis¬ 
grace to civilisation that a poor woman in labour cannot 
command skilful attention in her dire distress. 


THE MEDICAL INSPECTION OF SCHOOL 
CHILDREN. 

To the Editor of The Lancet. 

Sir,—I should be much obliged if your readers in other 
parts of the country would favour the medical profession 
with information as to bow their county councils are going to 
carry out the medical inspection of school children. Are 
they going to appoint whole-time medical inspectors specially 
for this purpose or are they going to intrust the work to be 
done to general practitioners ? It appears to me that the 
claims of tbe latter are being overlooked in the matter and 
that the county councils, in appointing a special staff wholly 
for this work, are embarking on an expensive method. The 
inspection is one which, in my opinion, will require great tact, 
and in this the knowledge of the local practitioner would be 
invaluable. I am, Sir, yours faithfully, 

Dec. 28th. 1907. GENERAL PRACTITIONER. 


A PERSONAL EXPLANATION. 

To the Editor of Tils LANCET. 

Sir,—W ill you permit an old correspondent whose first 
contribution appeared in your pages more than 50 years ago 
to make a personal explanation ? A few weeks ago, in 
sorting some papers that had accumulated, I came across a 
circular or report from the Autivaocinatlon Society. Glancing 
over it I saw a list of correspondents of the society in foreign 
parts. To my extreme disgust l found my own name pub¬ 
lished as the Hew Zealand (or Auckland) correspondent. My 
only correspondence with the society during the 34 years I 
have been in this colony was to answer an application from 
the secretary, who asked me whether I would allow extracts 
from a paper on Compulsory Vaccination which I had read 
here before our branch of the N Z. Institute to be published 
by the society. My reply was that they might reprint the 
whole paper (which was not a long one) if they liked, but 
that I would not allow extracts to be made. I have never 
had a reply to this. My object in refusing to allow extracts 
was that I knew they would pick out certain cases of vaccino- 
syphilis which I had seen in the days of arm-to-arm vaccina¬ 
tion, and not reprint the statement I made that no one who 
had seen a bad case of confluent small-pox would hesitate 
about preferring the risks attendant on vaccination to the 
risks of incurring such a disease as small pox. But as 
small-pox has never been epidemic here I see no necessity 
for enforcing vaccination. 


I may mention teat as physician of the small-pox hospital 
in Port of Spain, Trinidad, during the epidemic of 1871-72, 
I saw two cases of confluent small pox both of whom had had 
confl uent small-pox before in the severe epidemic. One I had 
had under my own care, the other one was seen in the 
ho spital by the medical man who had attended him in the 
fi rst attack. These ca tes are given in my little work on “The 
Pathology and Treatment of Small pox," published in 1872. 
I have had to bear a good deal of odium on account of my 
opposition to compulsory vaccination, and some people have 
treated me as a heretic about vaccination. I am perfectly 
orthodox on tbe subject and always have been, 

I am, Sir, yours faithfully, 

R. H. Bakswbll, M I). St. And., 
Surgeon-Captain (retired) Army Medical Staff. 

Auckland, N.Z., Nov. 10th, 1907. 


THE POWER OF LOCAL AUTHORITIES 
TO PROVIDE HOSPITALS. 

To the Editor of The Lanobt. 

Sir —The answers to the questions put by “ J. S.” in The 
Lancet, of Dec. 21st, 1937, p. 1793, seem to me to be as 
follows:— 

1. The education authorities have power compulsorily to 
acquire sites for their hospitals, because the provision of 
these hospital and vacation school sites. Ate., is by Section 13 
of the Education (Administration Provisions) Act, 1907, in¬ 
cluded in the powers and duties of a local education 
a«t lority under Part III. of the Education Act, 1902. For 
the pirposes of Part lit. of the Act of 1902 land may be 
taken in one of three ways : (a) by agreement under the 
agreement sections of the Lands Clauses Oonsolidation Acts, 
which Acts are expresslv incorporated in the Elementary 
Education Act, 1870, o. 75. s. 20 (1) (unrepealed) ; (J) under 
the School Sites Acts (Elementary Education Act, 1870, 
c. 75, s. 20, last clauses unrepealed); (c) "Otherwise than 
by agreement,” that is, compnlsorily under the Land Clauses 
Consolidation Acts. 

2. With regarl to the question of employing qualified 
medical practitioners I think that the education authority 
can employ any snitable person, whether a qualified medical 
practitioner or not. There is no provision in the Act. 
Section 136 of the Public Health Act, 1875, gives the local 
authority power in cases of any formidable epidemic disease 
to “appoint and pay suoh medical or other officers or persons 
and do and pro ride all such matters and things as may be 
necessary for mitigating such disease, ot for superintending 
or aiding in the execution of such regulations.” Although 
that section only applies in case of a formidable epidemic, 
yet we may draw the inference that as the local education 
authority has authority to establish hospitals it has the 
power to appoint any qualified nurses, or, in fact, any 
suitable pe> son to look after them. Id the case of a small¬ 
pox hospital the Local Government Board has not objected 
to the medical officer of health acting as medical super¬ 
intendent, but it considers, in view of the duties which he 
has to perform as medical officer of health, that it would be 
undesirable that he should reside in the hospital. 

3. I thiDk that the treatment need not be free, for the 
education authority has power under tbe Elementary Educa¬ 
tion Act, 1870, c. 75, s. 3 (still nnrepealed), to charge pupils 
fer education in their elementary schools any sum not exceed¬ 
ing ninepence per week per scholar, consequently the authority 
would Beem to have the power of charging for medical 
attendances when the parents are capable of paying. 

4 The authority does not appear to have the power to 
admit to eneb hospitals the children of ratepayers who do 
not send their children to the elementary schools, for Section 
13 specially mentions children attending elementary schools. 

5. I think that the local education authority may, with the 
approval of the Board of Education, supply free of charge 
spectacles and surgical appliances under s 13, subs. 1 (J) of 
the Act of 1907. I think that the words, “the power to 
make such arrangements as may be sanctioned by the Board 
of Education for attending to the health and physical condi¬ 
tion,” confer such power. 

6. I am of opinion that the authority can decide that the 
child requires spectacles and that the parent can afford to 
pay for them, and if the child comes to school without 
spectacles the authority can refuse it admission and prosecute 
the parent for not sending it to school, as such a rule would 



52 Thh Lancet,] 


CHOLERA IN RUSSIA. PERSIA, AND TURKEY. 


[Jan. 4,1908. 


be reasonable. (See the case of a verminous child in 
The Lancet, Nov. 9th, 1907, p. 1342.) 

I am, Sir, yours faithfully, 

Dec. 28th, 1907. A LAWYER. 

THE NEEDS OF LONDON MEDICAL 
STUDENTS. 

1o the Editor of THE LANCET. 

SIR,— In the controversy now proceeding with regard to 
the allied, but by no means identical, subjects of the title of 
'• Dr.” and degrees for London students of medicine it is as 
well to endeavour not to confuse the real issues. There is, 
on the one hand, a demand that the degree of "M.D.” 
should be in some way brought within the reach of all those 
who are of average mental capacity and have studied medi¬ 
cine sufficiently to pass a qualifying examination. There is, 
on the other hand, the demand that all those who have 
passed any qualifying examination should be entitled to 
assume the prefix of "Dr.” With regard to the former, 
what we desire to know is. What are the impediments which 
prevent all London medical students from matriculating at 
the University of London 1 When these are clearly set out 
it will be easy to consider what modifications can bene¬ 
ficially be made in the existing regulations. The second 
demand is quite on a different footing. It seems that 
the public has made up its mind that a university 
education is of advantage in a doctor and prefers 
to go to those who have obtained the stamp of 
"M D.” Those who have not obtained this stamp there¬ 
fore declare that they are at a disadvantage and that they 
must be allowed to pretend that they have obtained the 
coveted stamp by placing the title “ Dr.” before their 
names. This appears to be a distinctly dishonest expedient, 
and the dishonesty is not lessened by the fact that the word 
“doctor ” is the recognised popular term for a medical man. 
A solicitor does not put on his brass plate "Solicitor J. 
Jones,” but “Mr. J. Jones, Solicitor.” There would 
presumably be no objection to a doctor who was not a 
member of a university similarly putting " Mr. E. Smith, 
Doctor.” I venture, however, to prophesy that this 
would not satisfy the claimants for the title “Dr.” Yet if 
it does not, it seems clear that what they desire is not to be 
known as doctors but to be falsely reputed to have obtained 
a university degree. While, therefore, there is every reason 
to endeavour to facilitate the entrance of students of 
medicine at the London and other universities, there is none 
for altering the present arrangements by which the M.D. 
degree is obtainable only by members of a recognised uni¬ 
versity. Nor does there seem any reason to complain that 
London has but one university, so long as that university 
embraces many constituent schools scattered over the metro¬ 
politan area, at which there is plenty of room for medical 
students. I >">, Sir, yours faithfully, 

Dec. 29th, 1907. _ VERAX. 


To the Editor of The Lancet. 

g 1B _Year after year one reads in the columns of 

The Lancet letters from discontented individuals who wish 
to get an M.D. degree without working for it. The care is 
always the same: Mr. Smith, M.R C.S. or L.S.A., is ashamed 
of his qualifications and jealous of his neighbour Dr. Jones 
who has gone through a much more advanced course of 
study and obtained the degree of Doctor of Medicine. The 
arguments adduced by the advocates of the " M.D. England ” 
and repeated with such monotonous regularity are decidedly 
amusing and would make interesting reading did not their 
frequent distortion of facts and wilful misrepresentations 
remind one rather too forcibly of the antivivisectionist 

literature. , 

However, there are two real gems in your issue of 
Dec. 21st. The first is a letter signed by “ Have Not,” in 
which we find the brilliant suggestion that the University of 
London might “institute a degree for Conjoint men of 
mature age much on the lines of that of St. Andrews.” 
Apart from the incongruity of the whole thing, there is 
something inexpressibly quaint in the very idea of venerable 
practitioners of 15 or 20 years’ standing flocking on a 
pleasant picnic to South Kensington and returning home 
with an M.D. degree in their pockets. “Sympathiser" 
supplies the second in seriously proposing a revival of the 
ancient custom of the granting of the M.D. Lambeth by the 


Archbishop of Canterbury. One can almost imagine the 
learned Primate of all England, suitably robed for the 
occasion, personally conducting a vivA vooe examination in 
medicine with the aid of the most recent edition of the 
“Family Physician.” But seriously, such retrogressive 
steps as suggested in these two letters would simply be an 
absurdity to the intelligent, and demoralising by their 
conscious support of falsehood and fraud. 

I am, Sir, yours faithfully, 

Kensington, Dec. 24th, 1907. M.D., M.R.O.S., L.R.C.P. 


CHOLERA IN RUSSIA. PERSIA, AND 
TURKEY. 

(From the British Delecate on the Const antinopie 
Board op Health.) 


The outbreak of cholera in Russia is now subsiding. It 
has not been a eevere one in comparison with many that 
have occurred there in the past. It has, nevertheless, 
carried off a not inconsiderable number of victims. The 
total number of cases officially reported since the beginning 
of the epidemic on July 3rd down to Nov. 6th 1 is placed at 
11,472 and that of deaths at 5493. The official returns for 
the six weeks preceding the date just named are set forth in 
the accompanying table. The figures therein contained are in 
continuation of those published in my preceding letters.- 

The weekly totals, as given in the last line of the table, 
are those officially returned by the Russian Government; it 
will be observed that they are incomplete and do not quite 
coincide with the sums of the individual figures in their 
respective columns. It is probable that all the figures must 
be regarded as aporoximative only. In European Russia the 
towns and governments along the valley of the A olga have 
been among the worst sufferers from the epidemic, hut the 
town of Kief has also been the scene of a serious outbreak. In 
Asiatic Russia the government of Tomsk and the Akmolinsk 
territory have been the most severely affected, and it cannot 
escape remark that nearly all the governments and provinces 
of Siberia, including the Transbaikal territory, have been 
invaded by the disease. 

The outbreak of cholera on Turkish territory, on the road 
between Kars and Erzeronm. reported in my last letter, 
seems to have subsided rapidly. Later information states 
that there were two groups of Russian emigrants, botti from 
the Caucasian province of Daghestan. The first, of 94 
persons, reached the Russo-Turkish frontier post of Keutekon 
Oct. 22od and left on the next day ; the second arrived there 
on the 24th and left on the 26th. Most of the cases appear 
to have occurred in the second group. Only villages on the 
line of march of these emigrants were affected by the 


A death from cholera recently occurred in Constantinople. 
The deceased man was one of a group of Mongolian pilgrims 
on their way to the Hedjaz. This group had come from 
some portion of the Chinese Empire, by way of Tashkent and 
Odessa. It had taken them 45 days to reach Tashkent; 
thence they travelled by rail, arriving in Odessa in five days; 
they Btayed a day or two there, took ship to Sinope, where 
they underwent five days’ quarantine and the disinfection of 
their clothes and effects. It may be added that they sailed 
from Odessa on Nov. 5th (New Style), reached Sinope on the 
7th, left there on the 12th, and arrived in Constantinople on 
the 13th. It was only in the night of the 14-15th that the 
symptoms of cholera appeared in one of them ; he died 24 
hours later. A bacteriological examination was made and 
a bacillus was isolated possessing almost all the characters of 
Koch’s comma vibrio ; the points in which it differed from 
the latter were that it coagulated milk and did not give the 
cholera red reaction. The case was treated in all respects as 
one of cholera ; the large khan in a densely crowded quarter 
of Stamboul where it occurred was evacuated, all the other 
pilgrims of the same group were removed to the lazaret at 
Kavak, at the northern entrance of the Bosphorus, where 
they did 15 days’ quarantine, the klian was disinfected, and 
other precautions were taken. A second case of illness 
occurred in the group, but clinically, pathologically, and 


1 Where not otherwise stated the dates mentioned in connexion with 
ho epidemic In Russia are all according to the Old Style, both in the 

ext and in the table. _ , inn ,, -ic-m 

2 The Lancet, Oct. 19th (p. 1119) and Nov. 30th 1907 (p. 1571)- 



The Lancet,] 


CHOLERA IN RUSSIA, PERSIA, AND TURKEY, 


[Jan. 4, 1908. 53 


I 

\ 

- 



From 

Sept. 26th to 
Oct. 2nd. 

From 

i Oct. 3rd to 
j Oct. 9th. 

From 

Oct. 10th to 
Oct. 16th. 

From 

Oct. 17th to 
Oct. 23rd. 

From 

Oct. 24th to 
.Oct. 30tb. 

From 

Oct. 31st to 
Nov. 6th. 

j Totals from be¬ 
ginning of epi¬ 
demic (July 3rd) 
to Nov. 6th. 

1 

European Russia. 



Cases 

Deaths 

Cases. Deaths 

Cases 

Deaths 

Cases. DeathB 

Cases 

Deaths 

Cases 

| Deaths 

Cases. Deaths. 

r 

Samara (town). 



i b 

3 

2 3 

i i 

2 

2 — 

1 

2 

1 

1 — 

383 204 


„ (government) . 



73 

27 

34 | 20 

41 

14 

38 27 

40 

21 

10 

6 

759 381 


Astrakhan (town) . 



4 

2 

2 | — 

- 


— — 

— 

— 

— 

— 

1683 873 


Arkhierei and Ataman. 



1 

2 

1 — 

1 - 

— 

— — 

— 

' — 

— 

— 

461 290 


Astrakhan (government) ... 


... 


— 

il - 

— 


— — 

— 

— 

— 

— 

796 376 


Saratof (town). 



4 

1 

—- j — 

1 

— 

— — 

— 

— 

— 

— 

210 62 


Tsaritsyn (town) . 



8 

3 

2 3 

1 


— — 

— 


— 

— 

586 I 291 


Saratof (government). 



IS 

3 

S 3 

3 

2 

4 — 

2 


8 

2 

I 413 197 


Kazan (town) . 



1° 

11 

1 32 11 

20 

24 

1 13 9 

2 

2 

1 

— 

203 113 

5 

,, (government). 



— 

— 

1 1 

— 

— 

2 1 

— 

— 

— 

— 

- - 


Nljni-Novgorod (town). 



7 

4 

9 | 2 

1 

2 

2 1 

— 

— 

— 

— 

1 245 97 


„ „ (government! 



42 

24 

14 9 

6 

3 

8 4 

5 

2 

1 

1 

497 242 

[i 

Simbirsk (town) . 



— 

— 

_ _ 

- 

| — 

— — 

— 

— 

— 


5 ! 4 

it 

m (government). 



5 

4 

3 1 

6 

2 

— — 

— 

— 

— 

— 

353 1 170 

i, 

Yaroslavl (town) . 



— 

— 

— — 

— 

— 

3 2 

5 

6 

15 

8 

60 30 

* 

•f (government. 



__ 

— 

6 , 1 

4 

1 

— 1 

1 

2 

— 

2 

52 I 22 

i 

Penza ,, . 



12 

6 

- - 

— 

— 

7 2 

26 

15 

23 

9 

160 78 


tt (town) . 




— 

_ — 

— 

— 


— 

— 

— 

— 

9 2 

i 

Vladimir (government) 




— 


— 


— — 


— 

— 

— 

6 2 

a 

Moscow (town). 



— 1 

— 

— — 

— 

_ 

— | — 

— 

— 

— 

— 

2 1 


•« (government). 



— 1 

— 

_ — 

— 

— 

— — 


— 

— 

— 

15 8 

a, 

Kostroma (town) . 



2 

— 

_ — 

_ 

— 

— 1 

1 

— 

2 

1 

53 22 


•• (government) ... 



8 

4 

6 , 1 

14 

6 

— 2 


— 

— 


205 100 

a 

Ufa (government). 



— 

— 

2 1 2 

5 

5 

— : — 


— 


— 

11 10 


Viatka (town). 


... 


— 

— I — 


— 

— ; — 


— 


— 

9 1 


i« (government) . 



1 

1 

— — 

— 

— 

— j — 


— 


— 

15 6 


Perm (town) . 



— | 


— — 

— 

— 

— — 

— 

— 

_ 

— 

15 10 

* 

tt (government) . 


... 

— 

— 

— — 

1 

1 


— 

— 

— 

— 

6 5 

b 

Ekaterinoslav (town) . 



37 

19 

29 13 

26 

19 

15 10 

10 

6 

8 

3 

146 76 

i 

„ (government) 



i j 

1 

8 1 

6 

2 

4 

4 

1 


— 

37 11 


Don Territory. 



21 

12 

63 21 

39 

22 

14 16 

14 

7 

8 

8 

201 1 102 


Bostof on Don. 



32 

23 

28 16 

8 

5 

11 j 8 

4 

1 

3 

2 

204 1 106 


Kishlncf (town) . 



— 

— 

1 


— 

— 

— 

— 

— 

— 

1 - 

i 

Kief (town) . 



256 

30 

543 126 

202 

68 

147 57 

53 

16 

20 

3 

1237 305 

r. 

„ (government). 



6 

2 

26 21 

74 

31 

49 j 15 

16 

1 

17 

3 

186 75 

M 

Volhynia (government) 



— 

— 

— — 

4 

3 

— — 

— 

— 

— 

— 

14 9 


Tchernigof „ 



2 

2 

25 11 

28 

16 

13 13 

22 

10 

3 

8 

98 63 


Kherson 



— 

— 

— — 

— 

— 

5 — 

— 

— 

— 

— 

11 4 

ie 

Poltava 



1 

1 

11 3 

10 

4 

5 2 

3 

4 

1 

— 

35 16 

c 

Kharkof (town) . 


... 

— 

— 

5 1 

— 

— 

— — 

— 

— 

— 


5 1 

it 

„ (government). 



- 

- 

— - 

— 

— 

4 3 

— 

— 

12 

9 

16 12 

i 

Kiazan (town) . 



3 


— — 

— 

— 


— 

— 

— 


3 “ 


t* (government). 



2 

2 

— — 

1 

— 

— — 

— 

— 

— 

— 

7 5 

- 

Kursk ,« . 



— 

— 

7 2 

16 

8 

13 

31 

12 

10 

1 

95 49 


Minsk .. . 


... 

— 

— 

_ — 

- 

— 

1—1 

1 

— 

1 

— 

5 2 

i 

Mogilef .t . 



- 

- 

- - 


- 


7 

1 

5 

1 | 

39 13 


Tambof tt . 



— 

— 

— — 

— 

— 


— 

— 

— 

— i 

1 — 


oronezh „ 



— 

— 

— — 

— 

— 

— — 

1 

— 

— 

— 

4 1 

( 

Theliabinsk (town) . 



1 

— 

7 3 

— 

— 

— — 

— 

— 

— 

— 

23 11 


Orenburg (government) ... 



— 

— 

— — 

— 1 

— 

5 4 

— 

— 

— 


52 36 


Asiatic Russia. 















Tiflis (town) . 



— 

— 

— — | 

1 

1 


— 

— 

— 

— 

1 1 


Baku (town) . 



21 

8 

24 16 

13 

7 

23 8 

17 

12 

1 

2 

147 77 

! 

tt (government) . 



— 

— 

— — 

— 

— 

— — 

- 

— 

— 

— 

1 1 

j 

Black Sea Government 



— 

— 

— — 

— 

— 

— — 

— 

— 

— 

— 

1. 1 

i 

Krasnovodsk (town) . 



— 

— 

— — 

— 

— 

— — 

— 

— 

— 

— 

1 1 

i 

Krasnoyarsk „ . 



6 

5 

— — 

— 

— 

— I — I 

— 


— 

— 

13 7 

* 

Tashkent „ . 



— 

— 


— 

— 

— 1 — 1 

— 

— 

— 


7 1 

i 

Syr Daria Territory . 



— 

— 


— 

— 

— 1 — 

— 

— 

— 

~ i 

2 2 


Turgai Territory . 


... 

— 

— 


2 

1 

— — 

10 

9 

— 

- 

12 10 


Semipalatinsk (town) . 



— 

— 

8 8 

— 

— 

— — | 


— 

— 


22 16 


„ (territory) ... 



— 

— 

18 5 ; 

— 

— 

— — 

— 

— 

— 


35 15 


Akmolinsk ' ,« 



81 

43 

28 16 

20 

11 

18 9 

9 

4 

23 

13 

548 239 


Tobolsk (government). 



11 

4 

34 14 

- 

— 

— — 

30 

30 

— 

— 1 

154 73 


Tomsk (town) . 



9 

3 

n l 

19 

7 

3 2 

— 

— 

— 

- ! 

42 13 


„ (government) . 

... 


159 

61 

101 60 

39 

46 

42 18 

82 

49 

10 

23 

822 470 


Yeniseisk (government) 



4 

4 

— — 

— 

— 

— — 

— 

— 

— 

— 

15 12 


Irkutsk (town). 



11 

8 

3 — 

— 

— 

— — 

— 

— 

— 

— 

29 13 


Transbaikal (territory). 



— 

— 

— | — 1 

1 

— 

— — 

— 

— 

— 

— 1 

2 1 


- 



896 

- 

1702 | — | 

614 

318 

— — 

410 

225 

182 

105 

11,472 5493 













’51 The LANCET,] CHOLERA IN RUSSIA, PERSIA, AND TURKEY.—THE LUSITANIA. 


[JAN. 4, 1908. 


bacteriologically it appears not to have been one of cholera. 
No other cases occurred in Stamboul. 

A far more serions outbreak of the disease is now running 
its course at the lazaret of Sinope, on the southern shores of 
the Black Sea. The pilgrim steamer, Gregory Merck, which 
had left Odessa on Nov. 22nd (New Style), arrived at Sinope 
on the 24th with 2100 Moslem pilgrims on board. They were 
subjected to the five days’ quarantine now in force for such 
ships. Some suspicious deaths seem to have occurred among 
them at or before their arrival there. On the 28th it was 
reported that a severe outbreak of cholera existed among the 
pilgrims from this ship and the daily telegrams received 
since have confirmed both the intensity of the outbreak and 
the difficulty in bringing it to an end. Between Nov. 27th 
and Dec. 1st 54 cases with 36 deaths were reported ; on the 
2nd there were 2 new cases and 1 death, on the 3rd 5 cases 
and 6 deaths, on the 4th 4 cases and 5 deaths, and on the 
5th 3 cases with 3 deaths. The totals on the 5th had reached 
the high figures of 68 for the cases and 51 for the deaths. 
This outbreak proves once more, if proof were needed, the 
exceptional danger that masses of Moslem pilgrims present 
for the spread of cholera. It is noteworthy that Odessa, the 
port they had sailed from, is, so far as is known, a ’‘clean ” 
port—that is to say, no case of cholera is known to have 
occurred there. The pilgrims in question had, however, evi¬ 
dently come from, or traversed, some of the infected regions 
enumerated in the accompanying table, and the infecting 
material there acquired must have remained dormant, either 
in their persons or in their clothes or effects, until about the 
time of their arrival at Sinope. 

In consequence of this outbreak it has been decided 
that all ships from Russian ports of the Black Sea will 
undergo a thorough inspection on arriving at Kavak at the 
entrance of the Bosphorus ; if a case of cholera is found on 
board the ship will be sent to the Sinope lazaret (if it is in a 
condition to receive any more ships) or to the Russian 
lazaret of Theodosia, where the Russian Government has 
consented to receive them. If no case is found at the inspec¬ 
tion the ship, if there are no pilgrims on board, will be 
quarantined at the Kavak lazaret; but if there are pilgrims 
on board she will be sent to the Clazomene lazaret, near 
Smyrna. A number of other measures, which it would take 
too much space to mention in detail, have also been put in 
force to diminish the risk of further spread of cholera by 
pilgrims travelling from Russia by sea or land. The 
measures on land have been shown to be necessary by the 
discovery that a number of pilgrims were leaving Russian 
territory by way of Roumania or Hungary and, striking the 
main Oriental railway at some point, were arriving in 
Constantinople by train. In addition to the above measures 
the Board of Health has formulated a “j;«•«," desiring the 
Russian Government to do all in its power to prevent the spread 
of the disease by its pilgrims and adding that the end could 
best be attained by subjecting those pilgrims to disinfection 
and isolation for a fixed period before their departure from 
Russian territory. Under Article 87 of the Paris Sanitary 
Convention of 1903 this measure is compulsory, if local 
circumstances permit, if the port where the pilgrims embark 
is infected. It is not, perhaps, clear whether this article is 
of general application, or applicable, like Article 86, only to 
ports of the Indian Ocean and Oceania. It is in any case 
desirable that the preliminary observation befoie departure, 
which has proved to be of such value in India in preventing 
the spread of plague and cholera from that country, should 
also be applied to pilgrims leaving Russian Black Sea ports. 
The outbreak at Sinope has shown what a real danger those 
pilgrims can be ; indeed, owing to the proximity of the ports 
in question, such pilgrims offer a greater danger for the rest 
of Europe than those embarking in ports of the Indian 
Ocean or Oceania. 

Some cases of cholera recently occurred in the lazaret of 
Camaran, in the Kid Sea, among pilgrims from two British 
ships. There were three cases from the first ship and three 
from the second. In reviewing the records of this great 
lazaret it is a striking fact that between 1890 (when complete 
records begin) and 1895 inclusive cholera was imported there 
on 11 occasions ; between 1896 and 1906 inclusive it was not 
imported on a single occasion : now, in the first two months 
of the 1907 pilgrim season, it has been twice imported. In 
1896, it will be recalled, plague first appeared in Bombay ; 
in 1897 the pilgrimage from India was prohibited ; since that 
date it has been permitted, but under certain precau¬ 
tions, the most important of which have been the indi¬ 
vidual inspection of the pilgrims before embarking, the 


disinfection of their clothes and effeots, and the isolation of 
the pilgrims in an observation camp for a fixed period before 
their departure. Some or all of these measures remained in 
force until the autumn of 1906, when the isolation before 
departure was abandoned owing to the fact that the pilgrim 
season, now and for Borne years to come, tends to fall more 
and more in the rainy season when such camps become 
almost uninhabitable. The fact that the Camaran lazaret 
(to which all Indian pilgrims are sent before admission to 
the Hedjaz) remained free from cholera from 1896 to 1906— 
that is to say, for just that period during which the 
departure of pilgrims from India was prohibited or only 
permitted under strict precautions—whereas in the six pre¬ 
ceding years importations of cholera there were frequent, 
and in the early months of the subsequent season two such 
importations have occurred, shows in a very striking manner 
the great value of the precautions in question, and justifies 
the conclusion that among those precautions the isolation 
of the pilgrims before departure must be regarded as one of 
the most efficacious. The measures in question, it should be 
added, were imposed with a view to prevent the spread of 
plague from India, but they have been equally effective in 
controlling at the same time the diffusion of cholera. 

The reports received here of the behaviour of cholera in 
Persia are very incomplete and conflicting. Some cases 
appear to have occurred in the fisheries on the southern 
shores of the Caspian ; on one or more ships plying between 
Astrakhan and Persian ports ; and at Astara, close to the 
Caucaso-Persian frontier. A deadly epidemic is stated to be 
decimating the garrison and population of Kuh-Malik-i Siah, 
on the frontiers of Persia and Beluchistan, but the nature of 
the disease is not known. Persia is reported to have closed 
her Russian land frontiers, except at the four points of 
Djulfa, Khoudaferin, Astara, and Bhahtadfi, where passengers 
are submitted to a medical inspection and other measures. 

Constantinople, Dec. 9th, 1907. 


THE LUSITANIA. 

A Vast Experiment in Ventilation.—An Example 
THAT MAY SERVE ON SHORE AS AT SEA. 

(From our Special Sanitary Commissioner.) 

The Luritania and the Mauretania are two floating 
towns. Big liners have often been compared to floating 
hotels ; but in any case, for these, the two largest ships in the 
world, the word “ town ” is more appropriate. Besides, the 
word “ hotel ” does not cover all the intricacies of the problems 
that have to be solved and the difficulties that must be over¬ 
come. A hotel may be a first-class or a second-class hotel; 
there are not different classes of hotels under one and the 
same roof and management. These big ships, on the contrary, 
are not only first-class hotels but they aie also second-class 
and third-class hotels and hold besides quite a large pro¬ 
fessional, artisan, working-class, and labouring population. 
In a word, all the gradations of people and occupations which 
constitute the population of a town are to be found on 
board. There is the fashionable promenade deck, where of 
late, on the Booth Line as well as on the Cunarders, has been 
introduced the French caf6, with its terrace, round tables, 
and light refreshments served in the open air. Adjoining 
there are not the small cabins where two or four pas¬ 
sengers sleep in such restricted space that only one of 
them can dress at a time but regal suites of rooms, 
drawing-room, dining-room, bedrooms, with real beds 
instead of bunks, and a private bathroom. Yet, while 
there are public and private saloons and other apart¬ 
ments that equal in luxury and art decorations the most 
beautiful palatial residences, these floating towns have also 
their poor industrial districts and even what might almost 
approximate to their slums. It is the firemen’s quarters that 
generally constitute the slum of a ship. On shore there are 
two main causes that bring about the existence of slums. 
There are, on the one hand, the defective construction of the 
dwellings and the unscrupulousness of the speculators in slum 
property ; and, on the other hand, the disorderly, thriftless, 
and dirty habits of the dwellers in the seslums. Legislation, 
at sea as on shore, has stepped in to mitigate these evils. 
At sea the law U6ed to stipulate for 72 cubic feet 
of space and this has now been increased to 120 cubic feet. 
The law not only attempts by such enactments to prevent 
o vercrowding in the quarters occupied by a ship's crew but 




Thk Lancbt,] 


THE LUSITANIA. 


[Jan\ 4, 1908. 55 


it also insists on some sort of ventilation. How such ventila¬ 
tion is to be given in a thoroughly efficient manner is a 
problem that neither the law nor any other authority has 
satisfactorily solved. Fortunately there is now before us 
in these two big ships an earnest attempt made to 
deal practically with the whole question. This endeavour 
commends itself all the more to public notice inasmuch as 
whatever is being done is not done merely for the saloon 
passengers but more especially for the crew and the third- 
class passengers. 

As with some of the dwellers in the slums of our great 
cities, so with the firemen on board, legislation can hardly 
force them to be clean ; but by insisting on 120 cubic feet 
per man this means that there shall be room for lavatories 
and space to wash. The English firemen, and especially 
those recruited at Liverpool, have the reputation of being the 
dirtiest men afloat and they are also the hardest drinkers. 
So we have here the required characteristics for the creation 
of a slum. On the other hand, this dirty and intemperate 
rough is just about the hardiest, the most plucky, and the 
most persistent worker that can be found in any part of the. 
world. It is only with such men in the stokehole that the 
blue riband of the Atlantic can be won. But from the sanitary 
point of view they constitute perhaps the most difficult 
problem that has to be solved. Fortunately, the firemen’s 
dirt is more offensive in appearance than in reality. His dirt 
mainly consists of coal dust and this has a purifying rather 
than a corrupting action. Another great difficulty is that 
after exposure to the scorching furnaces and the heat of the 
stokehole, the firemen, when lying down to rest in their 
bunks, are especially sensitive to draughts. Any ventilator 
admitting cold air at too great a velocity will very promptly 
be closed. In the firemen’s quarters more than in any other 
part of the ship is it necessary to divise means for intro¬ 
ducing a plentiful supply of fresh air without creating a 
draught. Thus it will be seen that on a great ship as in a 
town it is with the poor, the careless, and the dirtier sections 
of the community that the most puzzling administrative diffi¬ 
culties arise. 

Certainly magnificent ships like the Lusitania and 
Mauretania represent exceptionally prosperous towns, such 
as fashionable watering-places frequented by very wealthy 
people and where real poverty and squalor are almost un¬ 
known. Thus out of a total possible population of 3250, 
which both ships can carry, 550 would be first-class and 500 
second-class passengers, and they may be taken as repre¬ 
senting the upper and middle classes. Then there is room 
for 1300 third-class passengers and the crew is set down at 
800 to 900. How navigation has changed of late years is 
Bhown by the fact that while the engineering depart- 
ment employs no less than 390 persons the sailing 
department only employs 70 officers and seamen. Then 
there are 350 stewards, a number of stewardesses, 50 cooks, 
a band, telegraph and telephone and lift attendants, printers, 
and others, making up a total crew numbering from 800 to 
900 persons. The crew represents a population of workers 
of all ranks from the captain, the surgeon, and the superior 
officers who belong to the liberal professions down to the 
coal trimmer or the washers in the scullery who may be 
taken as 1 elonging to the unskilled labouring class. To 
house, to feed, and to keep in health such a mixed population, 
Buch a variety of classes, to say nothing of the variety of 
nationalities, constitutes a series of problems which resemble 
the difficulties that beset the administration of a town 
rather than the management of a hotel. All these people, 
differing so greatly one from the other, have all equal need 
of lodging, food, and cleanliness of person, clothes, and 
bedding. 

In regard to the food supply, the population of these 
large ships are better oil on board than onshore. Cooking 
done on a large scale is likely to be more clean and much 
cheaper than done in detail. Also the food is more strictly 
examined, not merely according to the usual methods, 
but also by the special Board of Trade inspectors. 
Therefore it is prooable that more unwholesome food 
would be found in the retail shops of a town than on 
board ships leaving an English port. In thus comparing 
these very large ships to a small town the fact 
will become evident that we have here an attempt at 
collective administration for an entire community that 
may set an example capable, at least in some phases, of 
application to towns that do not float across the Atlantic but 
are content with remaining affixed to terra firma. Speaking 
now exclusively of the Lusitania and the Mauretania , two 


small floating towns with populations comprising all classes 
and varying from, say, 2300 to 3250, we have provided for all 
these people one and the same system of ventilation and 
likewise the same unique system of cleanliness and washing. 
It is just conceivable that we may find in this a working 
example of what might be done, if not for an entire town at 
least for a district, a cluster of dwellings, especially large 
tenements and blocks, and more particularly for clusters of 
small workshops where industrial dust and inefficient 
ventilation play havoc with the working population. 

Over and over again when dealing with ventilation, 
whether of a great building, a theatre, or, for instance, 
the Paris Sorbonne, or only Dr. T. Glover Lyon’s modest 
and private dining-rcom where not more than 14 persons 
can sit at table, the same inevitable conclusion forces 
itself forward. Obviously no method of ventilation can 
be satisfactory unless mechanical force is employed, and 
intelligently employed—that is to say, modified from 
time to time as the conditions dealt with themselves 
alter. It is alto obvious—and this is admirably demon¬ 
strated by Dr. Glover Lyon's experiment 1 —that mechanical 
force and scientific ventilation could only be obtained 
by very wealthy persons if provided especially and solely 
for one individual. In the case in question the installa¬ 
tion for ventilating one single small room would cost at 
least £150. On board the big ships in question, however, 
ample mechanical ventilation is supplied not merely to the 
wealthy saloon passengers but also to the steerage or third- 
class emigrants and to the poorest among the unskilled 
workers forming part of the crew. All, rich and poor alike, 
workers and idlers, passengers and crew, have fresh air 
pumped down to them all day and all night by mechanical 
power. Doing this on a wholesale scale certainly does not 
cost anything like £150 per room capable of sealing 20 to- 
dinner. It would be of considerable practical use to know 
what is the cost per head of the mechanical ventilation 
applied to these ships. 

The system as installed on the Mauretania has already 
been described.’ This was, however, a theoretical descrip¬ 
tion, and since then I have had a brief opportunity of seeing 
the same system in actual work on board the Lusitania. 
With the courteous permission of the Cunard Company, and 
accompanied by the ship’s surgeon and also by members of 
the staff of engineers, I visited all parts of the ship while 
she was on her way from Liverpool to Queenstown. The 
weather, however, was not propitious. Everything went 
wrong and the only consolation is that there is no 
reason why the experiment should not be repeated 
in more favourable circumstances. At 7.30 p.m. on 
Saturday, Nov. 30th, the Lusitania was to start from the 
Liverpool landing stage for Queenstown and New York. At 
midday I was to take the large tender, the Skirmisher, meet 
the chief engineer, Mr. Leonard Peskett, and spend the 
afternoon with him examining the whole system of venti¬ 
lation before the ship came alongside the pier to embark the 
first- and second class passengers. Mr. Peskett managed to 
get on a small tender with some workmen. After crawling 
through the fog for an hour they came upon the Lusitania 
and it was only after bumping up against her Bides that they 
discovered it was the ship for which they were looking. The 
other tender which I was awaiting was lashed alongside the 
Lusitania and did not venture to leave the ship till some 12 
hours later, at about 1 o’clock in the morning when the fog 
lifted. In vain I waited on the landing stage in the thick of 
the fog from noon till nearly 4 o’clock in the afternoon. Some 
800 emigrants were there also, as they should have gone on 
board in the morning by tenders. They suffered from cold and 
damp, then later from hunger. The little buffet on the land¬ 
ing stage was soon stripped of all its provisions. There were 
other ships, a Booth line steamer for Portugal and the 
Brazils and an Elder Dempster line steamer, to say nothing 
of the cross Channel services to Ireland and the Lie of Man 
with their quota of passengers, all on the look-out 
for tenders or ships that could not find their way 
through the fog, and as these people, numbering more 
than a thousand passengers, waited and waited for 
hours they got more cold, more damp, and more hungry. 
The smaller steamers were at anchor near the landing stage 
and tenders managed to get off to them later in thealternoon. 
Bat the huge Lusitania was anchored far away near Hock 
Ferry and in so thick a fog could not be reached by the 
tenders. Food in carts and great caldrons of hot tea and 

1 See The Lamckt, March lot, 1902, p. 620. 

* See The Laxcet, Nov. 23rd, 1907, p. 1182.) 




56 The Lancet,] 


THE LUSI1ANIA. 


[Jan. 4,1908. 


coSee had to be brought down to the landing Btage bo that 
the emigrants might be fed and kept warm. Finally the 
hope of Btarting that day was abandoned and all the 
emigrants marched back to their lodgiDgs, and rooms were 
secured in the hotels for the first- and second-class passengers. 
By this time I had learnt something as to the difficulties 
of navigation in such a climate as onrs but was not any 
further enlightened in regard to the problem of ventilation. 
Fogs of such density as completely to paralyse all traffic 
on the Mersey do not often occur but they are to be expected 
occasionally. As, however, they may at any moment and 
quite suddenly disappear the passengers dare not leave 
the pier. In such circumstances it seems to me that 
better shelter and better and more numerous fires might be 
provided in better furnished and more comfortable wait¬ 
ing rooms. The Prince's landing-stage at Liverpool is a 
very pleasant and interesting place on a fine summer's day 
but it is just the reverse during rigorous winter weather. 

On the next morning a little after 6 o’clock telephone 
messages were ringing up the passengers at all the hotels and 
by 8 o’clock a large crowd had already gathered on the 
pier. Soon the great ship loomed through the morning haze 
and was lashed alongside ; then with incredible speed all 
the passengers and all their luggage were taken on board. 
This haste, however, was of no service ; the big ship moved 
away from the landing stage but could only descend the 
river a mile or two and then the fog once more thickened 
and it was necessary to cast anchor. But, in any case, I 
was at last on board the ship and profited by this delay to 
have a thorough look round. It was, however, soon obvious 
that the ventilating system was not yet in working order. 
The experience acquired on this occasion was very valuable. 
It conclusively demonstrated that it does not suffice to have 
a Bystem of ventilation installed, however perfect it may be. 
Indeed, it seems only natural to conclude that the better the 
system the greater will be the intelligence required in its 
handling. It is only technicians who should be intrusted 
with instruments of precision. It would not be wise to hand 
over expensive chemical scales to the tender mercies of a 
greengrocer. Obviously the study of navigation does not 
include the management of ventilating fans and steam coils 
used for warming purposes. On the Luritania the officers’ 
quarters really consist of a small separate house built on the 
upper—that is, the navigation—deck, with its own special 
thermo-tank on its roof or deck. These thermo-tanks, the 
manufacturers state, ‘ ‘ are capable of changing the air either 
by exhaust or supply in the various compartments to which 
they are connected at least ten times per hour and they are 
also capable of maintaining a temperature of at least 65° F. 
in the coldest weather.” Doubtless this is so when 
they are properly managed. Fig. 1 is the reproduc¬ 
tion of a photograph which I took of the thermo-tank 

Fia. 1. 



The thermo-tank ventilating and warming apparatus for the 
officers’ quarters. 

above the officers’ quarters. There is, it will be seen, no 
lack of means to regulate the supply of air and heat. 
Nearest to the part containing the rotary fan to the left is a 
valve for regulating this fan when used for exhausting pur¬ 
poses. In that case the mushroom covering of the cylindrical 
part which contains the steam coils is raised to enable the air 


drawn from below to escape. If the fan is made to revolve in 
the contrary direction then it pumps air down after passing it 
over the steam coils when it is desirable that it should be 
warmed. The second valve regulates the supply of air ; the 
third regulates the supply of steam to the heating coil; and 
the fourth regulates the flow of steam from the heating coil 
back to the condenser. But that is only a part of the 
mechanism. There are means of regulating the velocity at 
which the fan revolves when it pumps the air into the 
ship and so directing the fresh air that only a portion of it 
goes over the heating coils and the rest descends fresh into the 
cabins. There is also means of discharging a small atomised 
steam-jet into the air so as to add moisture in excessively dry 
weather. With all this at their disposal I had hoped to find 
the officers living in an ideal atmosphere and temperature. 
As a matter of fact, the apparatus had been so worked 
that after suffering from such excessive heat that 
the woodwork in the cabins showed signs of warping 
the officers were glad to cut off all connexion with their 
thermo-tank. Consequently, as there were no other means 
of warming, the cabins were very cold, and as for 
ventilation that depended on the accident of open doors or 
portholes. Of course, this state of affairs will not last. 
The thermo-tank will have been set to work again and this 
time it is to be hoped properly regulated. But the incident 
is instructive, because it shows that even with the best 
machinery ventilation cannot work automatically : it must 
be watched and controlled carefully and by a technician. 

In the firemen’s quarters the experience was just the 
reverse ; their thermo-tank was working vigorously, in fact 

Fig. 2. 



A therrao-tank for the second-class cabins, showing the " starting 
rheostat.” 

too vigorously, and the air which it sent down was too cold. 
Consequently most of the air inlets were closed. A fireman 
was attempting to sleep in an upper bunk within three or 
four feet of the trunk shaft in which the air descends and 
which is affixed to the roof of the cabin. There was a 
valve just facing this fireman and I opened it. Obviously 
had 1 not closed it again the man could not have 
remained in his bunk. The cold air rushed in with great 
force creating a dangerous draught. Evidently the thermo¬ 
tank supplying this compartment was working too fast and 
had not warmed the air sufficiently, if at all. Then there 
was no sort of bailie, nothing to break up and to disperse the 
current of air as it rushed through the valve aperture. But 
it is not necessary to pump the air down at such a rate that 
it creates a nuisance. Fig. 2 shows a thermo-tank placed 
outside a structure which • serves as a light and air trunk to 
the condenser room and stands on one of the decks reserved 
for the second-class passengers. Above and to the left a 
small box-like arrangement with two pipes coming out 
underneath is called the “ starting rheostat.” This is used 
for starting and regulating the speed of the fans. Therefore 
the velocity at winch the air travels can be controlled ; only 
someone must watch in order to see what is needed and to 
act accordingly. Then I photographed a row of thermo-tanks 
near the great funnels which supply the first-class state¬ 
rooms. (See Fig. 3.) Just as the air leaves the thermo¬ 
tank and commences its journey to the cabins below a small 
hole has been out in the trunk air shaft and a thermometer 






Tas Lancet,] 


THE LUSITANIA. —BIRMINGHAM. 


introduced. There is a thermometer thus attached to ever} 
thermo-tank and it is therefore easy to ascertain promptly 
what is the heat of the air pumped down into the ship. But 
again someone must see to this and find out what the heat 
ought to be according to the distance to which the air has 
to travel, the needs of the part of the ship which it has to 
supply, and the general condition of the weather at the time 
in question. 

To meet these ever-varying conditions numerous and very 
careful experiments will have to be made. Every thermo- 
tank bears an inscription stating what part of the ship 
it supplies, and considering the variety of the distance and 
the disposition of the different compartments no one rule 
would apply. On the Mauretania there are 65 thermo-tanks 
and they pump air through 17,000 feet of trunking. Thus 
there are in all three and a quarter miles of air channels, made 
for the most part of galvanised sheet iron and including 
some 5000 bends, T-pieces, &c. Is it conceivable that air 
can be automatically propelled along this enormous distance 
at exactly the rate and temperature desired ? All honour to 
the constructors of these splendid ships for having introduced 

Fl3. 3. 



A row of thermo-tanks supplying air to the (irit-elass state-rooms. 


such a vast and comprehensive system of warming and venti¬ 
lating. But it would be a fatal illusion to imagine that ail 
this will work when once wound up like an eight-day clock 
and that it need not be touched again till the end of the week. 

The Lusitania has not quite as many thermo-tanks as the 
Mauretania but there is no practical difference between the 
two ships. When I looked at the thermometers attached to 
the thermo-tanks I found that their temperature varied from 
55° to 120° F. ; this showed that some of these apparatus 
had not yet been regulated. Doubtless all this was rectified 
when the ship got further under way. Bat the fact that this 
was not done at starting shows how difficult is the problem 
and how much still remains to be achieved before experienoe 
has taught the lessons that have yet to be learnt. It will be 
necessary to secure the services of a few thoroughly com¬ 
petent engineers to regulate these apparatus, to visit 
and to watch over all parts of the ship, and to be constantly 
verifying whether the system is working properly. It will 
also be necessary in many instances to make considerable 
alterations in the valves, notably in the firemen’s quarters, 
where the air is admitted, so that it may be split up, diffused, 
and not create an injurious draught. But it will at onoe be 
seen that these finishing touches to the system represent a 
mere trifling outlay when compared with the vast sums that 
must have been spent over the thermo-tanks, the 2000 h.p. of 
electricity used, among other purposes, for settiDg the 
fans in motion, the three and a quarter miles of air trunks, 
the condenser and steam-heatiDg coils, Ac. We have now 
reached the stage when it is only necessary to apply the 
old saying, namely, “Not to spoil the ship for the sake of 
a pennyworth of tar.” There can be little doubt that 
in the course of a few months when the necessary experience 
is acquired the great problem of warmiDg and ventilation 
will practically be solved in regard to these great ships. 
Indeed, I have just been informed that the patentee of the 
ventilation apparatus and the draughtsman who had charge 
of this particular section of the work sailed in the Mauretania 


[Jan. 4, 1908. 57 


on her last voyage to regulate the valves and to see to all the 
details. As a result no complaints have been made. On 
Saturday, Dec. 28th, the manager of the ventilating system 
and the draughtsman sailed with the Lusitania and it is 
anticipated that they will be equally successful in putting 
everything in order. The whole system has been carefully 
gone over and there is no reason why the defects should not 
oe remedied now that efficient technicians are on board. If 
so we shall have here a most valuable object-lesson. 
Throughout I have compared the ships to towns, and I 
believe that much of what is done on board could with equal 
economy and benefit be applied on shore. Why not consider 
a thoroughfare of large houses, such as Victoria-street, to 
represent on one side the Mauretania and on the other side 
the Lusi'ania, and proceed to warm and to ventilate all the 
rooms in a similar manner? The experience now in the 
conrse of acquisition on board these great liners may be of 
use on shore as well as at sea. The entire nation has 
manifested enthusiastic pride in these magnificent record- 
breaking ships. For my part I see their utility not merely 
in regard to quick and lnxnrions travelling but as a vast field 
of experimentation where some of the most difficnlt problems 
affecting the sanitation of dwellings and of workshops may 
find an effective and economic solntion. 


BIRMINGHAM. 

(From our own Correspondent.) 

luberculous Milk. 

The medical officer of health, Dr. J. Robertson, reports that 
after prolonged investigation it is found that 14 per cent of 
the milk sent into Birmingham contains living tubercle 
germs. The health committee, having considered the 
report, has decided to recommend that, in the event of the 
Government not taking the matter up and as the existing 
legal powers are not sufficient to enable effective steps to be 
taken to deal with this “ grave danger to the public health,” 
additional local powers shall be sought. The position of the 
health committee would be strengthened if it could give 
some definite idea of the effect produced by the contaminated 
milk in any particular cases. 

The\Medical Students’ Dinner. 

The annual dinner of the Birmingham University Medical 
School was a more than usually successful event. There was 
a good attendance to meet Dr. W. Hale White and Dr. 
William Wright, the latter of whom was a great favourite 
with the Btudents when he held the post of senior demon¬ 
strator in the anatomy department at Birmingham. The 
speeches were good but rather long, and the humorous vein 
was a little lacking except in Mr. H. G. Barling's reply for 
the medical school. One opinion that Mr. Barling expressed 
when he passed into a serious phase is well worthy the 
attention of the public and of the authorities of schools who 
are constantly struggling to increase the number of their 
students. He stated that he would prefer 100 well-educated 
medical men to 200 who were imperfectly educated, and he 
expressed the belief that the public would be better served 
by the former than by the latter. 

Distribution of Prizes at the Dental Hospital. 

Considering the great demand there is in the Midland 
district for dentists, it is somewhat surprising to learn from 
the statements of the speakers at the annual distribution of 
prizes at the Dental Hospital and at the annual dinner of 
the Dental Students’ Society that the number of the students 
at the Dental Hospital does not exceed 30. The only reason 
that can be assigned is that in years gone by the Dental 
Hospital did not offer all the facilities which could be desired. 
Such, however, is not the case to-day; the hospital is now 
ODe of the most efficiently equipped in the country and the 
staff are energetic and determined. It may be hoped, there¬ 
fore, that the number of the students will rapidly increase 
and that the wants of the district will be properly supplied. 
Mr. W. F. Haslam. who spoke after the distribution of the 
prizes, drew special attention to the necessity of students 
avoiding desultory reading, and his remarks are particularly 
important to Birmingham students who have a tendency to 
distribute their energies over too many objects at one time. 

Hospital Sunday Collections. 

At last the full accounts of the Hospital Sunday collec¬ 
tions in Birmingham for 1907 are to hand and they show 






58 The Lancet,] 


BIRMINGHAM.—MANCHESTER. 


[Jan. 4, 1908 


an ' improvement of about £300 on the collections of 
the previous year. So far as it goes this is satisfactory, 
but it is not what was hoped for, and it appears from 
the statement of the Lord Mayor, who presided at the 
recent meeting of the friends and supporters of the Hospital 
Sunday Fund, that the active sympathy and help of all 
religious denominations which it was hoped would be 
secured on behalf of the collections were not obtained. 
This is greatly to be regretted, for the one virtue which 
should be common to all religions is that of charity. 
Whilst it mnst be admitted that the Hospital Sunday 
collections in Birmingham were not what was desired, 
the case in Dudley is still worse. In the area from which 
the Guest Hospital, the Dudley Dispensary, and the Dudley 
Eye Infirmary receive patients are 146 churches and chapels 
and the average amount which they collect for hospital 
purposes is £67 per annum. This is scarcely surprising when 
it is found that at a meeting called to discuss the question, to 
which the heads of all the religious bodies had been invited, 
only three ministers and three laymen attended. Clearly 
there is something wrong in the Dudley religious organisa¬ 
tions, and unless some adequate explanation can be put 
forward the surrounding districts will be inclined to point to 
Dudley as an example of considerable laxity so far as the 
Hospital Sunday Fund is concerned. 

The Health of Brass Casters. 

An inquiry has recently been held in Birmingham at which 
evidence was produced by the employers who object to some 
of the draft regulations which the Home Department has 
proposed with the object of regulating the arrangements 
in brass-casting works in order that the standard of health of 
the workers may be improved. So far as the Birmingham 
trade is concerned it is obvious that in fairness to the workers 
something must be done, and judging from the statements 
made by some of the witnesses useful and efficient 
means of diminishing the dangers of the work by removal 
or dispersion of the dangerous fumes can be adopted 
without the incurring of any prohibitive cost and without 
impairment of the efficiency of the work. Apparently, how¬ 
ever, the brass casting in other places is not the same aB in 
Birmingham and an application was made to the Home 
Office Commissioner that further evidence should be taken in 
Glasgow, Newcastle, and London before final regulations 
were decided npon, and to this obviously reasonable proposi¬ 
tion the Commissioner agreed. There can be little doubt 
that a fair solution of the difficulty of dealing with what is 
an acknowledged evil will eventually be arrived at and that 
the workers at the trade of brass casting will materially 
benefit. 

Dec. 31st, 1907. _ 


MANCHESTER. 

(From our own Correspondent.) 


Christmas in Manchester. 

From Christmas Day, and even from a few days earlier, to 
the close of the old and the advent of the New Year Man¬ 
chester is much given up to holiday, and the same is true of 
Lancashire as a whole, ft is sometimes said that this festival 
season is more generally, or at all events more heartily, kept 
than in the south ; bat however that may be, Manchester can 
claim that " Dr.” Byrom. the author of the best and widest- 
known of all Christmas hymns, “Christians, awake," was one 
of her townsmen, and that Wainwright, the composer of the 
tune almost universally sung to it, was from Stockport. 
Byrom studied medicine at Montpellier and waB termed 
“ Dr.” by his friends, but he never took his degree. He 
was an adherent of, or at least favourable to, the cause of 
the Stuarts, as is pretty evident from the toast to the King 
which he is said to have proposed. The version known to 
the writer, for there are said to be some slightly varying, is 
as follows:— 

God bless the King, God bless the Faith's Defender, 

G< d bleBa—no harm in blessing—the Pretender; 

But which Pretenner is, and which is King, 

God blesB us all, is quite another thing. 

The season is marked at the various hospitals by entertain¬ 
ments to please both young and old, and the inmates of the 
workhouses are'not forgotten. Perhaps the Christmas 
festivity at the Children’s Hospital at Pendlebnry may 
be taken as an illustration of what is done to brighten, 


for the time at least, the pain and weariness from 
which the patients too often suffer. There are about 
160 children there and on Christmas morning each one 
finds at the comer of the bed a stocking full of odds 
and ends. Then large Christmas trees are brought into 
the wards and round them the nurses are very busy. In 
due time the trees burst out in a display of coloured 
lights, while more or less bulky parcels are seen hanging 
from the branches, each one having the name of one 
of the little patients, all of whom are keenly interested in 
the proceedings. The routine of the hospital cannot be 
suspended too long, but for two hours the children were 
allowed not only to enjoy their new toys but to be made 
much of by the visitors whose sympathy and kind words 
must often cheer the sufferers. The patients are all under 
14 years of age and receive presents suitable to their years, 
some of the older girls, for instance, having work-boxes. 
Carols were also Bung by the members of the choir of 
Holyrood Church, Swinton, who walked in procession through 
the wards and corridors. There are, of course, differences 
in the procedures at the various hospitals, but the main object 
is to add to the enjoyment or to lessen the sufferings of the 
patients. 

A Large Family. 

A female claimant at the St. Helens county court 
surprised the judge one day lately by saying that she had 
plenty to do with the money, as she bad 21 children. This is 
unusual enough, but even this family was smaller than that 
of a late rector of Eccleston, near Chester, who was some¬ 
times said to have had 21 children twice over, the fact being 
that after the death of the twenty-first child another was 
born, so that his wife was the mother of 22 children. 

Death of Mr. E. M. Wilkins , M.B. Viet., M.R.C.8. Eng. 

Dr. Eric Maurice Wilkins, son of the late Professor Wilkins 
of the Victoria University, was found dead yesterday at his 
house in Victoria Park. No details are as yet known. He 
was 27 years of age and was a remarkably skilful athlete. 

Coroner's Busy Day. 

The festive season is too often shadowed by tragedy. 
Nearly 20 sudden deaths were reported the other day and 
inquests were held in 12 cases and the jury were occupied in 
viewing bodies (that old custom against which so much can 
be said and something also in its favour) for almost three 
hours. Four children sleeping with their parents were found 
dead in bed. The coroner took a very charitable view of the 
matter, attributing it in part, at all events, to the very cold 
weather. In all likelihood the children habitually slept 
with the parents without fatal accident, but if the in¬ 
dulgence of a little extra drink at Christmas time had 
been yielded to the probability of overlying would be 
enormously increased. It is, however, the idea among 
parents that there is no danger in the practice if we may 
judge by the answers to the questions put by the coroner. 
Two women, one aged 50 and the other 58 years, were killed 
by falling down cellar steps on Christmas Day. 

Crowded Asylums. 

The overcrowding of the County Asylum is becoming more 
acutely felt. The Lancashire Asylums Board has intimated 
to various boards of guardians that it wishes them, if 
possible, to accommodate some of the harmless chronic 
patients. The Prestwich guardians have just discussed the 
subject. It was suggested that when the new union 
infirmary was opened in the year on which we are just 
entering some room would be available at Crumpsall. The 
house committee is to consider the question. It seems 
as if all estimates tend to grow so vigorous as to be irre¬ 
pressible. Then, too, the problem of the unemployed, some 
of whom [if they seek for employment do not want work, and 
the unemployable is always present, and apropos of this the 
board approved a resolution passed by the parish of 
Paddington urging on the Local Government Board the 
necessity of speedy legislation for the establishment of 
“ labour colonies ” on the lines of the Swiss system. 

The Manchester Crematorium. 

The annual meeting in connexion with the Manchester Cre¬ 
matorium was held yesterday. The report states that in the 
year 104 cremations took place and that there was a profit of 
£100. The chairman said that the late Bishop Fraser, Bishop 
Moorhouse, and Dr. Knox, the present Bishop of Manchester, 
all approved of cremation. The secretary Baid he thought 
that the movement was retarded by the conditions of the 



Thr Lancet,] LIVERPOOL.—WALES AND WESTERN COUNTIES NOTES.—SCOTLAND. [Jan. 4 1908. 5£ 


Cremation Act, 1902. and suggested that the whole of the 
crematoriums in England and Scotland should join together 
and see if the; could not get the rules and orders altered, 
such rules not being required in cases of ordinary burial. 
The precautions alluded to were, of course, intended to be 
safeguards against crime, but if they can be made less 
inconvenient and yet effective safeguards no one would be 
likely to object. The suggestion of the secretary was 
.adopted and he was asked to write to the authorities of the 
crematoriums. 

Dec. 31st, 1907. _ 


LIVERPOOL. 

(From our own Correspondent.) 

Liverpool Education Committee: Medical Inspection of 
School Children. 

The chairman of the education committee of the city 
council at its meeting on Dec. 23rd last moved the adoption 
of the report of the special medical inspection of school 
children subcommittee, which had expressed the opinion that 
the work of inspection could best be carried out under the 
immediate control of the education committee, and recom¬ 
mended that a special medical officer should be appointed for 
the purpose at a salary of £4C0 per annum. The subcom¬ 
mittee's intention was to take the medical officer of health 
into consultation but to retain the control itself. It did 
not wish to clash with any other corporation committee and 
according to the chairman of the education committee 
they had no desire to override the work which Dr. E. W. Hope 
had already done outside the schools and they desired that that 
work should still be continued. Alderman Salvidge opposed 
the recommendation on the ground that it would create a 
new department, whereas it had not yet been proved that 
the present health authority was unable to carry out the 
extra duties suggested. He moved that the recommendation 
should be referred back to the subcommittee in order that an 
opportunity might be afforded it of discussing the matter with 
the healtli committee. The amendment having been duly 
seconded was agreed to. 

Liverpool School of Tropical Medicine: The Prevention of 
Yellow Fever. 

A despatch has been received by the secretary of the 
Liverpool School of Tropical Medicine from the Foreign 
Office respecting the presentation of the Mary Kingsley 
medals conferred by the school upon Senator Professor Golgi 
(Italy), Dr. Charles Finlay (Cuba), Professor Danielewsky 
(Russia), and Professor Theobald Smith (United States). 
The despatch was accompanied by a translation of a lengthy 
report from the Official Gazette of the Republic of Cuba of 
the ceremony at which the medal was handed to Dr. Finlay, 
the discoverer of the mosquito theory of yellow fever, by the 
Provisional Governor of Cuba. The ceremony took place at 
the great ball of the University oi Havana in the presence of 
a distinguished gathering, and the speeches delivered 
were so interesting that some are worth reproducing at some 
length. The Hon. Charles E. Magoon, Provisional Governor 
of Cuba, presided, and in handing the medal to Dr. Finlay, 
said: “An important foreign scientific institution, the 
Liverpool School of Tropical Medicine, in recognition of the 
eminent services rendered by Dr. Charles Finlay in his 
devotion to the cause of science, which culminated in his 
discovery of the agent by which the yellow fever germ is 
transmitted, has conferred upon him the Mary Kingsley 
memorial medal. This medal was designed upon the 
death of the famous African traveller, whose name 
it bears, in commemoration of her labours in the 
tropics, to be bestowed upon those persons who may 
have distinguished themselves in special work and re¬ 
searches in tropical medicine, and has been received by 
the Government of Cuba from the Minister of His Britannic 
Majesty with the request that it be officially handed to Dr. 
Finlay.” The Rector of the University having addressed Dr. 
Finlay, the latter replied thanking the speakers, the 
University, and the Liverpool School of Tropical Medicine. 
Referring to the Liverpool school he said: “ I wish 

more especially to return thanks to the Liverpool School 
of Tropical Medicine for the honour they have done 
me in conferring upon me the Mary Kingsley memorial 
medal. The honour is shared with Colonel W. 0. 
Gorgas of the United States Army. The same distinction 
has also been bestowed upon Manson, Laveran, Ross, Koch, 


and others who in different parts of the world are associated 
with the labours of the school founded by the mercantile 
community on the banks of the Mersey.” 

Deo. 31st. 1907. _ 


WALES AND WESTERN COUNTIES NOTES. 

(From our own Correspondents.) 

Homing in Swansea. 

The Swansea corporation has decided, upon the recom¬ 
mendation of the housing committee, to erect 55 houses at 
a cost of £180 each, to be let at a rental of 5< 6 d. weekly, 
and 44 double tenement hoi sts at a cost of £300 each, to 
be let at a rental for each tenement of 4*. 6 d. weekly. 
Arrangements are in progress for holding an exhibition of 
cottages and a conference oa the 1 ou-ing qn»>-tion in 
Swansea under the auspices of the National Housing Council. 
The corporation is the owner of several large plots of land 
in the town and it is probable that one or more of these may 
be utilised for the purposes of the exhibition. 

An Asylum for Swansea. 

Since the establishment of the county asylum at Bridgend 
that institution has been available for patients resident in 
Swansea. The rapid growth of the county of Glamorgan 
led the asylum committee to give notice first of all to the 
Cardiff corporation and later to the corporation of Swansea 
to terminate the then existing arrangements and to provide 
separate accommodation for the needs of the two towns. 
Unsuccessful efforts have been made to make arrangements 
for sending Swansea patients to the asylum at Talgarth, 
which is owned jointly by the county councils of Brecon and 
Radnor, and it appears now to be probable that suitable 
accommodation will be provided by the erection of a building 
in the borough of Swansea upon land already in the 
possession of the corporation. Merthyr Tydvil having 
become incorporated will also have to sever its connexion 
with the county asylum and a suggestion has been made 
that the corporations of Merthyr and Swansea might advan¬ 
tageously combine for asylum purposes. There are over 300 
Swansea lunatics at Bridgend and about 200 from Merthyr. 

The Cardiff Mental Hospital. 

It is expected that the Cardiff Asvlum, or, as it is officially 
designated, the Mental Hospital, will be ready for occupation 
in about three months’ time. The equipment of the institu¬ 
tion is very complete and has been carefully thought out— 
so carefully, indeed, that the committee of the corpora¬ 
tion concerned with the erection of the buildings has had 
to stand a great deal of adverse criticism on account 
of the cost which has been incurred. This criticism 
has hitherto had but little effect in preventing the accom¬ 
plishment of what was really necessary. With such an 
excellent record it is difficult to understand the attitude of 
those members of the committee who have been able 
successfully to postpone the erection of an isolation hospital. 
In the original scheme this building was provided for at an 
estimated cost of about £3000. and although the medical 
superintendent (Dr. E. Goodall) expressed the opinion that 
the cost need not exceed £2000 it has been decided by 
4 votes to 3 to postpone the erection of this building until 
a future date, presumably until an outbreak of some 
infections disease has occurred which will prove its 
necessity. The majority of the members of the committee 
were evidently influenced in their decision by a report pre¬ 
sented to them showing that although most of the asylums 
in this country were provided with isolation hospitals they 
were very rarely used. In spite of this it is quite certain 
that the Commissioners in Lunacy will quickly draw the 
attention of the committee to the absence of this very 
necessary accessory to every well-ordered asylum. 

Dec. 31st, 1907. _ 


SCOTLAND. 

(From our own Correspondents.) 

St. Mungo's College. 

The Faculty of Medicine of St. Mungo's College has pre¬ 
sented a memorial to the governors of the College in which 
it states its views as to what should be done in order to 
insure the prosperity and even the existence of the College. 




60 The Lancet,] 


SCOTLAND.—IRELAND.—BUDAPEST. 


It is the unanimous opinion of the Faculty that the only solu¬ 
tion of the present difficulty lies in maintaining a complete 
medical school in connexion with the College with classes 
covering every subject in the curriculum. It points out 
that it was the absolute necessity of a proper supply of 
students for the wards of the Royal Infirmary that caused 
the Royal Infirmary Medical School to be brought into 
existence by the managers and this also constitutes the 
reason why the school should continue to exist in 
its entirety in the future. It is said that as a hos¬ 
pital without students the Royal Infirmary would fail to 
secure the services of the most eminent physicians and 
surgeons upon its staff, except in so far as appointments at 
the Royal Infirmary might be regarded as stepping stones to 
similar positions at the Western Infirmary. It has been 
generally admitted that in the interests of the Royal 
Infirmary it is eminently desirable that its own medical 
school should be adequately endowed and affiliated to the 
University of Glasgow, and it was for the accomplishment of 
this purpose that the affiliation section was introduced into 
the Universities Act of 1889 at the instance of the managers 
of the Glasgow Royal Infirmary. In our opinion (says the 
memorial) affiliation is the only solution of the difficulty. As 
to the sum necessary to enable the governors to seek affiliation 
it is for the Universities Committee of the Privy Council to 
fix this; the University itself has no say in the matter. 
In this connexion, however, it is pointed out to the 
governors that prior to the absorption of the Queen Margaret 
College for Women by the University the University Court 
passed a resolution in favour of the actual affiliation of that 
College, the endowments of which amounted to between 
£40,000 and £50,000 in addition to the buildings. The 
memorial then goes on to deal with the probability of 
University students voluntarily attending their later classes 
at the Royal Infirmary if their earlier classes were taken at 
the University. The University has no power to compel any 
of its students to study in the Royal Infirmary wards, and 
the St. MuDgo’s Faculty is of opinion that no means short 
of compulsion would secure Euch attendance by men who 
have for three or four years been attached to another 
teaching centre. Attention is drawn to the fact that the 
experiment of sending students to other institutions for their 
earlier studies was actually made by two of the London 
schools and this experiment resulted in failure. 

7 he Medical Profession and Notification of Births in Bhugom. 

A deputation representing the medical profession in 
Glasgow waited on the health committee of the town council 
last week to explain the attitude of the profession towards 
the Notification of Births Act which the corporation has 
decided to put into operation in the beginning of the year. 
The medical men of the city already, through a deputation 
when the omnibus Bill was under consideration last spring, 
assured the corporation of their entire sympathy with the 
object of the Bill, namely, the reduction of the infantile 
mortality amongst the poorer and less informed classes of 
the community. They are now of opinion, however, that 
the means by which this object is sought to be attained 
in the Notification Act, in the form In which it has 
emerged from Parliament, are clumsy and in certain 
respects of a highly objectionable character. The deputation 
urged that to make notification compulsory for the medical 
man would be contrary to the obligations of the medical 
oath. It was further pointed out that the cases with which 
the Act was intended to deal were not for the most part 
attended by medical men. This fact was illustrated in recent 
reports by the medical officer to the corporation, in which he 
showed that in the Cowcaddens district of the city, for 
instance, in which the infantile mortality is deplorably high, 
there was no medical man present in 76 percent, of the births 
investigated. The medical profession in Glasgow propose 
in the case of each birth in connexion with which they are 
called in to place in the hands of the father or other 
responsible person a simple form of notification with 
directions for its transmission to the medical officer of health. 
The deputation concluded by asking the corporation without 
adopting any resolution on the subject to accept such notifi¬ 
cation as falling within the scope of the exemption clause of 
the Act, which provides that no person Bhall be liable to a 
penalty if he has reasonable grounds to believe that notice 
has been duly given by some other person. 

Crathie and Braomar Parish Council: Medical Officer ship. 

At the first meeting of the newly elected parish council of 


[Jan. 4. 1908. 


Crathie and Braemar held on Dec. 13th, 1907, it was moved, 
in regard to the uppointment of a medical officer— 

That in the opinion of the majority of the council the appointment 
of the present medical officer was irregular; that three months’ notice 
of dismissal be given and the usual steps taken for the filling of the 
vacancy. 

Objection was made to the motion that it was incompetent, 
out of order at the meeting, and at the best only based on a 
matter of opinion. It was also pointed out that at the date 
of the appointment referred to a copy of the minutes and all 
particulars connected were forwarded by the clerk to the 
Local Government Board and that the clerk received con¬ 
firmation of the appointment. The motion was carried by 
6 votes to 2. 

Perth Royal Infirmary: Reconstruction .^oheme. 

The subscriptions towards the reconstruction scheme for 
Perth Royal Infirmary now total £14,601. 

Dec. 31st, 1907. _ 


IRELAND. 

(From our own Correspondents.) 

Lord Kelrin. 

Very great sorrow in Belfast was felt at the announce¬ 
ment of the death of Lord Kelvin who was born in Bdfast 
in a house still existing in College-square East (No. 18), at 
present occupied by a member of the medical profession. 
Lord Kelvin’s father, Dr. James Thomson, came originally 
from Ballynahinch, in county Down, and was professor of 
mathematics in the old Belfast Academical Institution. He 
wrote a famous book, “Thomson’s Arithmetic,” long 
popular in Ulster, and he was afterwards professor of mathe¬ 
matics in the University of Glasgow where Lord Kelvin 
studied before going to Cambridge. 

The Tuberculosis Exhibition. 

On Dec. 17th, 1907, in the presence of a large audience, Her 
Excellency the Countess of Aberdeen opened the Tuberculosis 
Exhibition in Lurgan and formed the Lnrgan and Dis¬ 
trict Branch of the Women’s National Health Association of 
Ireland. On the 18th Sir John Byers gave a lecture on Why 
Tuberculosis is so Common in Ireland: on the 19th Dr. 
John McCaw lectured on Tuberculosis in Children ; on the 
20lh Professor W. St. Clair 8ymmers gave an address on the 
Germ of Tuberculosis and some of its Effects; and on the 
21st Professor Mettam, F.R.C.V.S., lectured on Tuberculosis 
in Animals. There were immense audiences and the great 
success of the tuberculosis exhibition in Lurgan is due to 
the unceasing exertions of Dr. Samuel Agnew, medical 
officer of health of Lurgan. 

Hospital Medical Reports. 

It is always pleasant to record the publication of medical 
reports by hospitals, for they save much valuable material 
from oblivion. The lateBt hospital to publish its records 
is the Ulster Hospital for Children and Women and Dr. 
H. H. B. Cunningham is acting as editor. The first 
issue contains an article by the same gentleman on 
Adenoids ; one on Hsematuria due to Cystic Kidney, by 
Mr. A. B. Mitchell ; one on Cancer of the Uterine 
Cervix by Dr. Marion B. Andrews; one on Congenital 
Lymphangeioma by Mr. Howard Stevenson ; and the report 
of a fatal case of Cerebro-spinal Meningitis complicated by 
Parturition. We wish these records a successful and long- 
continued future. 

Dec. 31st, 1907. 

BUDAPEST. 

(From our own Correspondent.) 

The Differential Tuberculin Reactions. 

At a recent meeting of the Budapest Royal Society of 
Medicine Dr. Lfiszlo Detre, privat-docent at the University of 
Budapest, delivered an address on the Differential Tuberculin 
Reactions. He said that these reactions were of assistance 
in various ways in the investigation of the biology of 
tuberculous infection. The researches which he had carried 
on aimed at the elucidation of the etiology of tuberculosis 
and the discrimination of a fresh case from an old one. Of 
late years two questions have received much attention from 
pathologists—namely, (1) Has the bacillus of bovine 



Tb* Lancet,] 


BUDAPEST. 


[JAN. 4, 1908 . 61 


tuberculosis any power of producing human tuberculosis ? 
and (2) Is it possible to distinguish the bovine bacillus from 
the human one so as to recognise which infection is present 
in a given case 1 The dnalistic theory originated with Fro. 
fessor Robert Koch who asserted that bovine tuberculosis 
and human tuberculosis were quite distinct from one another. 
There was now positive evidence that these two infections 
were caused by two kinds oi bacillus which although standing 
very near to each other could nevertheless be distinguished 
by certain signs. It was to the investigations of English 
and German physicians that the knowledge of these facts 
was chiefly due. The statement of Spengler that the two 
kinds of bacilli could be distinguished under the microscope 
when stained in a certain manner was not yet verified. A 
constant difference could be shown in the alkalinity of the 
bouillon culture of the two bacilli (Smith). An important 
difference between them was that the bacillus of bovine 
tuberculosis was much more virulent for mammalian animals 
than the human bacillus was. One milligramme of a culture 
of the bovine bacillus injected into a vein of a tame hare 
killed it within about three weeks, while several months 
were required for a culture of the human bacillus to kill a 
similar hare. By means of these differences it was possible 
to decide whether a given case of tuberculous infection in 
the human subject was caused by one or the other or by 
both types. 

Up to the present time there were 20 cases known in 
which the bacilli were of the bovine type. In these cases 
the cnltures were mostly obtained from the mesentery of 
children suffering from abdominal infection. Bovine bacilli 
had also been found in one or two cases of tuberculous 
meningitis and consumption. The difference between the two 
bacilli was so marked that Weber succeeded in cultivating 
both bacilli in one and the same case. No method has yet 
been discovered by which it would be possible to determine 
the type of bacilli present in a living subject. Dr. Detre has 
therefore endeavoured to draw some inference as to the 
nature of the infection from differences in the sensitiveness 
of the infected organism against the poisons of the two bacilli. 
It was known that tuberculous animals reacted strongly to the 
poison of the tuberculosis bacillus and that they reacted in a 
less degree to the poison of bacilli resembling the tuberculosis 
bacillus, though differing from it by their acid-resisting 
property. The reaction manifested itself partly in local and 
partly in general thermal and organic changes. It might, 
therefore, be assumed that the organism was most sensitive 
against the poison of the bacillus which had caused the 
infection. On the ground of this assumption Dr. Detre has 
compared the sensitiveness of some persons against the two 
kinds of tuberculous poison. In these observations he used 
the filtrate from bouillon cultures of the two bacilli—i.e., the 
human and the bovine bacilli. He did not use tuberculin, 
because Koch’s tuberculin did not contain all the poisons 
of the bacilli. 

Tuberculin and the filtrate were not chemically 
identical and there were also some striking physio¬ 
logical differences between them. In early cases of 
tuberculosis Dr. Detre has found that there was an 
intense sensitiveness against the filtrate ; and he has 
observed individuals who reacted to the Tooo’oooith of a 
centigramme of the filtrate, the Bymptoms being stroDgly 
marked local (edema and a rise of temperature amounting to 
0*3° or 0 4° C. On the other hand, it was known that with 
Koch’s tuberculin such small quantities never produced such 
a reaction. He therefore inferred that the filtrate contained 
an unstable, easily decomposing poison, which might serve 
to distinguish the two kinds of infection. His procedure 
consisted in giving to tuberculous patients subcutaneous 
injections of the filtrates from cnltnres of human and bovine 
bacilli in the same degree of dilution. He then observed 
which substance and in wbat concentration produced local 
reaction. When he injected in one arm of the patient the 
filtrate of the human bacilli and in the other arm the filtrate 
of the bovine bacilli considerable hypersensitiveness against 
the human filtrate could be seen. The differences between 
the effects of the two injections were sometimes very 
striking. For instance, on one side a given dilution, say 
1 in 100,000. gave no reaction at all, whilst on the other side 
there was an infiltration of the size of a penny or even larger. 
With some individuals the reaction to the bovine bacillus 
was stronger than the reaction to the human bacillus—a fact 
which proved that the deviations were produced not only by 
quantitative differences in the fluid injected but also by 
direct specific qualitative differences. In the course of 


these investigations it happened that Pirquet announced his 
discovery of the so-called “allergic reaction." The basis of 
this reaction is the “allergia”—that is to say, the changed 
capability of the organism with reference to reaction. He 
discovered that persons who had once suffered the effects of 
the poisons of the bacilli tuberculosis—that is to say, who 
had withstood a tuberculous infection or were at the 
time of observation still infected with tuberculin—showed 
the so-called cutaneous reaction if tuberculin was scratched 
into their skin, while, on the contrary, the skin of a normal 
person did not react at all to tuberculin. 

Having read about this discovery which Pirquet published, 
Dr. Detre at once proceeded to verify the results which 
he had already obtained with the cutaneous reaction. 
For this purpose he used concentrated and diluted 
solutions of Koch's tuberculin, Deny’s tuberculin, and 
Spengler’s human and bovine filtrate, and finally, for 
the sake of comparison, carbolic acid solution of 0 5 
per cent, strength, all according to the method of 
Pirquet. The first observations have already shown 
that the results of the cutaneous reactions entirely corre¬ 
sponded with those of the previously performed sub¬ 
cutaneous reactions, for persons who reacted t.o the sub¬ 
cutaneous injections of the filtrate of human bacilli gave 
a stronger reaction to the same filtrate also by the skin 
inoculation. These observations have also shown that 
the reactions had a quantitative Rvalue inasmuch as the 
diameter of the local reaction was in direct ratio to 
the dilation of the Koch tnbercnlin. Besides this the 
prevailing filtrates gave always stronger local reactions 
than the ten-fold dilution of Koch’s tuberculin that was of 
the same concentration as the filtrate. This fact supported 
the assumption that the filtrate contained thermolabile toxins 
which Koch’s tuberculin had lost daring the process of pre¬ 
paration. One considerable drawback to the Pirquet reaction 
was that the great majority (90 or 95 per cent.) of adults 
gave it positively. From this it could be easily understood 
that it was of no considerable valne. Dr. Detre has inves¬ 
tigated whether there were any differences in the size of 
the local reaction according as the case was recent or of long 
standing, and his inoculations have shown that fresh cases 
were distinguished from old ones by the former having a 
greater sensitiveness to the filtrate. It was an open question 
whether there was any constant difference (caused by various 
degrees of sensitiveness to the poison) between the reaction 
of the Koch tuberculin and the filtrates. For elucidating 
this Dr. Detre has carried out special investigations in which 
he used (1) Koch’s tuberculin in a concentrated form ; (2) the 
filtrate from human bacilli ; (3) the filtrate from bovine 
bacilli ; and (4) the comparison solution of carbolic acid. 
These observations have Bhown that the single infections 
could be classified according to certain types of reactions. 
In the recent progressive cases, sensitive to the bacterial 
poisons, the local reactions following injections of the filtrate 
were larger than, or equal to. or nearly as large as the 
local reactions due to tuberculin. In chronic cases the 
reaction after the injection of the filtrate was inferior to that 
produced by Koch's tuberculin as regards size. Finally, in 
inveterate or very extensively spread cases the reaction 
might be entirely negative. This fact has been already 
mentioned by Pirquet. 

The explanation of this difference was that the 
energetic reaction of the fresh cases was caused by 
their sensitiveness to the poison ; at a later period the 
organism became tolerant of the labile poison and It 
was sensitive only to the protein ; finally, it lost its 
sensitiveness even to the protein. In the investigations 
conducted by Dr. Detre the differences between the human 
and bovine infeotions were clearly shown in the local reac¬ 
tions produced by the two filtrates. He bad some cases 
in which the local reaction due to the bovine bacillus had a 
diameter of 1 5 millimetres, whilst the local reaction due to 
the human bacillus had a diameter of 12 millimetres. On 
the other hand, there weTe cases, though fewer in number, 
in which the local reaction due to the human bacillus was 
considerably surpassed in size by the reaction due to the 
bovine bacillus. This fact proved that there were not only 
quantitative differences in certain cases. It was a general 
law of immunity that the organism reacted most distinctly 
to substances provoking the immunity. And because the 
allergio reaction was an immunity reaction it was very prob¬ 
able that the cases of bovine reaction were caused by the 
bovine bacillus and the cases of human reaction were 
caused by the human bacillns. In a certain number of cases, 



62 The Lancet,] 


CONSTANTINOPLE.—CANADA. 


[Jan. 4,19C8. 


however, there were no appreciable differences between the 
two reactions ; in these cases Dr. Detre assumed that the in¬ 
fection was “ mediated ” by both bacilli. He did not consider 
that one bacillus wsb the infecting agent and that the other 
only accompanied it; he held this opinion because there were 
cases in which besides the great sensitiveness against one 
species there was no sensitiveness at all against the other. 
The infection might take place in the following manner—a 
view which is also taken by Professor Behring. Duiing 
infancy a child became infected with the bovine bacillus 
through taking milk, butter, &c., and this bovine infection, 
if it was not entirely recovered from, created a predisposi¬ 
tion to the human infection contracted at a subsequent 
period by inhalation when sensitiveness against both species 
developed in the doubly infected diseased organism. 

Dec. 20th, 1907. _ 


CONSTANTINOPLE. 

(From our own Correspondent.) 


Malaria. 

It is reported that malarial fever is raging at Smyrna and 
Konieh. The epidemic is attributed to the many swamps and 
marshes which are to be found almost everywhere in the 
above localities. From Konieh comes an urgent demand for 
a medical man, but the authorities of the medical school in 
Constantinople think that medical skill will be of very little 
use if the source of the epidemic—namely, the marshes—is 
not removed. The municipal authorities of Konieh have, 
however, been informed that a medical man will be sent to 
the affected districts. In connexion with this subject the 
Turkish newspaper Sabah publishes some details concerning 
the irrigation of the plain of Konieh and the drying up of 
its marshy places which are of medical interest. The 
schemes proposed for carrying out the work have been 
approved by the Council of Ministers and sanctioned by the 
Sultan. Large areas of land will be rendered capable of 
cultivation and the Anatolian railway, which is now carried 
as far as Boulgourlou, will shortly reach Adana, the line 
everywhere traversing fertile land. The water required for 
irrigation is to be supplied by Lake Beyshehir, situate 
about 100 kilometres to the west of Konieh. Two small 
streams, the Beyshehir Sou and Tcharshembe Sou, which 
provide an escape for the overflow of the lake, are to be 
canalised and controlled for a distance of about 145 kilo¬ 
metres. A canal of 30 kilometres will be built round the 
marshy depression at Karaviran, known as the Sogla Gol, 
and another canal of 20 kilometres will connect the two 
above-mentioned streams in the narrow Valikova Pass. 
Several barrages and three large reservoirs will also be 
necessary, as well as an aqueduct and innumerable small 
canals for the distribution of water for irrigation purposes. 
It is estimated that it will be possible to supply 600,000 
“deunums" with water; in other words, 132,500 acres of 
land will, it is hoped, now be brought under cultivation. 
Through this scheme it is expected that not only will the 
irrigated places produce annually grain of excellent quality 
sufficient to load at least 20,000 railway wagons but also 
that in consequence of the drying up of the marshes they 
will cease to be a source of malaria. 

The Italian Hospital. 

A service of gratuitous consultation and surgical treatment 
has been opened in the above hospital by its newly appointed 
surgeon, Dr. A. de Fabii, who has just arrived from Italy. 
He was surgeon to the principal hospitals of Rome and it is 
expected that he will be able to do much good work in the 
Turkish metropolis. The gratuitous operations will be 
performed daily from 9 to 11 A M., excepting Mondays and 
Thursdays. 

Cases of Extraordinary Longevity. 

The Stamboul newspapers assert that no other country 
produces so many cases of extraordinary longevity as does 
the Ottoman Empire. Not all the cases brought before the 
attention of the public are genuine or credible, but, on the 
other hand, an individual is occasionally found whose 
remarkably great age is proved by substantial testi¬ 
mony. The following case seems to be genuine. At Yeni 
Bagbtckd, Stamboul, there resides a certain Hadji Raif 
Effetdi who is 124 years old and who has been the book¬ 
binder of the Military School of l'ancaldi for the past 80 
years. This man’s father died at the age of 142 years. He 


was named Edhem Pasha and was a Government official. It 
seems that in Russia centenarians are also found. It is 
reported (this time it is the Levant Herald that is responsible 
for the news) from Revel in the Baltic Provinces that an 
Esthonian lady, born in 1783, and therefore aged 124 years, 
has just thought it about time to make her will in case 
“ anything should happen.” The old lady, who was born in 
the reign of Catherine II., has thus lived in the reigns of seven 
of the eight Tsars belonging to the house of Komanof- 
Holstein whose sway dates from 1762. 

Dec. 24th, 1907. _ 


CANADA. 

(From our own Correspondent.) 


Winnipeg General Hospital. 

The city council of Winnipeg has decided to grant the 
request of the hoard of governors of the Winnipeg General 
Hospital to raise the annual grant from $30,000 to $40,000. 
The former grant had been fixed on the basis of the work 
done in 1904, but since that time the number of city patients 
has increased 40 per cent. Last year the hospital under¬ 
took several absolutely necessary improvements and addi¬ 
tions caused by the great increase in its work. This 
involved an expenditure of $160,000 and so far the city 
has paid $125,000 of this amount. For the first time 
in the history of the hospital it was unable to pay 
its monthly accounts in October. These amount to 
about $13,000 per month. The board of governors also 
asked that the hospital be granted by the city 325,000 
at once on debenture account to close out the accounts 
incurred by building operations last year. They aho asked 
that legislation be obtained to provide for the immediate 
erection of a proper mortuary and a place for holding 
inquests, post-mortem examinations, kc. ; also a proper 
pathological department. Winnipeg requires a new isolation 
hospital; and the board requested that it be erected and 
conducted by the city and so relieve the General Hospital 
of the work of taking care of cases of infectious diseases. 
The cost of such a hospital for Winnipeg is placed at 
8150,000. It should accommodate from 80 to 100 patients 
and have provision for from 40 to 50 tuberculous patients. 

Toronto Hospital for Incurables. 

The annual meeting of the board of management and 
patrons of the Toronto Hospital for Incurables, formerly 
called the Toronto Home for Incurables, took place recently. 
Dr. Bruce Smith, the Ontario Government inspector of such 
institutions, was present and said that of ail similar institu¬ 
tions both in Canada and in the neighbouring country of the 
United States which he bad visited none could surpass the 
state of this hospital. He also pointed out that the grant 
of the Ontario Government of .$5323 and that of the city 
of Toronto of 84000 were totally inadequate when the 
importance of the work was considered. The secretary pre¬ 
sented the annual report and showed that during the past 
hospital year 176 persons had been cared for. On Oot. 1st, 
1906. patients numbering 139 were registered, and to that 
number 37 were added during the year. The deaths in the 
same period totalled 31 ; four patients left and there were now 
in the institution 141. There are 80 patients supported 
at present absolutely free of cost ; 18 pay a nominal 
amount for maintenance. The present year’s work was 
carried on with the small deficit of $486. The average 
cost of each patient was 66 cents per day. 

Alexandra and St. Paul's Hospitals, Montreal. 

These two hospitals in the city of Montreal look after 
respectively the cases of infectious and contagious diseases 
occurring amongst the English- and French-speaking popula¬ 
tion of that city. The first arrangement for tbe mainten¬ 
ance of these made with the city called for a grant to each 
of $15,000 per annum, but it has been found that almost a 
doubled grant would just about be adequate to continue their 
work. A new agreement Is now required from the city 
council. It is asked that each be granted 85000 for the 
balance of the presentyear and that on Jan. 1st next the total 
grant to each be 325,000, this agreement to last for a term 
of three years. The hospitals then agree to treat all 
patients without regard to religious denomination who may 
be sent to them by the city in such numbers as the said 
hospitals can accommodate, each accommodation not to be 



The Lancet,] 


CANADA.—NEW YORK. 


[Jan. 4,1908. C3 


for less than 100 patients per day. In case of an epidemic 
the city will be allowed to use all the beds for the treatment 
of cases of one contagions disease only. 

Montreal Maternity Hospital. 

The sixty-third annual meeting of the friends and 
supporters of the Uontreal Maternity Hospital was held 
recently in that city, Dr. T. G. Roddick being in 
the chair. In making a short address Dr. Roddick stated 
that the building was now practically free from debt 
owing to the energy of the ladies of the governing body and 
two or three good donations and bequests. The endowment 
fund was increasing gradually and now amounted to §6000. 
During the last hospital year 370 married women had been 
treated in the institution, and the report for the present year 
showed that the number had reached 440 Private patients 
had nearly doubled while the number of the unmarried 
patients had not increased. The hospital had conducted its 
financial affairs successfully during the year and there was a 
credit balance in the bank of §356. 

A Simple Staining Method for the Gonococcus. 

In the Dominion Medioal Monthly Dr. J. G. Fitzverald and 
Dr. E. H. Young of the Toronto Hospital for the Insane give 
a preliminary note on the above subject. It is simple and 
has been found useful by them and, as they state, must 
appeal to the busy general practitioner. The gonococcus is 
stained by an aniline basic dye and is decolourised by Gram’s 
method. Their method is simply the application of Nivel's 
soapy methylene-blue solution without any connter-stain, the 
volution being made as follows: methylene blue B. patent, 
3 ’75; Venetian soap, 175; and distilled water, 1000. The 
smears, which should be made on slides (and care must be 
taken to have them as thin as possible), are fixed in the air 
and then stained (without heating) for one minute with 
Nissl’s solution, washed, blotted, and are ready for examina¬ 
tion with the oil-immersion lens. 

Is Toronto to Have a Nerv Medical School ? 

McMaster University is a denominational institution in 
Toronto belonging to the Baptists. At a recent Baptist con¬ 
vention held at Woodstock the board of governors and Senate 
of McMaster University submitted to that convention a 
report recommending the project of establishing a medical 
faculty in connexion with that university. The University 
of Toronto, with which McMaster University is not affiliated, 
has a strong medical faculty, their freshmen numbering this 
year about 230. Probably McMaster University considers 
this is too large a class even of freshmen for one university 
to handle successfully and that it could attract to itself a 
considerable proportion of.the medical student body attached 
to the Provincial University. However, as yet no definite 
steps have been taken along the lines suggested by the Senate 
and board of management of McMaster University. 

Dec. 20th, 1907. _ 


NEW YORK. 

(From our own Correspondent.) 

A Centralised Ambulance System. 

Although New York was the first city in this country to 
adopt the army ambulance as a means of conveying the sick 
in civil practice there has never been a well-organised system 
of ambulance service. Each hospital has bad its own 
ambulances and the police officials have summoned them in 
cases of emergency. The police authorities have created 
districts for the different hospitals to which the ambulances 
of that hospital have been limited, except on occasions of 
great emergencies. The Municipal Hospital Commission 
recently devoted a session to conferences with representatives 
from the various hospitals for the purpose of obtaining 
information in regard to the working of the present system. 
The conclusion was that there should be a central ambu¬ 
lance station corresponding to the fire headquarters 
to which all ambulance calls should come and through 
which they should be assigned to the various hospitals. 

Flies the Cause of High Summer Mortality. 

The Merchants’ Association Committee on Pollution of the 
Waters has published the report of the bacteriologist of the 
Water Bureau of New York city on investigations to deter¬ 
mine the influence of river Hies in conveying the germs of 
disease to the people of the city. It appears that a large 
number of fiy-traps were placed underneath the piers of the 


city which were daily visited and the flies collected and sub¬ 
mitted to examination by counting and the best bacterio¬ 
logical methods. The examination Bhowed that a “South 
Street housefly” carried 100,000 bacteria. At the same 
time a careful investigation was made of the sanitary 
condition of the water front of the entire city. It was 
found that sewage abounded and that those flies were 
thickest at the point where there was the most sewage 
and that where it was scarce the flies were few in 
number. The flies were found to carry less bacteria in 
the early season than during the hot term. The tabula¬ 
tions and diagrams of the report show that the time of 
the greatest prevalence of flies in 1907 was the three 
months beginning July 1st and ending Oct 1st. A record of 
the deaths from intestinal diseases shows that the deaths 
from these diseases rose above the normal at the time at 
which the flies became prevalent, culminated at the same 
high point, and fell off at the time of the gradual falling-off 
of the prevalence of the insect. The report concludes with 
the assertion that this so-called harmless insect is one of the 
chief sources of infection, which in New York city causes 
annually about 600 deaths from typhoid fever and about 
7000 deaths yearly from other intestinal diseases. 

The Plague on the Pacific Coast. 

It appears from a report of a commission acting under the 
authority of the American Medical Association that the 
plague has not been exterminated from the Pacific coast. 
Since August 108 cases have been verified, of which 65 died. 
There was in addition a large number of suspected cases. 
The first recognised case occurred in 1900, but suspected 
cases had from time to time been previously reported. The 
effect of the great fire following the earthquake seems to have 
been to extend the disease by scattering tbe rats and the in¬ 
oculation of ground squirrels, though an enormous number of 
rats were killed in the fire. Another feature of tbe fire which 
increased the Bpread of the plague was the insanitary con¬ 
ditions which followed. The commission states that the 
sewer system was almost completely broken up, water was 
scarce, people were compelled to cook and almost to live in 
the streets, garbage was thrown about promiscuously, refugees 
were crowded together in tents and later in shacks, and these 
camps became filthy. Some of these camps are said to have 
become hives of dirty humanity and to have swarmed with 
rats and fleas. That the plague is now widely scattered 
among the cities of the Pacific coast is evident and the 
measures taken to arrest and exterminate it seem altogether 
inadequate owing to the indifference of the people and the 
local authorities outside of San Francisco and Oakland where 
thorough anti-plague work is being done. The commission 
concludes that tbe continued existence of such a disease over 
such an area, and for the time during which it is evident 
that the infection has existed here, would seem to make the 
infection a subject for national consideration. 

State Prohibitum of Nostrums. 

Tbe State of Massachusetts, through its board of health, is 
rigidly enforcing its laws against the sale of noxious 
nostrums, one of the most conspicuous of which is cocaine 
in various forms. The law, which went into effect on 
Sept. 1st, 1906, provides— 

That It shall bo unlawful for any person (Including physicians) to 
sell or to expose or offer for Bale or to give or exchange any patent 
or proprietary medicine or article containing cocaine or any of its salts 
or alpba-eucain or beta-eucain or any synthetic substitute of the 
aforesaid. 

A large number of preparations, generally advertised as 
remedies for catarrh or diseases or the throat, have been 
condemned by the board of health, and their proprietors 
brought into court and convictions obtained, i he effect of 
this law in the suppression of these injurious and often 
dangerous nostrums has awakened a wide spread interest and 
other States are certain to take similar action. 

Titleroulosis in Herds of Cattle. 

The New Y’ork State Veterinary College reports through 
its expert bacteriologist that 72 per cent, of the herds of the 
State of New Y'ork are tuberculous. This expert has made 
a careful study of meat inspection and states that although 
the citizens of the State are now thoroughly protected against 
Chicago and Western beef by the pure food and meht 
Inspection laws, the markets of the State are loaded with 
domestic beef, a large percentage of which is in'ected with 
the tuberculous germ. The statistics collected by Professor 
Moore show that of 364 herds examined 72 ■ 3 per cent, 
included tuberculous animals. Estimates based on these 



64 The Lancet,] 


NOTES FROM INDIA.—AUSTRALIA. 


[Jan. 4, 1908. 


statistics show in his opinion that of the 1,800,000 milch 
cows in this State 440,000 are infected with tnbercnlosis. 
The disease is constantly spreading throngh the traffic in 
cattle. The remedy is thorough inspection by a competent 
corps of State inspectors. 

Deo. 19 th, 1907. 


NOTES FROM INDIA. 

(From our Speciat. Correspondent.) 


Sanitary Reform in India,. 

The great event of the past week has been the issue by 
the Government of India to the various local governments 
of a letter on the improvement of the sanitary services in 
India. It is contemplated to employ a greatly increased 
number of medical officers of health as well as of sanitary 
inspectors, and more sanitary boards will also be created. 
There is not a word, however, regarding legislative 
powers which are at present very deficient, or as to 
how the expenses of sanitary improvements have to 
be met. Money is wanted badly by every municipality 
for public sanitary schemes but the difficulty in effecting 
improvements is still greater in the case of private indi¬ 
viduals. It is hardly recognised sufficiently that the 
sanitary evils chiefly pertain to the home, and to enforce 
measures of sanitary improvements in the case of private 
individuals is often a very serious hardship and perhaps as 
often an impossibility. The great mass of the people are 
poor and their unhealthy surroundings are largely due to 
their poverty. That more executive officers are required no 
one will question, and it is satisfactory to learn that the 
tenure of their appointments will be safeguarded by the local 
governments and will not be subject to the whims and fancies 
of municipal boards. A very large field of work will be 
thrown open to Indian medical men who have been trained 
in England and have taken a degree in sanitary science. This 
is as it should be, but this concession to Indians must 
not be carried too far and the higher posts should be 
reserved for British sanitarians. A temporary medical educa¬ 
tion in England does not produce that independence and 
force of character which belong to those Englishmen who 
have had a life’s training at home, and the ingrained 
habits of life in an Indian tend to reassert themselves when 
he returns to his native country. It iB curiously asserted 
that though certain appointments will be open to European 
and Indian officers, on grounds of economy preference would 
naturally be given to Indian candidates. The principle of 
prohibiting private practice for health officers is definitely 
laid down and the pay of such officers will be determined 
accordingly. A great deficiency at present exists in properly 
trained sanitary inspectors but an arrangement is 
contemplated for instituting some form of an examining 
board. This letter of the Government marks the commence¬ 
ment of sanitary reform but it all depends upon the local 
governments as to how the proposed scheme will be carried 
out. 

A Ncrc Parti Hospital in Bombay. 

The foundation-stone of a large general hospital for Parsis 
has just been laid in Bombay. It is hardly a generation ago 
that Parsis refused to go to hospital owing to the joint 
family system prevailing. First, however, a maternity hos¬ 
pital was started and proved very successful, then a fever 
hospital was established, which was also successful, and 
now by the liberality of certain wealthy members of 
this community, more especially the Petit family, a 
magnificent hospital costing nearly 14 lakhs of rupees has 
just been commenced. It will have a magnificent, aspect 
over the sea to the west and will consist of three main 
blocks connected by corridors. The outer blocks will each 
contain 120 beds and the central one will include the 
operating theatre, the laboratory, and rooms for electrical 
and light treatment. The equipment of the hospital 
generally will be on the most up-to-date lines. In the 
operating theatre the students will be shut off from the 
actual place of operations by plate glass and the sole ventila¬ 
tion of the theatre will be through an antiseptic pump. 
Considering that the population of the Farsi community in 
Bombay city is only about 80,000 it must be admitted that 
they are making most admirable provision for their Bick. 


Fever in Bengal. 

It will be remembered that the prevalence of malariajin 
Bengal was the cause of a special committee being appointed 
last year and it has now presented its report. It 
cannot be said, however, that there is much prospect of 
success. In addition to the waterlogged condition of the 
country the main causes of fever are accredited to the in¬ 
sanitary state of the village sites. Any improvement in the 
latter direction depends largely upon educating the villagers, 
which is bound to be a very slow process. The report says 
that the value of sanitation, the prophylaxis of malaria 
by the use of quinine and mosquito curtains, and the 
efficient treatment of malaria by quinine are matters 
which might well be taught in the schools. This is not 
very promising and the use of mosquito curtains for the 
poor villagers may be said to be impracticable. The 
distribution of quinine may easily be effected, but ' the 
destruction of mosquitoes in such low country, with water 
nearly everywhere, is hopeless. A certain amount of 
improvement may be attained in a few places by suitable 
drainage but the nature of the country puts many limitations 
on this procedure. It is natural that the committee should 
lay stress on the necessity for further inquiry. The medical 
aspect of the question is to be taken up more in detail. 

Dec. 12th, 1907. 


AUSTRALIA. 

(From our own Correspondent.) 


Patent Medicines in Australia. 

Under the existing Commonwealth law relating to the 
admission of patent medicines where a trade secret is 
involved no regulations can be framed prescribing the trade 
description unless the Governor-General considers such 
necessary for the welfare of the public. A new Bill has been 
introduced in which power is given to make a general 
regulation requiring a trade description, including disclosure 
of ingredients, for all medicines or food for infants or 
invalids, but in individual cases if the Governor-General is 
satisfied that it would mean disclosure of trade secrets and is 
not necessary for the public welfare he may allow a modified 
description. The trade description may require in the case 
of medicines a statement of the diseases or ailments which 
they are intended to cure. The practical meaning is that 
importers must show that a trade secret will be disclosed in 
order to obtain exemption from stating on bottle or packet 
its component parts. 

Melbourne Hospital Election. 

The annual report to the council of the dean of the faculty 
Of medicine in the University of Melbourne contained a para¬ 
graph referring to the method of appointing the staff at the 
Melbourne Hospital. The report suggested that a communi¬ 
cation should be made to the hospital managers pointing out 
that the University entrusts the whole general clinical training 
of its medical students to the hospital staff. "The present 
system,” the report continued, "of electing the staff is a 
disgrace to the hospital, to the medical profession, and to 
the community, and presents a bad example to the medical 
students. The Melbourne Hospital stands almost alone in 
its methods of election.” The council thereupon directed 
that the paragraph concerning the hospital should be for¬ 
warded to the President of the institution with the strong 
endorsement of the council and a request to bring it before 
the hospital committee. When brought before the com¬ 
mittee at itB last meeting the report met with a very chilly 
reception. Several members took exception to the strong 
terms in which it was worded and appeared to regard it as a 
slight upon their conduct of the institution. On the other 
band, the Rev. Dr. Marshall, a member of the committee, 
expressed the view that the language was perfectly justified. 
It is probable that reform in some lines will shortly be 
brought about but in view of the fact that the Government 
is bringing down a Charities Bill in which some proposals 
are embodied for the appointment of hospital staffs through¬ 
out the state nothing will be attempted until these provisions 
are open for discussion. 

Hospital Saturday and Sunday Collections in Melbourne. 

The annual Hospital Saturday and Sunday collections in 
Melbourne have been very successful. The total amounted 
to £6884, which is the largest sum received since 1888. Last 



AUSTRALIA.—OBITUARY. 


[Jan. 4, 1908 65 


Thb Lancet,] 


year’s total was £6170. The movement is now very well 
organised and works smoothly. The greatest contribution 
was made bv the police whose collection through their 
band was £605. 

Women's Hospital , Melbourne. 

A fund was recently started by the Lady Mayoress of 
Melbourne for extension of buildings at the Women’s 
Hospital. It is now announced that the fund has reached 
£5000. which enables the committee to claim a further sum 
of £5000 promised by the Victorian Government. 

The Protection of Infant Life. 

The Victorian Government has introduced a Bill dealing 
with this subject. In 1901 there were 525 registered nurses 
in charge of 779 children and the deaths were 12 • 7 per cent. 
There were 69 police inspectors. In 1902 the percentage of 
deaths was 15• 1 ; in 1903,13 7; in 1904 9 7; in 1905. 7 8; 
and in 1906, with 583 nurses and 974 children, the deaths 
were 10 ■ 9 per cent. The number of police inspectors had 
increased to 124. In introducing the new measure the Chief 
Secretary said the great difficulty was to induce a better 
class of women to register as nurses. He thought that this 
would be overcome by taking the inspection out of the 
hands of the police. In South Australia the Act was 
administered by an honorary council and in New South 
Wales by the chief officer of charitable institutions. Under 
the new Bill the control would be placed in the hands 
of the department for neglected children. That department 
had honorary committees chiefly of ladies throughout 
A'ictoria who were prepared to keep a supervision over the 
children. The payment of lump sums to nurses for taking 
charge of children was to be forbidden absolutely. The 
parents could pay a sum to the department but nurses 
would receive weekly payments. For the first 12 months 
the payment would be 10s. per week. After that the 
rate might be reduced to 7s. per week. There would be 
two or three female inspectors appointed and an extra £1000 
per annum would be required for payments to medical men 
for extra supervision. Particulars of a child’s parentage 
would be kept and revealed only by order of the Minister. 
In certain circumstances a medical certificate of death 
would be accepted instead of the statutory coroner’s inquiry 
as at present. Under the new Bill provision is also made for 
the establishment of maternity homes. 

Public Health in Queensland. 

The annual report of the Commissioner for Public Health, 
Queensland, was presented to Parliament last month and 
covers the work to June 30th. Dr. B. B. Ham refers at some 
length to the inadequacy of means of domestic storage for 
meat and milk and remarks: “The food ‘safe’ and larder 
may often be labelled as infected domestic areas. ” Ophthalmia 
is noted as an increasing danger to children in western 
-Queensland and the need for domestic care and school 
inspection is insisted upon. The inspection of foodstuffs was 
being carried out by the department as, with the exception 
of the Brisbane city council, local authorities continued to 
display great apathy. A marked improvement was generally 
manifested in existing conditions compared with those of a 
few years ago. 

Adelaide Children's Hospital. 

The thirty-first annual meeting of the friends and 
supporters of this institution was held on Oct. 31st under 
the presidency of the Governor of South Australia (Sir G. R. 
Le Hunte). The annual report showed that 593 in-patients 
had been treated with 36 deaths, that 563 surgical opera¬ 
tions bad been performed, and that the out-patient attend¬ 
ances totalled 8161. The revenue of the institution was 
well maintained and the hospital benefits largely from a 
legacy of £200,000 under the will of the late Mr. T. Martin. 
The share of revenue available from this fund will permit 
extension of the hospital buildings in the near future and 
the committee bad already been able to make some additions 
and renewals. The officer-bearers were re-elected on the 
motion of the Bishop of Adelaide. 

Transposition of Viscera. 

A patient recently died in the Queenstown Hospital, 
Tasmania, from acute nephritis. The medical officer noted 
during life that the heart was transposed and a post¬ 
mortem examination revealed complete transposition of all 
the viscera. The deceased was a boiler-maker and had always 
enjoyed vigorous health. 

Nov. 30th, 1907. 



SIR ALFRED BAKING GARROD, M.D. LOND., 

F.R C.P.Lond., F.R.S., 

COITSl.'I.TlNQ PHYSICIAN-, KINO'S COLLEGE HOSPITAL. 

By the death of Sir Alfred Baring Garrod, which occurred 
on Dec. 28th, 1907, at the advanced age of 88 years, the 
profession of medicine in the United Kingdom loses one of 
its oldest and best known members. 

Alfred Garrod was born in 1819, at Ipswich, and 
received his early education at the Ipswich Grammar School, 
whence, after serving an apprenticeship to Mr. Charles 
Hammond, surgeon to the East Suffolk Hospital, he 
proceeded to University College and the hospital attached 
thereto. He graduated at the University of London, being 
placed first in medicine at the examination for the degree of 
M B. in 1842 and also at that for the degree of 
M.D. in the following year. He became a Member 
of the Royal College of Physicians of London in 
1851, was elected a Fellow in 1856, served as Senior 
Censor in 1887, and as a Vice-President in 1888. In the 
year following his election as Fellew he was the Goulstonian 
lecturer, the subject of his lectures being Diabetes. In 
1858 he received the honour of being made a Fellow of the 
Royal Society of London. In 1883 he delivered the Lumleian 
lectures at the Royal College of Physicians of London, his 
subject being Uric Acid: its Physiology and its Rela¬ 
tion to Renal Calculi and Gravel. As regards his 
career as a practising physician, he was elected assistant 
physician to University College Hospital in 1847 and 
full physician and professor of therapeutics and clinical 
medicine in 1851. In 1863 he became physician to King’s 
College Hospital as well as professor of materia medica 
and therapentics and clinical medicine at the college. 
These posts he held until 1874 when he was made consulting 
physician. 

Bir Alfred Garrod is best known to the present genera¬ 
tion of medical men by his work upon materia medica, 
originally published in 1855, and by his researches into the 
nature of the pathological conditions which are associated 
with the terms “gout’’and “rheumatics." It was in 1847 
that he discovered the presence of uric acid in the blood 
of gouty patients and a paper by him upon this subject was 
communicated to the Royal Medical and Chirurgical Society 
of London on Feb 8th, 1848, by the late Dr. C. J. B. Williams. 
The paper was received with great interest and Dr. Williams 
pointed out that although he himself had for years taught 
that the presence of lithic acid in the blood was the cause of 
gouty manifestations yet the demonstrative proof that this 
acid did exist in the blood in such circumstances was 
entirely due to Dr. Garrod. The subjects of gout and rheu¬ 
matism continued to interest Dr. Garrod for many years and 
in 1859 he published his well-known work upon the Nature 
and Treatment of Gout and Rheumatic Gout. This latter 
disease he proposed should in future be called rheumatic 
arthritis, a designation which is cow giving way to arthritis 
deformans. It was in this book that he drew attention to 
the use of the lithium salts for gouty conditions. In 1883 
Dr. Garrod delivered the Lumleian lectures as stated above. 
In these lectures he first discussed the probable seat of 
origin in the body of uric acid, alluding naturally to bis own 
discovery of that substance in the blood in 1847. He also 
considered the urines of all classes of the animal kingdom 
with which he bad made many experiments, as he had also 
done with their blood by his now classical thread test. He 
entered very fully into the whole matter, concluding that 
the evidence was strongly in favour of the true renal origin 
of uric acid. He then discussed the bearing of his views on 
calculus formation and the influence of different diets 
upon that disorder, and finally described experiments which 
he had made to check the late Sir (then Dr.) William 
Roberts’s well-known work on the Solubility of Uric Acid 
in Alkaline Carbonates and Other Reagents. This excellent 
course of lectures proclaimed him a patient investigator 
and a clear thinker on a subject in which he was keenly 
interested. In these lectures be did not expound his views 
on uric acid in relation to gout but it is interesting to recall 
them as he expressed them elsewhere. He held that with 
lessened alkalinity of the blood there was increased uric acid 
owing to faulty elimination and that this diminution of 
alkalinity caused the deposition of the sodium urate, which 
required a more alkaline medium to hold it in solution. 





66 Tot Lancet,] 


OBITUARY. 


[Jan. 4, 1908 


The acute paroxysms were due, be considered, to an 
accumulation of uric acid in the circulating blood and their 
sudden crystalline deposition around the affected joint. 
Besides his Lumleian lectures The Lancet at different 
times published interesting communications from Dr. 
Garrod, amongst which we may mention especially a note on 
some chronic diseases of the alimentary canal and liver, 
also of the skin and articulations and their treatment by the 
long-continued use of small doses of sulphur given in the 
form of compound lozenges with cream of tartar, which had 
proved useful in his hands. 1 Another excellent paper con¬ 
tributed to these columns was on Aix-les-Bains and the 
value of its course in rheumatoid arthritis, gout, rheu¬ 
matism, and other diseases. 9 

Although the study of gout and rheumatism ocoupied a 
large portion of his activities he by no means confined 
himself to these subjects. As we have said above, he 
took for the subject of his Goulstonian lectures the condition 
known as diabetes. Materia medica and therapeutics also 
took up much of his attention and his lectures upon the I 
application of the science of chemistry to the dis¬ 
covery, treatment, and cure of disease which were 
delivered at University College Hospital and were pub¬ 
lished in The Lancet of 1848, showed a knowledge of 
the interaction of chemistry, physiology, and pathology which 
in those days was rare. His text-book of “ Materia Medica 
and Therapeutics,” first published in 1855, was the work to 
which medical men and students through the greater part of 
the latter half of the last century were indebted for their 
standard text-book. When Garrod’s book appeared he was 
professor of clinical medicine at University College, his 
chair including the subjects of materia medica and 
therapeutics. The book on its appearance ran to 280 
pages and its value was hardly recognised from the 
first, as nearly ten years had elapsed before a second 
edition was called for, by which time its author had 
changed his allegiance to the King’s College school. 
In 1874 a fourth edition was reached, and of this Dr. 
Buchanan Baxter acted as editor ; the book was by that time 
an established success and 1886 saw the appearance of its 
eleventh edition, for which Dr. Nestor Tirard was responsible 
under the author’s supervision, Bince Dr. Baxter, the first 
editor, bad died. Sir Alfred Garrod was always interested 
in pharmacological and pharmaceutical matters and read 
papers before the medical and other societies on such subjects 
as the action of alkalies on alkaloids. 

He was for some years a Physician Extraordinary 
to the late Queen Victoria who shortly before appointing 
him to this post conferred upon him the honour 
of knighthood at her Jubilee in 1887. On Dec. 6th 
of that same year he received the honour of being 
entertained at a complimentary banquet given by the 
members of his profession resident in bis native town of 
Ipswich. Ilis health was proposed by Dr. W. A. Elliston, 
physician to the East Suffolk and Ipswich Hospital, who, 
our readers will remember, was President of the British 
Medical Association when it met at Ipswich in 1900. Dr. 
Elliston, in referring to Sir Alfred Garrod’s labours on the 
subjects of gout and rheumatic gout, concluded by saying 
that in his opinion the guest of the evening had done for the 
Btudy of these allied diseases what Jenner had done for that 
of continued fever. Our knowledge of these two diseases, or 
should we say our consciousness of what gout and rheu¬ 
matism are not, has grown greatly since the date of the 
appearance of the book in question, but when we reviewed 
the first edition in The Lancet of Dec. 24th, 1859, we 
concluded as follows : We do not hesitate to affirm that we 
never had the pleasure of reviewing a work from the perusal 
of which we have derived more advantage, and we can con¬ 
fidently recommend it as not only highly philosophical but 
likewise thoroughly practical.” 

In his later years Sir Alfred Garrod had wholly 
relinquished practice, and the increasing infirmities of old 
age prevented him from taking any share in the life of the 
profession or appearing in public. He, however, continued 
his experimental work on the subjects in which he was most 
deeply interested. He died quite peacefully from old age 
on Dec. 28oh. 

In 1845 he married Miss Elizabeth Anne Colchester, 
by whom he had six children, of whom three survive 
him. The eldest son, Alfred Henry Garrod, who was a 


1 The Lancet, April 6th, 1889, p. 665. 
9 The Lancet, Mny 4th, 1889, p. 869. 


distinguished biologist and F.R.S., died, aged 33 years, 
in 1879. 

Dr. Nestor Tirard writes to us as follows concerning his 
old teacher:—“ The death of Sir Alfred Baring Garrod at 
an advanced age removes one who in his prime bad an 
enormons influence on the practice of medicine generally and 
on the development of therapeutics in particular. Before 
he became professor of materia medica and therapeutics at 
King’s College he had published a text-book on this subject 
which for very many years was in the hands of most 
students and practitioners. He had also published a treatise 
on gout and rheumatic gout (rheumatoid arthritis), and the 
quotation from J. J. Rousseau on the title-page— 

4 Observez la nature, et auivez la route qu’elle voub trace ’— 

may well be taken as the keynote of his teaching and 
influence upon his students. In his wards and in his lecture 
room he continually referred to clinical observations whether 
relating to the symptoms of disease or to the remedial 
measures to be adopted. This tendency served to vitalise 
the details of materia medica and to encourage others to 
follow in his footsteps. Those who were fortunate enough to 
be bis pupils instinctively felt that he was master of his 
subject and that they had only to name their difficulties to be 
supplied with illuminating explanations and illustrations. 
Some years after the calls of private practice had necessitated 
the relinquishment of his professorial duties and of hospital 
work I again had the advantage of meeting him frequently 
in connexion with the production of a new edition of 
his book on materia medica. In this he took an ex¬ 
tremely active part, personally retaining the control of 
some of the sections, notably that dealing with the different 
mineral waters. When the British Pharmacopoeia of 1898 
was in course of revision Sir Alfred Garrod was chairman of 
the committee appointed by the Royal College of Physicians 
to make suggestions for omissions, additions, and alterations. 
His keen interest led him to preside, if I remember rightly, 
at all the meetings and the changes he advocated invariably 
found ready acceptance. Though he has outlived many 
distinguished pupils and associates, the influence of his 
work is still evident in many directions ; his books may 
still be consulted with advantage and many of us will 
alwavs feel proud of having been privileged to study under 
him.” 

Sir Dyce Duckworth has kindly sent us the following 
appreciation of the venerable physician's work. “Full of 
years, and regarded with esteem and affectionate regard by 
all who knew him, Sir Alfred Garrod has passed away after 
leaving a record of effective service in his profession which is 
known and appreciated wherever a scientific study of medi¬ 
cine is cultivated. His epooh-making disclosure in 1848 of 
the intimate relation between gouty disturbances and the 
behaviour of uric acid in the system formed a contribution 
of large importance to clinical medicine, one which has 
stimulated research in the same direction, and can 
never be ignored in discussing the still unsolved patho¬ 
logy of gout. All careful observers have had to acknow¬ 
ledge his facts, although different conclusions have 
been drawn from them by various investigators. As an 
exponent of organic and clinical chemistry Garrod’s 
methods were exact and persistent. His laboratory was the 
human organism, ever the best for the bedside physician. 
His discoveries, whether in toxicology, pharmacy, or the 
improvement of the materia medica, were always designed 
in support of the art medcndi, for the benefit of the patient; 
and his success in practice was greatly due to this pro¬ 
cedure, so that it was wont to be said of him that * Garrod’s 
medicines always did good.’ We may cherish this recollec¬ 
tion in these days when some of these matters are greatly 
neglected both in teaching and practice. After all, it was 
Garrod’s method which made him an outstanding man 
amongst his contemporaries, the method of Hunter, to think 
first and then to try, for this gives the best indication in its 
possessor of the mens medica. With this, we, who knew him 
well, recognised his unfailing gentle kindness and sympathy 
and his genial interest in all matters relating to the pro¬ 
fession. When the first Moxon medal was awarded by the 
Royal College of Physicians in 1891 it was felt that no 
worthier British recipient of it could be found than Garrod 
as fulfilling the requirements of ‘ distinguished research and 
observation in clinical medicine.’ Sir Alfred Garrod’s work 
and method have laid a responsibility on all who have entered 
into his labours to follow in the like path of duty and fruitful 
service for our common humanity.” 



The Lancet,] 


OBITUARY. 


[Jan. 4, 1908. 67 





Sir Alfrrd Baring Garrod, M.D. Lond., F.R C.P. Lond., F.R.S. 

COXSULTrifG PHY8ICIAX, kING'8 COLLEGE HOSPITAL. 

(From a photograph taken about 1887.) 






The Lancet ] 


OBITUARY. 


[Jan. 4, 19C8. 


SIB PATRICK HERON WATSON. LL D. Edin.,M.D.Edin., 
F R.C.S. Edin., Hon. F.R.C.S. Irei,., 

HONORARY SURGEON IN SCOTLAND TO THE KING. 

The medical profession in Scotland has lost one of its 
most prominent members by the death of Sir Patrick Heron 
Watson of Edinburgh. The sad event was not unexpectfd, 
for he had been in poor health for some years and during the 
last six months be had been seldom out of doors. Heart 
failure was the cause of death and he passed awav on 
Dec. 21st, 1907, at his residence in Charlotte-square, Edin¬ 
burgh. 

Patrick Heron Watson was a son of the late Rev. 
Charles Watson, D.D., parish minister of Burntisland, Fife- 
shire, and was born on Jan. 5Mi, 1832. In 1853 he graduated 
as M.D. at the University of Edinburgh ; in the same year he 
also became a Licentiate, and two years later a Fellow, of the 
Royal College of Surgeons of Edinburgh. On the outbreak 
of the Crimean war he joined the Army Medical Corps as 
staff assistant surgeon, afterwards being assistant surgeon in 
the Artillery and Royal Horse Artillery For six weeks after 
reaching the Crimea he was invalided with typhus fever and 
then was attached to the battery at Bilaclava, where he had 
dysentery and was seriously ill. For his services in the war 
he received the Crimean, Turkish, and Sardinian medals 
On his return home Dr. Watson commenced the teaching 
of surgery at High School Yards, Edinburgh ; was subse¬ 
quently elected lecturer on systematic and clinical sur¬ 
gery at the school of the Royal College of Surgeons of 
Edinburgh ; and was then appointed surgeon to the Royal 
Infirmary, of which he continued a consulting surgeon. 
He was also consultirg surgeon to Leith Hospital and 
surgeon at Chalmers Hospital, Edinburgh. He represented 
the Royal College of Surgeons of Edinburgh on the General 
Medical Council from 1882 to 1906, succeeding the late 
Mr. James Spence and being himself succeeded by Dr. 
J. W. B. Hodsdon. He was also a member of the Edin¬ 
burgh University Court, a curator of patronage, and an 
honorary Fellow of the Royal College of Surgeons in Ireland. 
In 1884 he received the distinction of LL.D. from the 
University of Edinburgh; he was an honorary surgeon in 
Scotland to Queen Victoria and was honorary surgeon 
to the King. He was a Chevalier of the Order of Carlos III. 
of Spain, was a surgeon of the 5fch Volunteer Infantry 
Brigade, and held the Volunteer Decoration. He was 
also a Deputy Lieutenant of the City of Edinburgh. 
No surgeon was more widely known in Scotland, and 
his services as operator or consultng surgeon were in 
request in difficult cases all over the country. In July, 
1903. he received the honour of knighthood. As President of 
the Royal College of Surgeons of Edinburgh he took a lead¬ 
ing part in the celebrations of the quatercenterary of the 
College in 1905. That was the second occasion upon which 
he bad held t.he position of President, the previous occasion 
being in 1878. His principal published works, with their 
dates, were “The Modern Pathology and Treatment of 
Venereal Disease” (1861) and “Excision of the Knee- 
joint” (1867) He also edited the late Professor James 
Miller’s “System of Surgery.” He married a daughter of 
Professor Miller to whom he acted as assistant for several 
years after his return from the Crimea. His wife pre¬ 
deceased him several years ago but he is survived by two 
daughters and two sons. 

For the following appreciation of the life and work of the 
deceased we are indebted to Mr. Rutherford Morison of 
Newcastle-on-Tyne:— 

“The death of Sir Patrick Heron Watson must leave in the 
minds of his old pupils a sense of painful bereavement, for 
his was a unique and impressive personality. To his old 
bouse surgeons he was a hero they worshipped, for to work 
with him was an inspiration which could not fail to leave it6 
mark on the least plastic of men. It was my privilege to act 
as his resident surgeon in the year 1875 in the old Royal 
Infirmary at Edinburgh. His reputation was then made and 
he was universally recognised as one of the foremost 
operators in the world. He had already performed most of 
the abdominal operations which are now common property, 
and had excised the spleen, the kidney, ovarian and uterine 
tumours, and portions of intestine at a time when it was 
thought impossible to bring such undertakings to a success¬ 
ful issue. He had then also excised the whole larynx for 
malignant disease and had performed Feveral successful 
thyroidectomies by a new and original method, since 
generally adopted, of ligaturing the arteries of supply before 


interfering with the gland itself. It has indeed often seemed* 
to me, in looking back to the time when I was working with 
him, that most of what he did then is the operative surgery of 
to-day and was at least 20 years in advance of that period. 
That he has not received the recognition as a surgical pioneer 
he deserved is due solely to the fact that he failed to avail* 
himself, as so many of the strongest and ablest men of that 
generation did, of the revolution in the treatment of wounds 
which was being brought about by Lord Lister. It was 
impossible for him to accept the new principles in the whole¬ 
hearted fashion necessary to carrying out the details with 
success. Operations such as lateral lithotomy, excision of 
the jaw and tongue and rectum, which he performed with a 
skill I Dever saw equalled, gave brilliant results ; many 
others, more dependent on attention to antiseptic detail, were 
in spite of his diagnostic ability and manipulative dexterity 
doomed to failure. 

At the time previously mentioned (1875) and for twenty 
years afterwards his whole time was busily occupied by pro¬ 
fessional work. In addition to the largest surgical practice 
in Scotland, consulting and operating, he constantly had 
medical patients with all sorts of ailments under his care, 
and how he managed to get through all he had to do was a 
mystery to his friends. Yet he never appeared to be in a 
hurry and always found time to spare for his hospital work 
and surgical lectures and private pathological museum. 
Patients came from all parts of the world to consult 
him and with such faith it was a common saying in 
Edinburgh 4 that most of them would rather be killed 
by Dr. Watson than cured by anyone else.’ Small wonder 
that patients trusted him. Everyone who saw him felt at 
once his strength and capacity. Every surgeon must have 
experienced after finishing an anxious and difficult operation 
doubt as to whether he did the best that could be done to 
meet some sudden and unforeKpen emergency, but nobody 
ever doubted this of Sir Patrick Heron Watson. He seemed 
to have considered every possibility beforehand, and any 
difficulties were so quietly met and so methodically dealt 
with that they could not appear, except to the initiated, as 
difficulties at all. There was a stronger individuality about 
Dr. Watson than about anyone else I have known and though 
this cannot be conveyed to strangers his old house surgeons 
will remember his military walk, his correct attire, his 
neat, plainly-written notes, his method of interviewing and 
prescribing for out-patients, his courteous manners, his 
independence of character, and his ready command of 
language, which might not always be to their satisfaction 
hut was always to their lasting advantage, as peculiarly hia 
own. There are many of us who will revere these memories 
for we loved the man.” _ 


JOSEPH LLEWELYN WILLIAMS, M B., C.M. Edin., 
M.R.C.S. Eng., L.S.A. 

The medical profession in Wrexham and district has lost 
one of its kindest and most lo*val colleagues in the lamented 
death of Dr. J. Llewelyn Williams of Holt street House, 
which occurred somewhat suddenly on Friday evening, 
Dec. 13th, 1907, from heart disease. By his death the profes¬ 
sion suffers a severe loss and to those who knew him best his 
sterling qualities and steadfast friendship will ever remain as 
cherished memories. Dr. Williams was the son of the late 
Dr. Edward Williams, who died in 1893. after many years 
of extensive practice in Wrexham and the surrounding 
neighbourhood. Dr Llewelyn Williams, like his father, 
was an ideal “family doctor.” His gentle voice, honest, 
grave eyes, and sympathetic personality did much ta 
cheer and help those in suffering and sorrow; always 
patient and ready to hear and to sympathise with their minor 
troubles and worries, he Dever left a bedside without a cheery 
word of help and comfoit for his patient. Dr. Williams 
to< k his medical course at the University of Edinburgh, 
where he graduated with the degrees of Bachelor of Medicine 
and Master of 8urgery in 1867 ; he al>o studied at St. Bartho¬ 
lomew’s Hospital and qualified as M.R C S. Eng. and L S. A. 
He was a justice of the peace for the county of Denbigh¬ 
shire and took a keen interest in his magisterial work. 

In 1876 he was elected honorary surgeon to the Wrexham 
Infirmary, a post which he held until 1881. During this 
period he gave his time, experience, skill, and encourage¬ 
ment to the suffering poor under his care, and there the 
kindly acts and unostentatious aid rerdered to so many in 
a humbler sphere, although unrecorded, will not be forgotten. 
When a vacancy occurred later on the staff of that institution 



70 Thjc Lancet,] 


OBITUARY.—MEDICAL NEWS. 


[Jan. 4,1908. 


he was urged by some of his colleagues to apply for that 
post but could not be induced to do so. He was for some 
years medical officer of health of the borough of Wrexham 
and rendered valuable services in the advancement of sanitary 
science and public health. He was a former president of the 
North Wales branch of the British Medical Association and 
his year of office was a most successful one. He had high 
ideals of medical ethics and his advice was always in con¬ 
sonance with the best traditions of the duties of members of 
the profession to the public and to one another. Not the 
least of his characteristics were bis modesty and unassuming 
manner. To all who knew him he was the embodiment of 
uprightness of conduct and he lived and died a pattern cot 
only of a good physician but of an English gentleman. 


THOMAS ANNANDALE, M.D. Edin., F.R.O.S. Eng. 
and Edin., D.C.L. Durh., 

REGIUS PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF 
EDINBURGH. 

It is difficult for those who knew Professor Annandale 
and frequently saw him going to, or returning from, the 
infirmary to realise that his figure has finally disappeared 
from the streets of Edinburgh. l*'ew men were more widely 
known to sight by the general public. No one would have 
guessed that he would so suddenly have been removed from 
the sphere of active surgical work. On Thursday afternoon, 
Dec. 19th, 1907, he operated in the infirmary, dined at home, 
retired early as was his habit, and on Friday morning was 
found dead in bed. That this was a great shock to his 
colleagues and professional friends can easily be realised. 
There had been no bint of indisposition of any kind ; no man 
seemed to carry his years more easily ; no man appeared 
more equable or seemed to work with greater ease; and 
yet within the space of a few hours he passes from 
the operating theatre to the final bourne. That bis more 
intimate friends in the Senatus and outside should have 
been stunned by the occurrence is not difficult to realise. 

Professor Annandale was born in November. 1838, so 
that he had only reached his sixty-ninth year. He 
was a native of Newcastle and made his first acquaintance 
with surgery in the hospital of that town and in his father’s 
practice. In 1856 he became a student of medicine in Edin¬ 
burgh. He graduated in 1860 and received a gold medal for 
bis thesis on the Injuries and Diseases of the Hip-joint. In 
1859 he obtained the M.R.C.8. Eng. Immediately after 
graduation he became house surgeon to Professor Syme, 
a post which he held for 12 months. In this position he so 
impressed his great master with his surgical capacity that 
Syme made him his private assistant. He occupied this 
important position from 1861 to 1870, when Syme died. He 
accompanied his master to operations all over the country 
and when he became a candidate for an honorary surgeoncy 
in the infirmary he had Professor Syme's warm support, a 
support which no doubt weighed heavily in determining 
his appointment. Before this appointment he had been 
awarded the Jacksonian prize for his essay on the 
Malformations, Diseases, and Injuries of the Fingers and 
Toes and their Surgical Treatment. In 1871 he became a 
full surgeon to the infirmary and became entitled to 
lecture on olinical surgery. He was a popular lecturer and 
always drew a large number of students to his lectures and 
his ward clinics. When in 1877 Professor (now Lord) Lister 
resigned the chair of clinical surgery Mr. Annandale was 
appointed his successor. This post he filled until his death. 
Professor Annandale’s professional life was thus spread over 
a very remarkable period in the history of surgery. He 
began surgery at a time when expertness and dexterity, 
nerve, and courage were absolutely necessary to the surgeon. 
He had as his master in these departments the great Syme. 
Meanwhile Lister was slowly, laboriously, but surely laying 
the foundations of a scientific side of surgery that was 
destined to revolutionise the whole practice and to transfer 
technical dexterity with the operating knife to dexterity in 
asepsis. Following upon this came abdominal surgery where 
patient labour in the depths of that cavity led to the great 
victories gained in this region. Professor Annandale’s 45 
years of active surgical work thus covered a time marked 
by the beginning, the growth, and the complete success of 
a revolution in his own department. 

In virtue of his surgical instinct and his great experience 
bis opinion was often invaluable ; his dexterity, resourceful¬ 
ness, and nerve never forsook him. He was known wherever 
Edinburgh graduates were placed ; he was proud of his 
friends and former students dotted all over the globe ; he 


used to boast that he had operated in three, if not in four, 
continents. He was a member of various learned societies 
and he was Burgeon-General to H.M. the King’s Bodyguard 
for Scotland—the Royal Archers. In all University matters 
he took the warmest interest, especially in all matters 
affecting the comfort, or well-being, or interests of the 
students. He took a prominent part in connexion with the 
Students’ Union and with the Athletic Club and otherprojects 
which he regarded as for the good of the students. He was 
much liked by them; indeed, their liking amounted to 
affection. He was a kind-hearted, friendly, and genial 
influence in Edinburgh medical life. 

Professor Annandale married in 1874 a daughter of the late 
Mr. William Nelson, of the well-known publishing firm. 
There was a family of three sons and three daughters. The 
funeral took place on Dec. 23rd from St. John's Episcopal 
Church to the Dean Cemetery. 


Dkaths op Eminent Foreign Medical Men. —The 
deaths of the following eminent foreign medical men are 
announced:—Professor Adalbert Tobold, privat-doeent of 
laryngology and rhinoscopy in the University of Berlin. 
Dr. Oskar Lassar, primt-docent of dermatology and syphilis 
in the University of Berlin. 


SUttral jUtos. 


University of Cambridge.— The following 

appointments have been made: Senior Demonstrator in 
Anatomy, Dr. W. L. H. Duckworth; Junior Demonstrator in 
Anatomy, Dr. D. G. Reid. The following has been exa¬ 
mined and approved for the degree of Master of Surgery:— 
E. W. Sheaf, Donning. 

At examinations for Medical and Surgical Degrees held in 
Michaelmas Term, 1907, the following candidates were 
successful :— 

Second M.B. Examination. 

Unman Anatomy and Physiology.— R. L. Barker, B.A., Caius ; F. S. 
Bedale Clare; J. P. Benskin, Christ's; D. C. Bluett, Emmanuel; 
C. H. B. Booth, King's; E. G. S. Cane, B.A., Jesus; R. G. Canti, 
B.A., King’s; R. F. P. Cory, B.A., C&ius; II. T. Depree, B.A., 
Clare; C. Ede, King’s; K. Ellis, B.A., Catharine; A. G. Evans, 
Trinitv; J. T. Fox, B.A., Sidnev Sussex; A. W. Gaye, B.A., Caius; 
A. C. Uemmell, B.A., Trinity ; R. W. B. Gibson, B.A., Jesus; H.K. 
Griffith, B.A., Trinity; L. S. M. Habich, B.A., St. John’B; J. B. 
]Is nee, Christ’s; L. C. D. Irvine, Emmanuel; A. C. Jepson, B.A., 
Pembroke; J. C. John, King’s; L. F. G. Lewis, B.A., Christ’s; 
J. R. Marrack, St. John's; W. G. Marsden, Emmanuel; C. C. 
Mess iter, B.A.. C. G. H. Moore, B.A., and P. A. Ople. B.A , Caius; 

G. M. Parker, B.A.. Emmanuel; A. B. Pavey-Smith, Clare; J. W. 
Pigeon, Christ’s ; H. B. Pope, Caius; F. A. Powell, B.A., Trinity; 
R. A. Ramsay, Caius; K. Rayner, Pembroke; W. D. Ross King’s; 

A. Sandlson, B.A., Trinity; F. P. Saunders, B.A.. Clare; W. 
Shipton, B.A., Emmanuel; I. Singh, B.A., Pembroke; G. N. 
Slathers, Trinity; F. J. Thorne, B.A..Jesus; P. B. Wallis, B.A., 
Pembroke ; and F. H. Watson, B.A., and J. B. A. Wigmore, Caius. 

Third M.B. Examination. 

Part II. , Surgery, Midwifery, and Medicine.— J. B. Banister, M.A., 
Jesus; J. W. B. Bean. B.A., 11. Selwyn; E. Beaton, B.A., Caius; 

H. S. Berry, M.A., Clare: C. W. Bowie, B.A., Trinity; D. W. A. 
Bull, B.A., Caius; B. P. Campbell, B.A., Clare; J. It. C. Canney, 

B. A., Christ’s; H. B. Carlyll, B.A., St.John's; R. G. Chase, B.A., 
Trinity; R. N. Chopra, B.A., Downing; F. Clayton, B.A., Trinity; 
H. N. Coleman, B.A., Christ’s ; G. H. Davy, B.A., Caius; A. W. C. 
Drake, B.A , Pembroke; N. M. Fergusson, B.A.. Magdalene; G. B. 
Fleming. B.A.. King's; R. L. Gamlen, B.A., Caius; G. Graham, 
B.A.. Trinity; F. W. W. Griffin, B.A., Kings; O. Heath, B.A., 
Trinity; E. B. Hinde, B.A., Emmanuel; A. F. Jackson, B.A., 
Peterhouse; K. A. Lees, B.A., King’s; S. G. Luker, M.A., 
Pembroke; M. W. B. Oliver, B.A., Trinity; E. V. Oulton, B.A., 
Christ's; B. II. Palmer, B.A., Pembroke; W. G. Parkinson, B.A., 
Emmanuel; B. A. I. Peters, B.A., Jcsub; J. II. Ryffel, M.A., 
Peterhouse; L. Shingleton-Smith, B.A., St. John’s; E. Slack, 
M.A., Pembroke; E. C. Sparrow, B.A., Trinity; H. H. Taylor, 
B.A., Pembroke; C. H. Treadgold, M A., Clare; F. B. Treves, 
B.A., Caius; P. J. Verrall, B.A.. Trinity; K. M. Walker, B.A., 
Caius; and A. Wilkin, B.A., King's. 

London School of Tropical Medicine.—T he 
following students of the above school successfully passed 
the examination in Tropical Medicine held at the end of the 
twenty-fifth session,October to December, 1907 :— 

•Graham U. Smith, M IL, D.P.II., M.R.C.S., L.R.C.P.; "Major W. 
Westropp White, I.M.S., M.D.. M.Ch., M.A.O.; *H. L. Deck, 
M.R.C S., L.K C.P.; *J. Cross, M.B., Ch.B.; G. II. Hustler, M.B., 
Ch.B. (Colonial Service); Captain M. J. Quirke, I.MS., M.B., 
Ch.B.; F. L. Henderson, M.K C.S., L.R.C.P. (Colonial Service); 
T. L. Craig, M B., B.Ch. (Colonial Service); W. R. Larbalestier, 

L. R.C.P., M. H.C.S., L.D.S. (Colonial Service); A. E. Oakeley. 

M. R.C.S., L.R.C.P.; W. R. Gibson, F.K.C.S., L.R.C.P.; F. A. 





The Lancet,] 


MEDICAL NEWS. 


[Jan. 4,1908 . 71 


Wille. M B., Ch.B., AI D , D.P.1I. ; T. 

M.R.C.V.S. ; K. Fltzllerbert Johnson, 

Snell. L.K.C.P., L.R.C.S. (Colonial Servi 
# With distinction. 

Donations and Bequests.— Under the will of 

Mr. Isaac Coley of Peckbam, S.E., Gay’s Hospital, St. 
Thomas’s Hospital, University College Hospital, and the 
Lying-in-Hospital will each benefit by a sum of about £3000. 

Medical Magistrates.— The Lord Chancellor 

has, on the recommendation of the Dnke of Fife, the Lord 
Lieutenant of the county, added the name of Dr. R. J. Collie 
to the commission of the peace for the county of London.— 
Dr. Henry Willson of Weybridge has been placed upon the 
commission of the peace for the county of Surrey. 

Presentation to a Medical Practitioner.— 

Mr. J. W. Smith, M.R.O.S. Eng., L.S.A., was on Dec. 25th 
last presented with a motor-car with accessories and 
motor-house by the inhabitants of Weaverham, Acton, 
Delamere, Cuddington, Norley, and surrounding districts in 
recognition of 40 years’ professional servioes and 18 years’ 
service as a Cheshire county councillor. 

Tragic Death of a Medical Man.—D r. George 

John Sealy of Weybridge, Surrey, lost his life on Dec. 24th 
last in a tragic manner. He was riding on horseback witb his 
groom along the towpath towards Chertsey. Owing to the 
floods the path was quite unsafe and near Chertsey Bridge 
Dr. Sealy’s horse, which was leading, plunged and slipped, 
with the result that both horse and rider were precipitated 
into the river. The horse managed to get out again but 
nothing could be seen of Dr. Sealy. The groom dismounted 
and tried to render assistance, as did also the driver of a van 
who witnessed the accident but neither could render any 
help to rescue the unfortunate medical man. Dr. Sealy 
became M.R.C.S. Eng. and L.S.A. in 1861 and M.D. 
St. Andrews in 18b2 and worked in conjunction with Dr. 
K. D. R. Crofton-Atkins of Weybridge. 

The Children’s Sanatorium (Holt, Norfolk). 
—A first report, with accounts from March, 1904, to 
Dec. 31st, 1906. with a list of subscribers, has recently been 
issued. The sanatorium is established for the treatment of 
children, few Banatoriums taking children under the age of 16 
years. The age of admission for girls is from two to 16 years 
and for boys (until permanent buildings are erected) from two 
to seven years. Cases must be in the early stage of pulmonary 
tuberculosis. Payment for cases depends ou the condition 
of the maintenance fund. A limited number of cases are 
received at 7». 6 d. per week, other cases at 15*. per week, 
and other cases from unions or other local authorities are 
received by special arrangement. The length of stay 
depends upon the report of the visiting medical officer 
(Dr. J. B. Gillam of Holt) and upon the continuance of the 
payment, if any. On August 1st, 1906, the first batch 
of children arrived at Holt, “and up to the present 
time” (presumably the end of October, 1907) some 
21 cases have been received. From the accounts we 
gather that £220 have been spent on the maintenance 
of cases, and that of the 21 cases so far taken 15 
have paid 7*. 6 d. a week, five have paid 15*. a week, and 
one has been taken free. The income annually required to 
maintain always 15 cases (a full occupation of the accommo¬ 
dation), if taken quite free, would amount to £850, or if the 
same number of children were to pay 7*. 6 d. per week each 
the sum necessary would be £550 per annum. The com¬ 
mittee, however, appeals for an annual subscription of £700 
in order that about half the cases may be taken without 
payment and half at 7*. 6 d. per week. It also appeals 
for donations to the buildiDg fund. Dr. F. W. Burton- 
Fanning of Norwich, who is the honorary consulting 
physician, states that the Children's Sanatorium has 
acquired an ideal site at Holt and he trusts that it 
will be supported in its endeavours to supply a pressing 
want. Donations for the building fund, or donations or 
annual subscriptions for the maintenance of cases fund will 
be gratefully received by the honorary secretary of the sana¬ 
torium (Mr. T. H. Wyatt, M.V.O.), at 68. Denison House, 

A anxhall Bridge-road, London, S.W. The bankers are 
Messrs. Hoareand Co., London. The Rev. E. C. Bedford is 
the chairman of the committee and the treasurer is Mr. Alfred 
Hoare. As soon as the money is forthcoming 50 patients can 
be dealt with. Holt (near Cromer) should be ot interest to 
Cambridge graduates on account of its connexion with Sir 


Thomas Gresham, “ the Royal Merchant,” who went to Cains 
College, Cambridge, and who, it is recorded, was called by 
Caios “ Doctissimus mercator.” Some authorities say he 
was born at Holt, but more maintain that London was his 
birthplace. However, he founded a school at Holt. 

Derbyshire Women’s Hospital.— The new 

buildings which form the extension of the Derbyshire 
Women’s Hospital, Derby, were opened on Dec. 12th, 1907, by 
Lady Fitzherbert. The new buildings comprise an out-patient 
department, with waiting-room for 50 people, consulting and 
retiring rooms, and a dispensary ; a ward containing seven 
beds and two smaller wards for such cases as are being 
treated apart ; additional accommodation for the nursing 
and domestic staff; and a laboratory and workroom. The 
estimated cost of the additions to the hospital is about £2000. 
The hospital was founded in 1891, during which year 34 
patients were treated. In 19C6 the in patients numbered 136 
and the out-patients 1284. 

Livingstone College.— Satisfactory progress 

in the work of this college is shown by the report for the 
year 1906-07, which was adopted at the annual general 
meeting of members held at the college, Leyton, London, 
E., on Dec. 10th, 1907. The deficiency of £522 at 
the commencement of the financial year has been re¬ 
duced to one of £404. 32 students entered for the 

whole or part of the complete session of nine months, 
representing 15 different missionary societies, some of 
these coming from Germany, Switzerland, Sweden, 
Finland, and South Africa. The report points out that 
missionaries abroad are often responsible for the education 
of the young in the districts in which they are placed, 
and that they may be the means of giving instruction in 
hygiene, which may be of the utmost importance to the 
people of the country. Malaria, plague, and sleeping sick¬ 
ness are all of them, to a considerable extent, preventable 
diseases, and Livingstone College students may do much to 
combat their ravages. 

Leprosy in India.— At Sabathu, where there 

is a large leper asylum for natives, a small cottage 
was set apart some time ago by Dr. Carleton, tbe 
American missionary in charge, for two European young 
women who had contracted the disease, and recently the 
number of inmates has been increased to five by the admis* 
sion of two boys and a middle-aged man, all three with white 
skins. The price of grain food in India is at present very high, 
and we learn from the Timet of India that mainly owing to 
this cause the bank account of the Mission to Lepers, of 
which Mr. Wellesley O. Bailey is superintendent, is now over¬ 
drawn to the extent of £1000. In Purulia, where there are 700 
lepers in the asylum, the food is being bought at what once 
were considered famine rates, and at the Allahabad asylum 
the ‘difference between former and present cost comes to 
Rs. 150 a month. Similarly depressing accounts are fur¬ 
nished by the numerous asylums in other parts of India 
which are dependent on the Mission. It is proposed to hold 
a conference next February at Purulia and delegates from 
Bengal, the United Provinces, the Central Provinces, and 
Central India are expected to attend. 

The Weymouth and District Medical Club.— 
This club has recently been started on what is believed to be 
original lines. All resident medical men, active or retired, 
are eligible for membership, whilst Service men are invited 
to attend, as honorary members, the ordinary meetings of the 
club. The objects of the club are stated in its rules to be 
“the promotion of social intercourse and mutual support in 
any difficulties which may arise from time to time affecting 
the profession or individual members.’’ The former object 
is attained by engaging a room in a central hotel, the 
Gloucester, in which the members may meet without any 
formality on ODe evening of each month in the winter, whilst 
provision is made for the latter by putting it into tbe power 
of any two members to bring any matter to the consideration 
of an early meeting of the committee, which consists of all 
the resident medical men in active practice. No permanent 
chairman or president is appointed but a new departure is 
made by a rule which places in the chair at any meeting 
of the club that member present who has been longest in 
actual practice in the district. An inauguration dinner, 
which was held at the Gloucester Hotel on Dec. 17th, 
1907, was a great success and was attended by nearly 
every medical man in the place, the navy being well 
represented. The rule placing in tbe chair the senior 


F. Macdonald, M.B., C.M., 
M.B., Ch.B. i and W. S. 


72 The Lancet,] 


BOOKS, ETC., RECEIVED.—APPOINTMENTS.—VACANCIES. 


[Jan. 4, 1908. 


practitioner present worked appropriately by making 
■President for the evening Dr. R. Palgrave Simpson who, 
after 40 years’ practice in Weymouth, is shortly retiring. 
An excellent dinner was served and after the toast of “The 
King ” allusion was made to the approaching departure of 
Dr. Simpson and his health was enthusiastically drunk. In 
returning thanks the chairman recalled the fact that he was 
the sole surviving representative of the old local book club 
which was already defunct before the arrival in Weymouth 
of any other medical man present. The remainder of the 
evening was occupied by an excellent programme of music 
and at the close of a very pleasant gathering the club con¬ 
gratulated itself on a most propitious “ send-off." 

Royal Microscopical Society.— At the Royal 
Microscopical Society on Dec. 18th, 1907, Mr. J. E Bernard 
showed a number of luminous bacterial cultures in test- 
tubes and flasks. He said that the bacteria were all of 
marine origin and that they were cultivated in an ordinary 
gelatine medium to which certain salts had been added. At 
first he used the chlorides of sodium, potassium, and 
magnesium in proportions resembling those in which they 
occurred in sea water, but he afterwards found that quite 
different salts, such as phosphate of sodium, were equally 
suitable provided the solution was isotonic to sea water. 
The light emitted was very nearly monochromatic, 
being included almost entirely between the F and 
•G lines of the solar spectrum. The curve of light 
energy therefore rose and fell very abruptly, forming 
quite a contrast to the gradual rise and fall of the similar 
curve for sunlight. Before leaving this subject we may 
mention that directions for the cultivation of tbe*e organisms 
will be found in The Lancet of Oct 13th, 1900, p. 1087. 
A paper by Mr. E. M Nelson on Gregory and Wright’s 
Microscope was read by the secretary. This microscope was 
made about 1786 by the firm of Gregory and Wright who 
were probably the successors of Benjamin Martin. It was a 
stage focusser and was described as an “ aquatic microscope ” 
—i.e., one in which the object-glass moved over the object 
instead of the object moviDg under the object-glass. Some of 
•the features of Ooerl si user's drum microscope, made in 1835, 
Were described. Another paper by Mr. Nelson, also read by the 
secretary and entitled “A Correction for a Spectroscope," 
suggested that the telescope of a spectroscope should have 
its object-glass pivoted so that the rays emerging from the 
prism might be received by it at varying angles. The 
secretary also read a paper entitled “ Some African Rotifers," 
by Mr. James Murray who was at preEent on his way to the 
Antarctic regions. Mr. Eustace Large exhibited as polari- 
scope objects a variety of sections of selenite illustrating the 
phenomena of “twinning.” They were shown both in table 
polariscopes and under low powers of the microscope ; the 
visible effects consisted of brilliantly coloured geometric 
patterns. _ 


BOOKS, ETC., RECEIVED. 


-Perla do. Paez y ca (Sociedad en Oomandita) (Sucesores de 
Hernando). Arena]. 11, 7 Quintana, 31. Madrid. 

Diagnostico y Tratamiento de las Knfermeriades de Irs Vi as 
UrinarUs. Lecciones elementales. Por Alberto Suarez de 
Mendoza, Profesor de Enfermedades de las Vlas Uriuari&s en 
la Facultad de Medicinade Madrid. Price 15 pesetas. 

Richards. Grant, 7.Carlton-street. London, S W. 

The Birds of the British Islands By Charles Stonbam, C.M.G. 
F.R.C 3., F.Z.S With illustrations by Lilian M. Me.iland. In 
20 parts. Part VIII. Price Is. 6d net. 

Rueff, J., 6 and 8, Rue da Louvre, Paris. (En Vente chez Vigot 
FRkRES, Paris.) 

Les Ferments Metalliques et leur Ktnploi en Th^rapeutique. Par 
Albert Kobin, Profe&seur de Clinique Therapeutique a la Faculie, 
Membre de l’Acadgmie de Medeciue. Frlce Fr 4. 

-Schoetz. Richard, Wilhelmstr&sse, 10. Berlin. 

Der tatsitchliche Krebserreger. sein Zyklus und seine Dauersporei. 
Von Dr. Robert Behla, Goheimor Medizinairat. Price M. 4.50. 

Walkfr, John, and Co., Limited, FarriDgdon House, Warwick lane, 
Loudon, E.C. 

Walker's Diaries for 1908. No. 7/77, American Russia, 3«. No. 23- 
Long-Grain, 2s. 6d. 17/417. Graphic, a* did Basil Is 6 d. 4/64, 
Long-Grain, 2s. 6 d. 3/53. cloth, 9d. 2/62, Long-Grain, Is. 6d- 
1/111, Solid Basil, Is. 1/81, Solid Pigskin, Is. 6 d. Quarterly 
Diary (Vest Pocket), Long-Gram, Is. 

Whitaker, J., and Sons, Limited, 12, Warwick-lane, Paternoster-row, 
London, E.C. 

An Almanack for the Year of our Lord 1908. By Joseph Whitaker, 
F.S.A. (Whitaker's Almanack). Price 2s. 6d. net. 

Whitaker s Peerage, Baronetage, Knightage, and Companionage for 
the Year 1908. Price 2s. 6d. net. 


Wilson. Effingham, 54, Threadneedle street, London, E C. 

A Practical Guide to the Dealh Duties and to tbe Preparation of 
Death tmty Accounts. By Charles Beatty, S--lieifcor, if the 
Estate Duty Office. Somerset House. Second edition (Revised 
arid enlarged). Price 4s. i.et. 

Wright and Potter Printing Company, State Printers, 18, Post 
Office-square, Boston. 

Twenty-eighth Annual Report of the State Board of Health of 
Massachusetts. Price not stated. 


appointments. 


Successful applicants for Vacancies, Secretaries of Public Institutions, 
ana others possessing information suitable for this column, are 
iynnted to forward to Thk Lancet Office, directed to the Sub- 
Editor, not later than 9 o'clock on the Thursday morning of each 
week, such information for gratuitous publication. 

Attenborough, Wilfrid, M.R.C.S., L.R C.P. Lond , has been 
appointed House Physician at Addenbrooke's Hospital, Cambridge. 

Byrnk, P. Kevin, M.D., M.K C.P. Loud., has been appointed Assistant 
Physician to the London Temperance Hospital. 

Clark, Robert V., M.B. Edin., has been appointed Medical Officer of 
Health of Leeds. 

Corbin. H. K.. M.K.C.S., L.R.C.P. Lond., D.P.H., has been appointed 
Medical Officer of Health of Stockport. 

Dimock. Horace, M.B., B C. Cantab., has been appointed House Sur¬ 
geon at Addeubrooke’s Hospital, Cambridge. 

Hailstone, J. E., M.R.C.S., L.K.C.P. Lond., has been Appointed 
Assistant House Surgeon at Addenbrooke's Hospital, Cambridge. 

Hawes, Ivon Henry Skipwith, M.B., B.S. Durh., has been appointed 
Medical Officer for the Wick District by the Chipping Sodbury 
(Glouc6Btersbire> Board of Guardians. 

Higgs, F. W.. M.B, B.S. Lond., M.R.C.P. Lond., has been appointed 
Medical Registrar to St. George's Hospital. 

HosfoRD, J. Stroud, F.R.C.S. Edin., has been appointed Assistant 
Ophthalmic Surgeon to tbe London Temperance Hospital. 

Houhigan, VV. P., L.U.C.S. Irel., L.R.C.P. Edin.. has been appointed 
Certifying Surgeou under the Factory and Workshop Act for the 
Freshford District of the county of Kilkenny. 

Hunter, William. M.D.. C.M. Edin., FR C.P. Lond., has been 
appointed Physician to Charing Cross Hospital. 

Jameson, K. C.. M.B., C.M. Kdiu., has been appointed Honorary 
Clinical Assistant to the Eye and Ear Department of the Leeds 
Public Dispensary. 

Johnsjn, L. Capper, M.B. Lond.. Ch.B. Vlct., M.R.C.8., L R.C.P. 
Lond., has been re-appointed Honorary Amesthetist to the Sur¬ 
gical Department of the Leeds Public Dispensary. 

Leggf.. J. H, M.B., B Sc. Lond., has been appointed Honorary 
Amesthetist to the Dental Department of the Leeds Public 
Dispensary. 

MacIIalr, P. J., L.R.C.P. & S. Irel., has been appointed Certifying 
Surgeon under the Factory and Workshop Act for the Belmullet 
District of the county of Mayo. 

Maclure, W. J ., M.B., B.S. Glasg., has been appointed Certifying 
Surgeou under the Factory and Workshop Act lor the Conis- 
borougb District.»f tbe county of York. 

O’Gkvdy. F. If. L.R.C.S. Irel., L.K.Q.C.P. Irel., has been appointed 
Certifying Surgeon under the Factory and Workshop Act for the 
Swineford District of the county of Mayo. 

Quick Hamilton Ernest, B.Sc., M.B., B.S. Lond., L.U.C.P., 
M.R.C.S., has been appointed House Surgeon at the Swansea 
Hospital. 

Sandilands. J. K., M.D. Cantab.. M.R.C.S., has been appointed Certify¬ 
ing Surgeon under the Factory and Workshop Act for the 
Winchester District of the county of Hants. 

Spriggs. N. I.. M.K.C.S., L.K.C.P. Lond.. has been appointed Certify- 
ing Surgeon uuder the Factory and Workshop Act for the 
Shrewsbury Disirict of the county of Salop. 

Sutcliffe, Amelia, M.B., Cb.B.Edin., has been reappointed 
Honorary Clinical Assistant to the Leeds Public Dispensary. 

Thomson, May. L.ll.C.P. A S. Edin.. L.F.P.3. Glasg., L.M. Dub., 
has been re-app.duted Honorary Clinical Assistant to the Leeds 
Public Dispensary. 

Ward, J., M.K.C.S.. L.S.A.^has been appointed Certifying Surgeon 
under tbe Factory and Worksh »p Act for the Leainlugton District 
oi tbe county of Warwick. 

Whalley, Frederick, M.B., Ch.B. Leeds, has been appointed Hono¬ 
rary Anesthetist to the Dental Department of the Leeds Public 
Dispensary. 

Whitehead, Francis Henry, L.R.C.P. Lond., M.R.C.S., has been 
appointed Medical Officer to t he Post Office at Battersea, 3. W. 

Wilson. E. Ai-lan, M.D. Lond., M.R.C.S., L.K.C.P. Lond., has 
been re appointed Honorary Anaesthetist to the Dental Depart¬ 
ment of the Leeds Public Dispensary. 


Uacanrics. 


For f urther information regarding each vacancy reference should be 
made to the advertisement (see Index). 


Bootlk Hospital for Infectious Diseases.— Resident Medical 
Officer unmarried. Salary £100 per annum, with board, washing, 
and apartments. 

Brighton, Susan x County Hospital. —Third House Surgeon, un¬ 
married. Salary £50 per annum, with board, residence, aud 
wash fug. 

Burslkm, Borough of.— Medical Inspector of Children in Public 
Elementary Schools (female). Salary at rate of £150 per annum, 
rising to £200. 





Thb Lancet,] 


VAOANOIBS.—BIRTHS, MARRIAGES, AND DEATHS. 


[Jan 4.19C8 73 


Cardiff Infirmary. Gknf.ral Hospital.— House Physician for six 
months. Salary £30, with board, residence, and laundry. 

Charing Cross Hospital.—A ssistant Physician. 

Chesterfield a»d North Derbyshire Hospital.—S enior House 
Surgeon. Salary £120 per year, with board, apartments, and 
laundress. 

Devonport, Royal Albert Hospital.— Resident Medical Officer, 
unmarried. Salary £100 per annum, with apartments, board. Ac. 

Enniskillen. Fermanagh County Hospital.— House Surgeon. 
Salary £52 per annum. 

Hartlepool# Hospital.— House Surgeon. Salary £100 per annum, 
with board, washing, and lodging. 

Hospital for Consumption and Diseases ok the Chest. Brompton. 
—Resident House Physicians for six months. Salary £25. 

Hull. Royal Infirmary.—T wo Casualty House Surgeons. Salary at 
rate of £60 per annum for six months and of £80 for 12 months, 
with board and lodging. 

Leeds Public Dispensary.— One Pathologist, Five Dental Surgeons, 
and Four ABS'Biant. Dental Surgeons, all honorary. 

Liykhpool Infectious Diseases Hospital.— Assistant Resident 
Meoical Officer, unmarried. Salary £120 per annum, with board, 
washing, and lodging. 

London Fkvkr H"»pital, Liverpool-road, N. — Resident Medical 
Officer. Salary £2oO per annum, with board and residence. 

London Lo« k Hospital, Soho. —House Surgeon to the Male Hospital. 
Salary £80 per annum, with board, lodging and * ashing. 

National Hospital for the Relief and Cure ok thb Paralysed 
ani> Epileptic. Queen-square, Bloomsbury.—Assistant Ptiysician 
for Out patients. 

Northampton General Hospital.— Assistant House Surgeon, un¬ 
married. Salary £60 per annum, with apartments, board, washing, 
and attendance. 

North Eastern Hospital for Children, Hackney-road, Bethnal 
Green. E.—Assistant Physician. 

Paddington Ghkkn Childrens Hospital, London, W.—Honorary 
Auers'hetist, also Honorary Radiographer. 

Portsmouth, Hoyal Portsmouth Hos htax.— Assistant House Sur¬ 
geon for six months. Salary at rate of £50 per annum, with 
board, Ac. 

Saint Georges Union Infirmary, Fulham-rond, London, S.W.— 
Second Assistant. Medical Officer. Salary £120 per annum, with 
board, residence, and washing. 

St. Mary’s Hospital Medical School, Paddington, W —Junior 
Demonstrator of Physiology. Salary at rate of £100 per annum. 

Sheffield, University of.—D emonstrator in Anatomy. Salary 
£150 per annum 

Somerset C»unty Council.— Chief Medical Inspector of Schools. 
Salary £500 per annum, with necessary out-of-pocket expenses. 

SURREY • ispensaRY, Southwark, S.E. - Physician. 

Swansea County Borough.— Medical Officer of Health. Salary £5C0 
per annum. 

Taunton Union. North Curry District.— Medical Officer. Salary 
£75 per annum and fees. 

University C llkgb Hospital, Gower-street, W.C.—Resident 
Medical Officer. 

Wadsley. near Sheffield, West Riding Asylum. —Fifth Assistant 
Medical Officer. Salary £140 per annum, rising to £160, with 
board. Ac. 

Warrington Union Workhouse.— Resident Medical Officer. Salary 
£lo0 ner annum and tees, with apartments, rations Ac. 

West-End Hospital for Diseases ok the Nervous System, 
Paralysis, and Epilepsy, 73, Welbeck-street, London, W. — 
Physician to Out-patients. 

West Ham Hospital, Stratford. E.—Junior House Surgeon for six 
mouths. Salary at rale of £75 per annum, with board, residence, 
Ac. 

Wrexham Infirmary.— Resident Medical Officer. Salary £80 per 
annum, with board, lodging, and washing. 


The Chief Inspector of Factories, Home Office, S.W., gives notice of 
vacancies as Certifying Surgeons under the Factory and Work 
■hop Act at Dron field, in the county of Derby ; and at Stratford, in 
the county ol Essex. 


Carriages, anb geatjjs. 


BIRTHS. 

Sibley. —On Dec. 27th, 1907, at The Mansions. Duke-street, Orosvenor- 
square, W., the wife of W. Knowsley Sibley, M.A., M.D., of a 
daughter. 

Worthington.— On Dec. 29th, 1907, at The Sycamores, Birchington, 
Thm.et, the wife of H. E. Worthington, M.R.C.S., L.R.C.P., of a 
daughter. _ 

MARRIAGES 

Greenwood Penny—Phillips.— On,Nov. 14th. 1907. at St. James’s, 
Exeter, by the Rev. P. Williams, the Rev. W. David and the Kev. 
E. Reid, Sydney Greenwood Penny, M.R.C.S , L.R.C.P., of Pen- 
mene'h, Marazion, Cornwall, younger son of the late Robert 
Greenwood Penny of Nethergrove. Cbulmleigh. N. Devon, to 
Gvtpulllau Helen Leigh, younger daughter of the late Rev. James 
Phillips of Exeter. 

Jones-Evans —On the 1st inst., at Aherayron. Edmund Benjamin 
Jones, F R C.S-Eng , of * Chatswort h ” North End-road Golder’s 
Green, N.W., to lna Margaret, second daughter of the late 
Llewelyn Evans, of Pantclynhlr. New Quay, Cardiganshire. 


DEATH 

Garrod. —On Dec. 28th. 1907. at Harley-street. Cavendish-square, W., 
Sir Alfred B. Garn»d, M.D., F.It C P., F.H S., Phvsician Extra¬ 
ordinary to her late Majesty Queen Victoria, iu his 89th year. 


N.B.—A lee ol 5s. is charged for the insertion of Notices of Births, 
Marriages, and Deaths 


Soles, Styort Comments, aitb Jnstoers 
to Correspondents. 

THE PUBLIC TELEPHONE CALL OFFICE AS A FACTOR IN 
TIIE SPREAD OF DISEASE. 

In our issue of July 27th 1907, p. 240, we directed attention to the un¬ 
ventilated condition of the public telephone call offices and to the 
possible risk of contracting infectious disease while using them. In 
the construction of these call offices It is essential that external 
noises should be excluded as much as possible in order that the 
person who is inside may he able more easily to hear what is said to 
him from the distant station. Hence the difficulty of ventilation. 
The substance of our article was reproduced in Didaskalta, a 
periodical published In Frankfort, and Mr. Richard Goll of that city 
has consequently written to us that he Is the patentee of a system of 
ventilation which has been successfully applied to telephone call 
offices. According to the description which we have received it is an 
arrangement of tubes or conduits ( tine Anordnung von Leitungen) 
the action of which is noiseless and automatic, depending only on 
natural or accidental differences of pressure ( Luftdrnckunterschiede ). 
Particular attention is called to the fact that at the Hotel Marquardb 
In Stuttgart there are four telephone call offices ( Tclcpkon-jellcn) for 
the use of visitors, and the ventilation of these by Mr. Goll's system 
has given satisfaction. 

HUMOUR. 

It is a good sign when human beings can appreciate humour. Not 
so very long ago a play of fancy was supposed to be incompatible 
with science. Science was regarded as a sober, solemn affair on no 
account to be treated lightly. Geniuses were seripus creatures of 
whom but a small minority could understand a jock and that, with 
<ieefficulty . To effect an entrance for a witticism into their surcharged 
sensoriums surgical opera'ions were a preliminary essential. We 
have been led to make these frivolous remarks by Captain J. Crawford 
Kennedy, R.A.M.C., who has successfully extracted “A Little 
Humour from the Malta Commission” for publication in the 
December number of the journal of his corps. At the risk of some 
of the allusions proving caviare to the general unfamiliar with the 
Internal economy of line regiments, we venture to reproduce the 
extract from an adjutant’s letter with which Captain Kennedy 
closes his article. 

Dear Kennedy, —P. has passed your note on to me, and all 
our men are now running about with butterfly nets, or trying to 
tempt the wily mosquito with lumps of raw meat, and I've 
indented for a small size of mouse-trap, but am doubtful if the 
Government will supply the necessary bait. Up to the present the 
bag Is one, and he si niggled bo w.hen our regimental poll e were 
effecting his capture that he had to be hit hard on the head ar.d 
I’m afraid Is almost, unrecognisable. PS.-Another capture just 
reported. We’ve put him in the guard room till your boxes arrive. 

He has been biting - and was consequently drunk and his 

capture was easy. Ought mosquitoes (when drunk) to have their 
boots removed ? 

THE MEDICINAL EMPLOYMENT OF SKA-WATER. 

In a recent number of t he Repertoire de Pharmacie M. P. Carles gives 
an interesting account of the use of sea-water in medicine. In 
addition to common salt sea water contains many important mineral 
substances, the totAl solid matter amounting to 3'2 to 3'8 per cent. 
Some of these substances are present only to an infinitesimal extent, 
but in biology the value of a substance is not necessarily dependent 
upon Its actual size or quantity. It has been shown that various 
marine plants have the power of extracting from sea-water minute 
quantities of compounds of iodine, bromine, arsenic, boron, 
manganese, lithium, fluorine, rubidium, crcsium, and other elements. 
Hence it was not unreasonable to suppose that t he higher animals 
might derive benefit from the assimilation of even minute traces of 
these physiologically active substances. The employment of sea¬ 
water as a remedial agent dates back to the time of Hippocrates, and 
modern physiological Investigations have led to its reintroduction inta 
medicine. Thus it has been shown that if a portion of the blood 
serum of a dog be replaced by an artificial serum the most suitable 
serum for the purpose is sea water, isotonic with the natural 
serum. Sea-water has been given by the mouth and by injec¬ 
tion with good results In cases of dyspepsia, loss of appetite, 
and tuberculosis. In general the appetite was improved and 
strength was rap dly regained. In order to obtain the beat and 
most immediate results it is necessary to observe certain 
precautions. The sea-water must be nat ural as it Is Impossible to 
imitate so complex a liquid. Indeed, it has been proved that sea 
salt, when r- -dissolved in distilled wat>r, lacks some of the 
properties of natural sea water, exerting a toxic action upon a dog 
when injected subcutaneously. It must be freshly collected, as It 
loses carbon dioxide on standing, with precipitation of some of its 
salts. It should be taken from the open boa remote from rivers and 
other sources of pollution. It should bo sterilised by filtration, as 
heat dissociates the bicarbonates and destroys the natural equilibrium 
of the liquid. When required for subcutaneous injootion it should 



74 The Lancet,] 


NOTES, SHORT COMMENTS, AND ANSWERS TO CORRESPONDENTS. 


[Jan. 4, 1908. 






Thb Lancet,] 


DIARY.—EDITORIAL NOTICES.—MANAGER’S NOTICES. 


[Jan. 4, 1908. 75 


Throat, Golden-square (9.30 a.if.), Guy’s (1.30 P.K.). Children Gt. 
Ormond-street (9.30 A.M.). 

At the Koval Kye Hospital (2 p.m.), the Royal London Ophthalmic 
10 A.M.), the Royal Westminster Ophthalmio (1.30 p.m.), and the 
Central London Ophthalmio Hospitals operations are performed daily. 


SOCIETIES. 

ROYAL SOCIETY OF MEDICINE, 20, Hanover-square, W. 

Thursday .—(Obstetrical and Qyiuecolorjical Section). 7.45 p.m., 
Dr. J. P. Uedley, Dr. Harold Siugton (introduced by Dr. 
Handheld-Jones), and Dr. A. H. N. Lea-era . Specimens. Mr. 
J. Bland-Sutton : On Carcinoma of the Ovary from a Clinical 
Standpoint. Dr. Carver and Dr. Fairbairn : On Haemorrhage 
into the Pons Varoiii as a Cause of Eclampsia. 

Friday.— (Clinical Section). 8.30 p.m.. Exhibition of Cases. Dr. 
Sidney Phillips: A Case of Fatal Illness in a Child with Post¬ 
mortem Appearances of the “ Status Lymphaticus.” The 
patients will be in attendance at 8 p.m. 

UNITED SERVICES MEDICAL SOCIETY, Royal Army Medical 
College, Millbank, S.W. 

Thursday.— 8.30 p.m., Major M. P. C. Holt, D.S.O. : The 
Advisability of Operation for Recurrence of Hernia in the 
Services. 

NORTH-EAST LONDON CLINICAL SOCIETY, Prince of Wales’s 
General Hospital, Tottenham. N. 

Thursday. —4.15p.m. f Address Dr. Robert Hutchinson : Modern 
Theories of Diet in their Relation to Practice. 


LECTURES, ADDRESSES, DEMONSTRATIONS, &c. 

MEDICAL GRADUATES’ COLLEGE AND POLYCLINIC, 22, 
Chenies-strect, W.C. 

Tuesday. —4 p.m., Dr. H. Campbell: Clinique (Medical). 

5.15 p.m., Lecture Dr. F. J. McCann: The Diagnosis and 
Treatment of Inflammation of the Fallopian Tubes. 
Wednesday. —4 p.m., Mr. Jackson Clarke : Clinique (Surgical). 

5.15 p.m.. Lecture :—Dr. Purvea Stewart: Psychasthenia. 
Thursday.— 4 p.m., Mr. Hutchinson: Clinique (Surgical). 

5.15 p.m.. Lecture : Dr. Beresford Klngsford: Some Special 
Methods of Administering Chloroform and their Relative 
Advantages. 

Friday.— 4 p.m., Mr. C. A. Parker : Clinique (Throat). 

LONDON INSTITUTION, Finsbury-square, E C. 

Wednesday.—8.30 p.m.. Lecture:— Dr. Dundas Grant: Some 
Important Aspects of Suppuration of the Middle Ear. 

MOUNT VERNON HOSPITAL, CENTRAL IN-PATIENT DEPART 
MENT, 7, Fitzroy square, W. 

Thursday.— 5 p.m., Opening Lecture :—Sir Thomas C. Allbutt, 
K.C.B.: Angina Pectoris (Post-Graduate Course). 

ST. JOHN’S HOSPITAL FOR DISEASES OF THE SKIN, 
Leicester-square, W.C. 

Thursday. — 6 p.m., Lecture-.—Dr. M. Dockrell: Bullous and 
Vesicular Eruptions: I., Urticaria; II., Pemphigus; III., 
Pompholyx; lv.. Varicella. 


editorial notices. 

It is most important that communications relating to the 
Editorial business of The Lancet should be addressed 
exclusively “To the Editor, ’’ and not in any case to any 
gentleman who may be supposed to be connected with the 
Editorial staff. It is urgently necessary that attention be 
given to this notice. _ 

It ii especially requested that early intelligence of local events 
having a medical interest, or which it'is desirable to bring 
under the notice of the profession, may be sent direct to 
this offiee. 

Lectures, original articles, and reports should be written on 
mu side of the paper only, AND WHEN ACCOMPANIED 
BT BLOCKS IT IS REQUESTED THAT THE NAME OF THE 
AUTHOR, AND IF POSSIBLE OF THE ARTICLE, SHOULD 
BE WRITTEN ON THE BLOCKS TO FACILITATE IDENTI¬ 
FICATION. 

Letters, whether intended for insertion or for private informa¬ 
tion, must be authenticated by the names and addresses of 
their writers—not necessarily for publication. 

We cannot prescribe or recommend practitioners. 

Local papers containing reports or news paragraphs should be 
marked and addressed “ To the Sub-Editor." 

Letters relating to the publication, sale and advertising 
departments of The Lancet should be addressed “To the 
Manager." 

We cannot undertake to return MSS. not used. 


MANAGER’S NOTICES. 

THE INDEX TO THE LANCET. 

The Index and Title-page to Vol. II. of 1907, which was 
completed with the issue of Lee. 28th, are given in this 
number of The Lancet. 


VOLUMES AND CASES. 

Volumes for the second half of the year 1907 will be 
ready shortly. Bound in cloth, gilt lettered, price 18s., 
carriage extra. 

Cases for binding the half year’s numbers are now ready. 
Cloth, gilt lettered, price 2 s ., by post is. Zd. 

To be obtained on application to the Manager, accompanied 
by remittance. _ 

TO SUBSCRIBERS. 

Will Subscribers please note that only those subscriptions 
which are sent direct to the Proprietors of The Lancet 
at their Offices, 423, Strand, London, W.O., are dealt with by 
them 1 Subscriptions paid to London or to local newsagents 
(with none of whom have the Proprietors any connexion what¬ 
ever) do not reach The Lancet Offices, and consequently 
inquiries concerning missing copies, tic., should be sent to 
the Agent to whom the subscription is paid, and not to 
The Lancet Offices. 

Subscribers, by sending their subscriptions direct to 
The Lancet Offices, will insure regularity in the despatch 
of their Journals and an earlier delivery than the majority 
of Agents are able to effect. 

The Colonial and Foreign Edition (printed on thin 
paper) is published in time to catch the weekly Friday mails 
to all parts of the world. 

The rates of subscriptions, post free, either from 
The Lancet Offices or from Agents, are :— 

Fob the Umitf-d Kingdom. I To the Colonies and Abroad. 

One Year .£1 18 S One Year .£1 14 8 

Six Months. 0 16 3 I Six Months. 0 17 4 

Three Month* . 0 8 8 | Three Month* . 0 8 8 

Subscriptions (which may commence at any time) are 
payable in advance. Cheques and Post Office Orders (crossed 
“London and Westminster Bank, Westminster Branch”) 
should be made payable to the Manager, Mr. Charles Good, 
The Lancet Offices, 423, Strand, London, W.O. 


TO COLONIAL AND FOREIGN SUBSCRIBERS. 

Subscribers abroad are particularly requested 
TO NOTE THE RATES OF SUBSCRIPTIONS GIVEN ABOVB. It 
has come to the knowledge of the Manager that in some 
cases higher rates are being charged, on the plea that the 
heavy weight of The Lancet necessitates additional 
postage above the ordinary rate allowed for in the terms of 
subscriptions. Any demand for increased rates, on this or on 
any other ground, should be resisted. The Proprietors of 
The Lancet have for many years paid, and continue to pay, 
the whole of the heavy cost of postage on overweight foreign 
issues; and Agents are authorised to collect, and generally 
do so collect, from the Proprietors the cost of such extra 
postage. 

The Manager will be pleased to forward copies direct from 
the Offices to placeB abroad at the above rates, whatever be 
the weight of any of the copies so supplied. Address— 
The Manager, The Lancet Offices, 423, Strand, 
London, England. 


METEOROLOGICAL READING 8. 

(Taken daily at 830 a.m. by Steward's Instruments.) 

The Lancet Offioe, Jan. 2nd, 1908. 


Da to. 

Barometer 
reduced to 
Boa Level 
and 32° P. 

Direc¬ 

tion 

of 

Wind. 

Rain¬ 

fall. 

Solar 

Radio 

In 

Vacuo. 

M&xl- 

mnm 

Temp. 

Shade. 

Mln. 

Temp. 

Wet 

Bulb. 


Remark*. 

Dec. 27 

29*70 

S.E. 


42 

39 

35 

34 

36 

Cloudy 

„ 28 

29-61 

E. 


37 

34 

34 

33 

3b 

Cloudy 

.. 29 

29-89 

N.E. 


36 

36 

34 

34 

36 

Overcast 

„ 30 

29 97 

E. 


36 

36 

34 

33 

34 

Overcast 

„ 31 

29-90 

E. 


39 

39 

34 

34 

35 

Overcast 

Jan. 1 

30-00 

E. 


37 

36 

3b 

33 

3b 

Overcast 

.. 2 

30-35 

N.E. 


43 

33 

30 

29 

31 

Fine 


Daring the week marked copies of the following newspapers 
have been received Coventry Herald and Free Press, 
Readmit Mercury and Oxford Gazette, Nottingham Evening News, 
North Mail (Newcastle). South Wales Daily News. Sanitary Record, 
Birmingham Despatch, Standard. Yorkshire Daily Post, Newcastle 
Chronicle. Preston Guardian, Dublin Evening Telegraph, Liverpool 
Courier, Pall Mall Gazette, Hereford Times, Yorkshire Daily 
Observer, Nottingham Press, dec. 




















76 The Lancet, 


ACKNOWLEDGMENTS OF LETTERS, ETC., RECEIVED, 


[Jan. 4, 1908. 


Oommnnicatio&g, Letters, sc., have been 
received from— 


A. —MonBieur J. Astler, AsniOres; 
Messrs. C. Ash, Sons, and (Jo , 
Loud.; Aberystwyth Infirmary, 
Secretary of ; Anglo American 
Pharmaceutical Co., Loud., 
Manager of -, Mr. A Anderson, 
Northampton ; Dr. 1/ett Ander¬ 
son, Loud. 

B. -Mr. C. A. Ballance, Lond.; 
Major Blackham, R.A.M.C., 
Devonport, Dr H. Biss. Lond.; 
Mr. T. B. Browne, Loud.; Mr. 
H. Butterfield, Northampton; 
Mr. A. E. Bailey, Lend.; Messrs. 

J. H. Booty and Bon, Lond.; 
Messrs. Batt ley and Watts. Loud.; 
Dr. Q. D. M Beaton, Blackburn , 
Bail hr o< k House, Bath, Medical 
Superintendent of: Dr. B- M. 
Bernheim Baltimore. U.S.A.; 
Dr. D. T. Barry Cork; Dr. 
Henry Bartlett, Haaliugs; Mr. 
Joseph Bruton, Hove; British 
Medical Benevolent Fund, Lond., 
Hon. Secretary of; Messrs. 
Robert Boyle aud Sons. Loud.; 
British Me- ical Temperance 
Association, Enfield, Hon. Secre¬ 
tary of 

C. — Dr. Edmund Cautley. Lond.; 
Mr. M. H. A. Clarke. Puteaux; 
Dr. S. G. Corner, Colchester; 
Chesterfield and North Derby - 
shhe Hospital, Secretary of; 
Messrs. A. H. Cox and Co., 
Brighton, Mr. P. W. Clarke, 
Chorlton-cum- Hardy; Central 
Mid wives Boaid, Lond., Secre¬ 
tary of, Mr P. W. Collingwood, 
Lond.; Central London Throat 
and Bar Hospital, Secretary of; 
Mr. C. Campbell, Southport; 
Messrs. Carmachu, Roldan, and 
Van Sickel, New York; Messrs. 

T. Christy aud Co, Loud.; 
Messrs. B. Cook and Co., Load.; 
Messrs. Claye and Son, Stock- 
port ; Messrs. Cornish Bros., 
Birmingham, Messrs J. aud A. 
Churchill, oond.; Mr. H. H. B. 
Cuunlugham, Belfast; Dr. 
Vi. H. Cooke Bath, Dr. Harry 
Campbell, Nice; Mr. Ih js. E. 
Coulson, Bristol; Dr. K. J. 
Collie, Lond. 

D. —Dr J. L. Dick, Ayr; Lieu¬ 
tenant-Colonel C. M. Douglas, 
A.M.S., Lmumow; Lieutenant 

K. Dixon. R.N., Louu ; Dr. 
A. B. Dunn, West Bridgford, 
Derbyshire Royal Infirmary, 
Derby, Secretary of; Mr. tf. 
Davey, Caterham Valley. 

E. Dr O. M. Bigood, Moseley; 
Major W. M. Earle, I.M.S., 
Loud.; Equipoise Couch Co., 
Ashford, Manager of. 

F. Dr. P. G. Foulkea, Dorchester; 
Fernianngh County Hospital, 
Enniskillen, Secretary of, Mr. 
A. C. D. Firth, Lond. 

Q,—Dr. Lachlan Grant, Ballachu- 
llsh i Guardian Assurance Co., 
Loud., Secretary of; Messrs 

R. W. Greeff and Co., Lend.; 
Messrs. Gaymer and Son, Attle¬ 
borough; Messrs. Gillies and 
Co.. Glasgow. 

H. Mr. r. W. Howe, Brighton, 
Dr. Musa T. Hassan, Atbara. 
Hospital Assistant, Kolhapur, 
Editor of, Heatley Pateut 
Commode Bed Co., Edinburgh, 
Dr. P. W Hampton, Douglas, 
Isle of Man; Hartlepools Hos¬ 
pital, Secretary of, Messrs. 
Haar and steinert, Paris, 
Messrs Hirschfeld Bros., Loud.; 
Mr. H. Hilliard, Loud.; Messrs. 
C. J. Hewlett and don, Lond.; 
Dr. Tetens Hald, opeuhagen. 
L—Messrs. Isaacs and Co., Loud.; 
Ireland Advertising Agency, 
Philade phia. U.6.A.; Iuter 
national Plasmon, Lond., secre¬ 
tary of. Incorporated Institute 
of Hygiene Loud., Secretary of. 

J. —Miss Jex blake, Hereford; 
Messrs. Jones Bros., Bristol; 
J. F. 

K. — *r. Newman Kaplan, Lond.; 
Messrs. Kimer bros, Lond., 
Messrs. Knoll and Co., Lond.; 
Mr. Kundig, Geneva; Messrs. 

S. Kutnow and Co., Lond.; Dr. 


K. M. Koury, Dueim, Sudan; 
Mr. S. Karger, Berlin. 

L. - Leslies, Ltd., Lond.; L. H.; 
Leeds Public Dispensary, Secre¬ 
tary of; Mrs. Ada M. Lewis, 
Neuilly sur Seine, Local Govern¬ 
ment Board, Lund., Secretary of; 
Mr. S. G Longworth, Melton; 
London School ol Tropical Medi 
cine, Secretary of; Leeds and 
West Riding Medico-Chirurgical 
Society, Leeds, Senior Secretary 
of. 

M. — Dr. D. M. MacRae, Edinburgh; 
Messrs. Mackie and Co., Warring- 
ton; Dr. J. Muir. Bellshill; 
Miraj State, India, Chief Medical 
Officer of. M. H. B ; Manchester 
Weekly Times, Editor of, Mr. J. 
Rutherford Morisou, Newcastle- 
ou-Tyne ; Medico - Chirurgical 
Society, Sheffield, Bon Secretary 
of; Dr. C. J. Marlin, Loud.; 
Dr. S G. Moore, Huddersfield; 
Messrs. Maple and Co., Lond.; 
Manchester Medical Agency, 
Secretary of; Messrs. Meister. 
Lucius, and Bruiting, Loud.; 
Dr C. W. MacGillivray, Edin¬ 
burgh; Mrs. Mathias, South- 
bourne. 

N. -Messrs. G. Newnes and Co., 
Lond. 

O. Odol Chemical Works, Lond., 
Secretary of. 

P. —Dr. J. S. Purdy, Auckland; 
Mr. A. J. Preasland, Edinburgh; 
Mr. C. S. H. Palmer, Loud.; 
Philips, Edinburgh; Pierre’s 
Dentin Ice, Lond. 

R. -Dr. C. neiesmann, Adelaide; 
Dr. C. Bollesum, Eastbourne; 
Mr. W. Ramsay, Melbourne; 
Rebman, Ltd., Lond., Secretary 
of; Dr. P. Kendall, Epsom; 
Messrs. Richardson ana Co., 
Lond.; Messrs. Reynolds and 
Branson, Leeds; Royal Albert 
Hospital, Devonport, Secretary 
of; Mr. W. Russell, Umioster, 
Mr. W. C. Rivers, Nortbwood; 
Registered Nurses’ Society, 
Loud., Secretary of; Mr. R. 
Redpath, Newcastle-upon-Tyne; 
Mr. H. Bundle, Southsea, Sir 
Henry B. Roscoe. West Horsley. 
8 .—Miss M. Slater, Plymouth; 
Messrs. 8avory and Moore, Lond.; 
St. Andrew’s Hospital, North¬ 
ampton, Clerk to the; Messrs. 
Smith, Elder, and Co., Loud., 
Star Engineering Co., Wolver¬ 
hampton; Saar bach's News Ex¬ 
change, Mainz; Swansea Cor¬ 
poration, Clerk to the, Messrs. 

G. Street and Co., Lond.; 
Mr. Herbert Sieveking, Lond.; 
Mr. Hugh Stott, Lewes; Mr. 
Geoige stoker, Lond.; Salford 
Royal Hospital, Secretary of; 
Mr. G. G. Steinickn, Munich, 
Dr. L. E. Stevenson, Temple 
Sowerby; Dr. A. K. Stevenson, 
Bally clare Mr. B. L. Davy 
Singh. Mannargudl, India 
Mesara. W B. Saunders and Co., 
Loud.. Dr. T. D. Savill, Lond.; 
Dr. M. Sharman, Rickmans 
wort h; Mr. T. Scott, Manchester; 
Mr. Edward Stanford, Lond. 

T. Dr. F. M. Turner, Lond ; 
Dr. A. G. Troup, Aberdeen; 
Mr. W. J. Teufel, Stuttgart; 
Dr. J. C. Thresh, Loud.; Mr. 
A. Taylor, Buruley. 

V. Mr. Dennis Vinrace, Lond.; 
Mr. S. G Vinter, Torpoint; Dr. 
T. C. Vibser, Winburg, Messrs. 
J. and J. Vickers and Co., Loud. 

W. Dr. J. J. Welply, Bancion; 
Messrs. W. Wood and Co., New 
York; W. J. L.; Dr. F. Warner, 
Loud.; Dr. W. Westcott, Loud., 
Messrs. Wyleys, Coveuiry; Dr. 
Henry WillBou, Wey bridge; 
Dr Watson Williams, Bristol; 
Windsor and District Medical 
Society. Hun. Secretary of; Mrs 
Wienh It, Lond.; Westminster, 
Medical Officer of Health of, 
Messrs. F. Williams and Co., 
Loud., Wrexham Infirmary, 
Secretary ol; W. N. H. 

Y. Dr. Krnest Young. Lond. 

Z. Messrs A. and M. Zimmer- 
mann, Loud. 


Letters, each with enclosure, are also 
acknowledged from— 


A. -Dr. J. Andrew, Coatbridge; 
Dr. A. B. Atherton, Frederic¬ 
ton; Dr. W. S. Anderson. 
Chapel - en - le • Frith; Ardath 
Tobacco Co., Lond.; A. B. M. T.; 
Messrs Armour and Co., Lond.; 
Apothecaries’ Hall of Ireland, 
Dublin, Secretary of; A. G. 

B Mr. J. A. Barth, Leipzig; 
Mr. T. Bates, Worcester; I)r. 
K. A. Bennett, Saltburn-by the- 
Sea; Dr. C. R. Box, Loud.; 
Dr. W. C. Brown, Lond.; The 
Hon. E. T. Born, Port Stanley; 
Dr. J. G. Biseet, Abeideeu; 
Dr. W. Ironside Bruce, Lond.; 
Dr. J. 8. Brown, Montclair, 

U.S.A.; Bel grave Hospital for 
Children, Loud.. Secretary of; 
Dr. H. S. Branfoot, Brighton; 
Dr. A. J. G. Barker. Sarawak; 
Dr. Hugh Boyd, Bendigo, Aus¬ 
tralia; Sir Hugh Beevor, Bart , 
Loud.; Mr. W K. Boulter, Wool¬ 
wich ; Messrs. Brady and Martin, 
Newcastle upon-Tyne; Birken¬ 
head Borough Hospital, Hon. 
Treasurer oi; British Viavi Co , 
Lond.; Messrs. Berryman and 
Sons. Lond. 

C. Dr. V. Cammareri, Messina; 
Dr. H. H. P. Crawfurd, Lond.; 
Miss E. Clapham, Load.; Dr. 
B. Collyer, Croydon; Messrs. 
J. A. Carvethand Co., Toronto; 
Mr. R. Connihan, Kilrush; 
Dr. H. J. Cardale, Lond.; Messrs. 
Curling, Wyman and Co., Lond.; 
Mr. H. F. Cottrell, Bristol ; 
Dr. W. B. Cooke, Wigan; Mr. 
A. E. Charles worth, B* scorn be; 
Dr. J. C. Connell, Kingston, 
Canada. 

0. Deputy-Inspector G. Dudley, 
R.N., Glenarm, Mr. J. Dunlop, 
Lond.; Messrs. Darley and Cum¬ 
berland, Lond.; Mr. R. Davis, 
Lond.; D. G. G. M.; Dr. D. 
Douglas, Bellshill; Messrs. 
Duncan, Flockhart, and Co., 
Lond. 

8.—Messrs. Evans, Sous, Lescher, 
and Webb, Lond.; B. B. 3.; 
Brnakulam, India. Chief Medical 
Officer of; Edinburgh Medical 
Journal Publisher of; Messrs. 
Evans. Sons, Lescher, and Webb, 
Liverpool. 

F. Dr. A. D. Fordyce. Edinburgh; 
Mown. Find later, Mackie, Todd, 
and Co., Loud.; Messrs. Fair- 
child Bros, and Foster, Lond.; 
Dr. T. 0. Fisher, Torquay; 
Dr. C. J. Finlay, Havana; Dr. 
W. 0. Faulkner, Waratah; 
Fellows Medical Manufacturing 
Co., New York; Mr. J. Flach, 
Lond., Messrs. Faulding and Co., 
Lond. 

G. - Mr. W. H Goesage, Chertsey; 
Messrs. C. T. Getting and Sons, 
Lund.; Mr. S. Greig, Edinburgh; 
l)r. M. H. Gordon, Lond.; Mr. 
II. T. Gray, Lond.; Mr. A. P. 
Ghatak, Arrah ; Dr. J. Gardner, 
Burscough Bridge; Messrs 
Grindlay, Groom, and Co., 
Bombay; Dr. A. Grant, Muar, 
Malay Peninsula; G. D. 

H. Mr. A. A. Hargrave, Tralee; 
Dr. H. H. Harrissou, St. Neots 
Dr. T. B Hearder, Ilkley; H. 8.; 
Dr. J. T. Harvey, Broken Hill, 
New South Wa.es; Mr. C. J. 
Heath, Lond.; Mr W. S. 
Handley, Lond.; Messrs. D. C. 
Heath and Co., Boston, U.S A.; 
I)r. K M. Howell, Torquay, 
Dr. K. K. Hunt, Brighton; 
Mr. T. H. Hewitt, Lond., 
Messrs. Hooper and Co., Lond., 
Dr. D. Hanciford, Nottingham, 
Messrs. C. Higbam and Son, 
Loud. 

J—Ur K. Jivanji, Secunderabad; 
Mr. T. J. JeukiuB. Henllan; 
The Jetter and Scheerer Co., 
Load., Manager of. J. H. B.; 
J. S..; J. M D ; J. M. 0.; J H. 
8. Messrs. Knox, Hassell, Dodd, 
and Co., Lond. 

L. Mr W W. Linney. Croydon; 
La Semaine Mtdicale, Paris, 
Manager of; Messrs. W. Le 
Lacheur and Son, Lond.; Mr. 
W. Stuart Low, Lond.; Mr. 


H. A. Lediard, Carlisle; Dr. 
R. Lozano, Zaragoza; Dr. P. H. 
Lang, Camperdonn, Victoria; 
Mr. L. F. Leslie, Evesham; 
Messrs. Loescher and Co. Home; 
Dr. J. Luke, Kilmalcolm; 
Mr. H. Le Soudier, Paris; 
Dr. D. G. Lairig, Bosworth; 
Mr. H. K. Lewis. Lond. 

M. —Dr. A. Mitra, Kashmir; 
Mr. J. Molr, Southampton; 
Dr. R. A. Macneil, Surbiton; 
Messrs. C. Mitchell and Go., 
Lond.; Mr. E. Merck. Lond.; 
Dr. D. M. MacRae, Philippolis, 
Orange hiver Colony; M., Ches- 
hunt; Dr. Monro, Glasgow; 
Dr. G. S. Middleton, Glasgow; 
Mr. W. Mair, Edinburgh. Mr. J. 
Mont ford, Upton - on - Severn; 
Messrs. Z. P. Maruya and Co., 
Tokyo; Mr. R. Mosse, Berlin; 
Mr. C. K Maitland. Lond.; Mr. 
F. V. Milward, Birmingham; 
Mental Nurses’ Cooperative 
Society, Lond., Superintendent 
of. Medical Officers' Library, 
Aldershot. Librarian of; Mr. W. 
Morgan, Lond. 

N. Dr. 0 R. Niven, Liverpool ; 
Mr. Cyril A. K. Nitch, Lond.; 
Nurses’ Co-operation, Lond.; 
Mr. J. C. Neertes, Lond. 

O. —Dr. J. O'Connell, Mallow ; 
Professor W. Osier, Oxford; 
Dr. C. Ormerod, Burgess Hill; 
Ottawa, Department of Agri¬ 
culture, Accountant to the. 

P. —Mr. Y. J . Pentland, Edinburgh ; 
Dr. H. I. Pinches, Lond.; 
Messrs. Parker and Son, Oxford; 
Dr. J. H. Parsons, Lond.; 
Messrs. Picard et Fils, Paris; 
Messrs. Pratt and Co., Manches¬ 
ter; Dr. A. E. Porter, Keigate; 
Mr. 8. G. Penny, Marazion; 
Rev. J. Pickett. Lond. 

R. —Mr. R. P. Rowlands, Lond.; 
Dr. E. D.Rowlands, Georgetown; 
Dr. N. Kivellini, Pontelandolfo, 
Italy; Messrs. Kayner and 
Stuart, Camberley ; Mr. J. 
Reidy, Lond.; Mr. G. Q. Richard¬ 
son, Lond.; Dr. M. A. Buffer, 
Alexandria. 

S. — Dr. A. Silberman, Lucerne; 
Mr. G. A Stamper, Skegby; 
Dr. D. d'O. Soares, Lisbon; 
St. Mungo's College, Glasgow, 
Cashier to the; Major W. D. 
Sutherland, I.M.S., Jubbulpore, 
India; Dr G. Slight, Sandown, 
Isle of Wight; Professor T. 
Schott, Frankfurt; Dr. F. M. 
Sand with. Lond.; Sir Thomas 
Smith, Bart. Lond.; Mr. J. 
Stewart, Leeds; Mr. 0. Scholl, 
Liverpool. Mr. A Saunders, 
Lond.; Scholastic, Clerical, Ac., 
Association, Lond., Accountant 
to the; Mr. S. T Shlrvaiker, 
Bombay ; S., Tunbridge Wells ; 
Messrs. Spiers and Pond, Load.; 
Dr. T. B. Smith, Bellshill; Dr. 
F. J. Smith, Lond., Messrs. 
Scott and Bowue, Lond.; Dr. 
J. A. Shaw-Mackeuzie, Lond. 

T. Dr. K. J. Toye, Bideford; 
Messrs. E. B. Treat and Co. New 
York, Mr J. Thin, Edinburgh; 
Mr. L. S Taibot, Timaru; 
Messrs. J. Timpson and Co., 
Lond.; Mr J. Taylor, Grenada; 
Taunton and Somerset Hospital, 
House Surgeon of; Mr. W. 
Turner. Loud. 

U. Dr. H. A Upward, Romford; 
Mr. H. Upcott, Hull. 

V. —Dr. H E. Vincent, Horley; 
Mr. F. H. V. Voss, Stroud; 

V. M. B. 

W. Dr. T. Whitelaw. Edinburgh; 
Mr W. F. A. Walker, Dinas 
Mawddwy; W. V. G.. Surgeon- 
Colonel F. H. Welch. Lond.; 
Mr. C P. White, Withington; 
Dr. S. L. B. Wilks, Grassington; 
Dr. S. West., Lond ; W. B.; 
Dr. J. W. White, Glasgow; Mr. 
J. R. Webb, Footsnray, Aus¬ 
tralia; Messrs A. J. Wilson and 
Co., Lond.; W. H. S.; West¬ 
minster Hospital Medical School, 
Load., Secretary of; Mr. W. A. 
Ward, Richmond; Dr. W. H. 
Willcox, Loud. 




THE LANCET, January 11, 1908. 


% Jwtort 

OH 

CERTAIN BACTERIAL INFECTIONS OF THE 
URINARY TRACT IN CHILDHOOD. 

Delivered at the Medical Qraduatei’ College and Polyclinic 
on Nov. 6th, 1907, 

By CHARLES R. BOX, M.D. Lond., F.R.C.P. 
Lond., F.R.C.S. Eng., 

PHYSICIAN IN CHARGE OF THE CHILDREN'S DEPARTMENT, 

ST. THOMAS'S HOSPITAL. 


Gkntubmkn, —Infections of the urinary tract in children, 
as in adults, may be classified as (1) descending infections, 
(2) ascending infections, and (3) infections by contiguity. 
The following remarks refer to the ascending and descending 
infections only. 

Defending infection is synonymous with infection carried 
to the kidney by the blood-stream and is often termed 
“ bsematogenoos ” for this reason. In certain cases of this 
variety of infection the kidney presents evidence of very 
gross disease. Renal infarction such as may occur daring 
the coarse of malignant endocarditis is an instance in point. 
Infective emboli may become impacted in the interlobular 
arteries, thrombosis and infarction result, organisms derived 
from the infected embolus invade the necrotic area and may 
make their appearance in the urine. The presence of a 
wedge-shaped infarct is not, however, infallible evidence that 
the infection is hsomatogenous, for infarcts of similar shape 
but limited to the pyramids or their extensions may arise as the 
result of Infections of an ascending character. In the course 
of general tuberculosis, too, macroscopic lesions of the kidney 
occur. This hsomatogenous infection gives rise to miliary 
lesions which appear in the perivascular connective tissue 
and are visible to the naked eye, whilst microscopical 
examination may also reveal the occurrence of “ excretion 
tuberculosis,” the bacilli passing through the glomerular 
tufts and infecting the interior of the urinary tubules into 
which they are extruded. It seems that the excretion of 
organisms by the kidneys occurs in other diseases also, and 
that the process may give rise to undue irritability of the 
urinary tract and even to evident pyelitis or cystitis. As 
examples of this process the bacilluria of typhoid fever and 
the occurrence of pyelitis or of transitory incontinence of 
urine in such diseases as measles, scarlet fever, diphtheria, 
and small pox may be quoted. But it is a remarkable fact 
that in many of the cases of bacilluria associated with 
typhoid fever, scarlet fever, measles, and diphtheria the 
organism present has on proper investigation been found to 
be the bacillus coli communis. 

There is, then, clinical evidence that the urinary tract may 
be the site of descending invasion. But it is important from 
the point of view of the prevention and treatment of urinary 
infections to inquire whether the common invasion in child- 
hood is really of a descending character. Conheim suggested 
that In the event of a general bacterial invasion the body 
protected itself by the secretion of living germs through the 
intact kidney, thus relieving the system from the noxious 
organisms. A point of such importance inspired observations 
by many other observers and amongst them Professor C. S. 
Sherrington has shown that, although it is true that certain 
organisms when injected into the blood may escape in this 
way, yet the excretion is neither rapid nor immediate and, in 
the case of innocuous organisms, may not take place at all. 
The inference is that it is only after a certain amount of 
damage has been inflicted on the renal secreting tissues that 
the escape of organisms takes place. When blood is present 
in the urine after such experiments it may be assumed that 
gross damage has occurred. The presence of a quantity of 
albumin may have the same significance but even in the 
absence of hsematuria or of albuminuria it cannot be assumed 
that some damage has not been inflicted on the kidney. 

The matter appears to stand thus : The body can dispose 
of enormous numbers of iojected bacilli without their 
appearing in the urine or other secretions. When they do 
appear the time of their appearance and the substances which 
appear with them lead to the presumption of renal damage. 
Tlie quantities which appear in the urine are not in any way 
comparable to the quantities injected. Now clinically, in 

No. 0402. 


cases of bacilluria, the organisms appear in the urine, even 
when freshly voided, in enormous numbers. It is quite the 
exception to obtain any definite evidence of renal damage in 
the form of casts or blood and, as already stated, the bacill¬ 
uria of typhoid fever, of scarlet fever, of measles, and of 
diphtheria has in many cases been proved to be a colon 
bacilluria. These facts lead to the suspicion that after all 
the common cause of bacilluria is due to an ascending 
infection, a suspicion which is corroborated by the sex 
incidence of the disease, for many more cases occur in 
females than in males. In some instances, too, the chrono¬ 
logical order in which bladder and kidney suffer admits the 
same explanation. 

Aicending infection .—In the adult the importance of 
ascending infection has long been recognised, but there can 
be no doubt that in childhood infections of this kind are 
muoh more common than ordinsurily is supposed. When atten¬ 
tion is seriously directed to the possibility of their occurrence 
a notable advance in preventive, if not in curative, treatment 
will have been made. The actual track of ascending urinary 
infections in the adult has been much discussed. Owing to 
the trivial character or even absence of lesions in the ureter 
some have supposed that the infection is carried either along 
the lymphatic channels which accompany the latter or 
directly through the chain of anastomising arteries or veins 
which link the bladder with the kidney, or even indirectly 
from the bladder to the kidney in the form of a true bsemato- 
genous infection. The lymphatic connexion between the 
bladder and the kidney appears to be neither free nor direct. 
Experimental injection of the connecting lymphatics is 
difficult and their exact pathological importance is as yet 
undetermined. There is also but little evidence to offer as to 
the part played by the anastomotic vascular links. The 
links in question consist of the chain which accompanies 
the ureter and also, in the female, of a chain forms d 
by the anastomosis of the vesical, uterine, ovarian, 
and renal vessels. There are experiments which appear 
to show without doubt that an induced cystitis with 
injury to the bladder can infect the kidney through the 
general circulation, for after excision or ligature of one 
ureter the corresponding kidney has become converted into a 
pyonephrosis in consequence of artificial infection of the 
bladder. 

But the ureter itself is commonly, and I believe 
rightly, looked upon as the highway of infection. It is 
generally acknowledged that ascending infection is to be 
expected where the ureter is blocked by a calculus, or where 
disease of its intravesical portion interferes with its efficient 
closure against reflux, or where there is obstruction to the 
outflow from the bladder. But the conditions here postu¬ 
lated are uncommon indeed in childhood, save in the csBe 
of boys with a tight prepuce, and, moreover, the infection 1 b 
more common in girls. The chronological sequence of 
bladder infection and renal infection in some cases has left 
no doubt in my own mind that the colon bacillus can prod nee 
an ascending infection apart from obstruction to the descend¬ 
ing urinary stream, a process which may be aided by its 
motility, as has often been suggested. Quite recently, too, 
it has been stated that ascending tuberculosis of the kidney 
can be experimentally produced by injecting an emulsion of 
the bacilli of bovine tuberculosis into the bladder with¬ 
out interrupting the flow of urine. The observations of 
Ur. C. J. Bond on the ascending currents in mucous canals 
are of interest in this connexion. He succeeded in demon¬ 
strating by the use of sterilised pigment that colouring 
matter deposited in the entrance of the urethra is carried 
by ascending currents into the bladder and that pigment 
deposited in the bladder Is in like manner conveyed to the 
pelvis of the kidney. But it must be admitted that a normal 
condition of affairs did not obtain in his experiments, for 
they were carried out in patients in whom by reason of 
cystotomy or nephrectomy the normal downward flush of the 
urinary passages had been interfered with. 

Nature and traclt of the amnion infection of childhood .— 
There is no doubt that in children the commonest infection 
of the urinary tract is that which is due to the colon bacillus. 
This has been the experience of all who have investigated this 
subject, and their conclusions I can, from my own observa¬ 
tions, confirm. Although the disease may occur in males it 
is much more common in females, which is strong corrobo¬ 
rative evidence of its ascending character, for the shortness 
of the female urethra and the proximity of its orifice to the 
anus render infection easy. In babies infection through the 
urethra may occur from soiled napkins or from the passage 
B 




78 This Lancet,] DR. BOX: BACTERIAL INFECTIONS OF URINARY TRACT IN CHILDHOOD. [Jan. 11,1908, 


of stools over the vulva. The presenoe of colon bacilli in 
the urine of infants suffering from diarrhceal diseases has 
been demonstrated by Trumpp. His proportions were two- 
thirds females and one-third males, a very significant 
preponderance of the females. In older children faecal 
contamination of the vulva must often take place, 
and is occasionally very obvious in the case of children 
brought to the out-patient department of the hospital. 

I have been surprised to find how often the colon 
bacillus is present in the urine of children suffering from 
thread-worms. Occasionally the ova of the parasites, and 
sometimes also the worms themselves, are found in the urine 
together with the bacilli. The coexistence of the bacilluria 
with the presence of the parasites in the bowel suggests that 
the worms may be in some way accountable for the urinary 
infection, either by the irritation and consequent scratching 
which they indace or possibly by acting as carriers of the 
bacilli from the anus to the vulva. It may be that the bene¬ 
ficial effect of circumcision in certain cases of incontinence 
of urine in the male is not so much due to the removal of 
mechanical irritation as to the abolition of a nidus of 
bacillary infection. I have also found that cases of colon 
cystitis and of pure bacillnria are much more common than 
cases in which the signs of pyelitis are present. This also 
appears to indicate that the infection is an ascending one. 
The facts bearing on ascending infection have recently been 
emphasised by H. Lenhartz who, investigating the cause and 
incidence of pyelitis in the adult, found that 66 out of 80 
cases were due to invasion by the bacillus coli communis and 
that males were rarely infected. He attributed much Im¬ 
portance to pregnancy, parturition, and menstruation in pre¬ 
paring the soil—conditions which naturally do not obtain in 
childhood. 

There are certain characteristics of the colon bacillus 
which are noteworthy and which, in some degree, explain 
the clinical manifestations of the infection. It is an organism 
which, although it grows by preference in alkaline or just 
neutral media, can also grow in acid urine and is not easily 
got rid of by altering the urinary reaction. The acidity of 
urine is inimical to many other microbic infections, hence 
the bacillus coli is often found in pure culture. In the 
second place, it does not decompose urea and so give rise to 
ammoniacal products which have a destructive influence on 
urinary epithelium and usually co-exist with the more severe 
forms of purulent inflammation. Writers have remarked with 
surprise that in urinary infections due to the colon bacillus 
vulvo-vaginitis is seldom present; stress has also been laid on 
the fact that in colon cystitis and colon pyelitis the inflam¬ 
mation as a rule is of a very superficial or catarrhal nature. 
Lastly, the organism is motile, and so may, without the 
assistance of urinary stagnation, make its way into the 
pelvis of the kidney. 

That acute ascending infections of the urinary tract may 
occur in adults suffering from gonorrhcea is undoubted. 
Whether these infections are due to the gonococcus or to 
the colon bacillus I am not in a position to state, but 
mention the fact of their occurrence because gonorrhoeal 
vulvitis is not unknown in little girls, and it would be well if 
cases of ascending infection in this disease were properly 
investigated. 

Clinical manifestations .—Infection of the urinary passages 
in childhood may manifest itself as pyelitis, cystitis, or 
incontinence of urine without obtrusive evidence of local 
inflammation. 

Pyelitis may occur as a febrile affection with sudden 
onset, chills, and pyrexia. The temperature chart may show 
marked daily fluctuations or closely resemble that of pneu¬ 
monia, or in some cases take the form of a succession of 
short febrile periods with intervening intervals in which 
the temperature is practically normal. The temperature 
may rise as high as 105° F. At the onset of the attack 
a certain degree of suppression of urine may occur, but 
may later on polyuria is the rule. The quantity, it is said, 
be increased to twice or thrice the normal, and frequent 
reflex micturition without evidence of cystitis is sometimes 
met with. When the course of the disease is protracted 
emaciation rapidly occurs. Enlargement of the spleen 
may often be detected and sweating may be pronounced. 
As a rule, the local manifestations of the disease are 
unilateral, and the right kidney is more likely to be 
affected than the left. Fain may be complained of and when 
present is generally subcostal and not lumbar in position. 
But the kidney may be found to be definitely tender and 
even enlarged in patients whose pain is trivial. The pain 


appears to be most severe in those in whom a certain degree 
of hydronephrosis has been induced by the disease. It is 
remarkable how quickly the renal enlargement may subside. 
The distension of the renal pelvis cannot be due to a twist¬ 
ing of the kidney, for undue renal mobility is extremely rare 
in infants and young children. It is possible that inflam¬ 
matory swelling of the mucous membrane of the pelvis, at 
its junction with the ureter, is the cause of the condition, 
for at this point the passage is naturally constricted. I 
believe that pyelitis occasionally occurs in a much milder 
form, characterised by very transitory attacks of subcostal 
pain with little or no fever. My reason for this belief is that 
more than once I have known such attacks of pain to occur 
in patients with colon bacilluria who were under treatment 
for incontinence of urine. 

Blight vulvitis is present in some cases of pyelitis and in 
some there have occurred symptoms of cystitis, in the form 
of painful, frequent micturition and hypogastric tenderness, 
before the actual onset of the pyelitis. The urine is usually 
acid and slightly turbid or opalescent. A slight sediment 
falls ; it consists of a few pus cells. In the more acute cases 
some erythrocytes and even a few hyaline casts may be seen. 
The presence of many tube casts indicates coincident inflam¬ 
mation of the kidney. The amount of albumin is slight and 
a certain amount of nucleo-proteid can be demonstrated by 
suitable tests. The turbidity of the specimen does not clear 
up with boiling or with acids and persists after repeated 
filtering. It is due to the presence of bacilli which almost 
invariably turn out to be the common colon organism. It is 
possible that repeated attacks of pyelitis of this nature may 
account for some of the cases of hydro- and pyo nephrosis 
which are found in adults and for which no obvious cause is 
present. 

The possibility of the presence of pyelitis should always 
be borne in mind when dealing with cases of obscure fever in 
childhood, whether of a sustained, remittent, or relapsing 
character. The occurrence of shivering or of rigors should 
especially direct attention to the urine and urinary tract. 
More than one specimen of urine should be examined, as it is 
not every portion obtained which shows the characteristic 
changes. The fever is sometimes erroneously attributed to 
gastro-intestinal disturbance, to deep-seated pneumonia, or 
even to tuberculosis. In malarial districts malaria may be 
closely simulated. 

Cystitis of a more or less acute character is not at all un¬ 
common in childhood The onset as a rule is sudden and not 
attributed to any definite cause ; but in some instances, as in 
adults, the symptoms appear to follow exposure to cold and 
in a few cases, of which I have met with instances, the 
attack has followed trivial injury to the perineum, such as, 
for instance, may be inflicted by falling astride a chair. In 
a severe case the temperature may rise to 103 d or more. 
Micturition is frequent and painful. Nocturnal incontinence 
of urine usually sets in. The child screams during the 
passage of urine and attempts to evade the act, often 
tightly crossing the legs. Pain is referred to the hypogastric 
region, the fronts of the thighs, and sometimes to the 
perineum. These regions may be decidedly tender. In 
some cases the act of micturition is accompanied by distinct 
rigors. A little blood may escape with the urine and in one 
of my patients the bleeding was so obvious that the mother 
volunteered the statement that the clothes were stained just 
as if the child (a little girl) were unwell. 

Just as with pyelitis, milder attacks occur in which there 
is no fever and the pain on micturition and tenderness of 
the bladder are very slight. The increased frequency of 
passing urine is the chief feature of these cases. The urine 
is faintly acid or neutral; it is important to recognise 
that the urine may remain acid both in pyelitis and 
cystitis, especially when the infection is due to the 
colon bacillus. It is always turbid or opalescent; if much 
blood is present it may be smoky. The amount oi albumin 
is variable ; sometimes it is considerable and may lead to a 
fear that the kidney is involved, but nevertheless entirely 
clear up. As in pyelitis and other conditions some nucleo- 
prcteid may be present. The sediment contains pus cells, 
sometimes blood corpuscles and epithelium ; in very acute 
cases membranous flakes may occur. The colon bacillus 
is almost invariably found. Needless to say, a proper 
bacteriological examination is essential for correct dia¬ 
gnosis. Abrupt stoppage of the stream during micturi¬ 
tion should always suggest the presence of stone and 
lead to farther examination by bimanual palpation of the 
bladder, x ray examination, and sounding. The possibility 




Thb Lancet,] DR. BOX : BACTERIAL INFECTIONS OF URINARY TRACT IN CHILDHOOD. [Jan. 11, 1908. 79 


of the stone being in the ureter or impacted in the com¬ 
mencement of the urethra should not be overlooked. The 
stream is sometimes stopped by reason of the intense pain in 
cystitis, but not abruptly, save possibly in the oases where 
large membranous shreds are present. Frequency of 
micturition occurs both in pyelitis and cystitis, but actual 
pain on micturition with tenderness above the pubes and in 
the perineum point to involvement of the urinary bladder. 
No differential value appears to belong either to the charac¬ 
ters of the epithelium or the amount of albumin present. 

Incmtincnce of urine, as is well known, may be associated 
with bacilluria, and again the organism present is almost 
invariably the bacillus coli communis. Some of the most 
inveterate cases of bed-wetting with which the physician is 
called to deal fall into this group, whilst, on the other hand, 
some of the cases in which the same organism occurs are 
quite mild and transitory, yielding readily to the simplest 
treatment. That in some instances the incontinence may 
greatly improve, although the organisms are still present, is 
also noteworthy. In inveterate cases the urine is always 
turbid from the presence of myriads of bacilli. In a few 
cases the urine is not decidedly opalescent but colon bacilli 
are found in large numbers in the somewhat flocculent cloud 
which quickly settles in the urine glass. Increase in quantity 
of the urine has generally attracted the attention of the 
mother and is usually remarked upon. The incontinence at 
first is nocturnal only and the bed may be wetted two or 
three times each night. In some instances diurnal incon¬ 
tinence sooner or later ensues ; in a few of my patients it has 
assumed that form in which urine escapes on coughing, 
aughing, or other physical exertion. 

The reaction of the urine is generally faintly acid, some¬ 
times neutral, never, in my experience, alkaline. A mere 
trace of albumin may be present by the boiling test. 
The centrifugalised sediment consists of a few pus cells 
and many bacilli. Casts of any sort are absent and 
the presence of urinary epithelium is quite the exception. 
Sometimes a few oxalate crystals are noted. I have once or 
twice met with the decomposition, with production of a 
curious odour described as “ fishy,” which is attributed by 
some authors to colon infection. In incontinence with 
marked bacilluria it is exceptional to obtain a history 
pointing definitely to cystitis or pyelitis but slight vulvitis is 
present in some instances. Exceptionally a history of supra¬ 
pubic pain at some stage of the affection may be elicited and 
some of my patients have had definite attacks of slight sub¬ 
costal pain whilst under treatment, which may indicate the 
presence of slight pyelitis. For some time past I have been in 
the habit of testing the urine of these cases for nucleo-proteid, 
the presence of which is assumed to indicate some irritation 
of the urinary tract. For this purpose Ott’s method has been 
adopted and the reaction is often well marked, but a similar 
reaction occurs in the urine of many other children who have 
no bacilluria. 

There is a curious resemblance amongst most of the 
patients who suffer from this form of incontinence—they 
are shy and nervous and frequently get the reputation of 
being stupid or sullen. This mental condition is much 
improved when the disease yields to treatment. Headaches 
are frequent, the tongue generally is coated, and the bowels 
are irregular in their action. A history of attacks of 
diarrhoea is not uncommon, but I have not been able to 
satisfy myself as to the condition of • ‘ coprostasis ” on which 
some authors lay so much stress. It is true that in some 
cases the abdomen is somewhat distended and tympanitic 
but this may be seen even when the bowels are acting quite 
regularly. 

The course of the disease appears to be not altogether 
afebrile. Slight elevation of temperature at night, rarely 
above 100° F., may occur for weeks at a time. The presence 
of worms together with bacilluria is not uncommon and, as 
already suggested, the connexion between the two conditions 
may possibly be one of cause and effect. The evidence of 
mothers as to the presence or absence of worms is frequently 
unreliable and in several instances their presence, though 
unsuspected, has been proved by the discovery of ova or 
even of worms themselves in the urine. 

Prognoti ».—The cyBtitis of childhood when caused by the 
colon bacillus calls for a guarded prognosis. A certain 
number of cases, particularly those with acute onset and 
marked bladder symptoms, clear up under the simplest 
medicinal and dietetic treatment. There are others, however, 
in which the local symptoms may be less pronounced, which 
drag on with intermissions and exacerbations, sometimes for 


months. Pyelitis due to the colon bacillus appears to be 
much less common than cystitis. My cases have been few in 
number and short in duration but if any parallel existB with 
similar cases in the adult the affection should vary 
considerably both in duration and intensity. The cases of 
incontinence of urine with which the colon bacillus is 
associated also vary very widely. In some cases the 
symptoms are transitory and clear up without any special 
treatment; others, as already indicated, resist all methods of 
treatment with the greatest obstinacy. The marked variations 
in the clinical course of these infections must be due either 
to variations in the virulence of the infecting organism or, as 
I believe is more probable, to variations in the resisting 
power of different individuals. 

Treatment .—If the theory of ascending infection be correct 
the importance of frequent bathing and of the avoidance of 
urethral contamination from the anus as preventive measures 
cannot be overrated. All cases of vulvitis should be recog¬ 
nised promptly and treated. The milder cases of cystitis, 
pyelitis, and incontinence of urine do well with the ordinary 
treatment by full doses of citrate of potassium combined with 
the sedatives of the belladonna group. In the treatment of 
severe cases of incontinence of urine, even though colon 
bacilluria is associated, the first care should be to determine 
the presence or absence of thread-worms. Careful examina¬ 
tion of the stools and urine is necessary for this purpose. 
The ova and embryos should be sought for, the former being 
easily recognised by their asymmetry, being flattened on one 
side. I do not propose to discuss the treatment of these 
parasites beyond saying that when injections are used for 
this purpose the proper time to give them is not necessarily 
at night or morning but after the howelt hare acted. 
Belladonna has proved a very disappointing drug in inveterate 
cases. I have not hesitated to push it until delirium was 
induced and even then it has failed. Neither have I been 
able to obtain any definite results with drugs of the formalin 
type, such as hexamethylene tetramine (urotropir.e) or its 
methylene citrate (helmitol) or its benzoyl derivative 
(hetraline). These drugs, although very effectual against 
the typhoid organism, do not appear to influence the colon 
bacillus. The results obtained with benzoate of ammonium, 
salicylate of sodium, and boric acid are no more encouraging. 
The latter in particular plays havoc with the appetite and 
soon induces nausea. 

With a view to test the theory that the bacillary infection 
is hmmatogenous and perhaps due to coprostasis, cases were 
treated for prolonged periods with mistura olei ricini (B.P.) 
and also with calomel to the point of producing slight stoma¬ 
titis. No improvement could be ascertained. Salol also failed. 
In one case of colon bacilluria and incontinence, after 
internal medication had failed, it was accidentally discovered 
that the use of boric powder to the vulva always stopped the 
incontinence. The same treatment was not successful in 
other cases. 

Finally, with the cooperation of Mr. L. S. Dudgeon the 
effect of anti-bacillus coli serum was tried. In one patient 
with inveterate colon bacilluria and incontinence, where the 
condition had resisted all treatment for 12 months, admission 
to hospital and three injections of 25 cubic centimetres of the 
serum stopped the incontinence although the bacilluria per¬ 
sisted in some degree. This patient relapsed, to the extent 
of one incontinence a week, a month after discharge, but she 
is much better than before the treatment was adopted. At 
one period she suffered from thread-worms. In another 
patient treatment with the serum both by subcutaneous injec¬ 
tion and by rectum failed after a prolonged trial. Dr. M. A. 
Cassidy carried out a series of vaccinations with no better 
result. On washing out the bladder with saline solution 
and leaving in 25 cubic centimetres of the serum daily for 
seven days the urine cleared in an extraordinary way and 
cultures were only with difficulty obtained from it. But the 
incontinence persisted and a few days after discontinuance 
of the treatment the bacilluria was as pronounced as ever. 
In the same patient irrigation with boric solution and also 
with quinine had practically no effect. Thread-worm 
embryos were found on microscopical examination of the 
fasces although their presence could not be determined in 
any other way. The case is still under observation. 

My acknowledgments are due to Mr. Dudgeon, the super¬ 
intendent of the clinical laboratory at St. Thomas’s Hospital, 
and also to Dr. P. N. Panton for the ungrudging assistance 
they have afforded me in the investigation of the bacteri¬ 
ology of a long series of cases on whioh this lecture was 
based. 

b 2 



80 The Lancet,] 


DR. A. T. BRAND: THE INFECTIYITY OB CANCER, 


[Jan. 11,1908. 


Some Juntarlis 

OK 

THE INFECTIVITY OF CANCER* 

Bciixtj an Address delivered at a Meeting of the East Yorks 
JJivision of the British Medical Association at Hull 
on Nov. 15th , 1907 , 

By A. T. BRAND, M.D.Aberd., V.D., 

EX-PBE91DKNT, EAST YORKS AM' NuRTH LIXCS I1RAXCH, HRITISR 
MEDICAL ASSOCIATION ; FELLOW OF THE ROYAL SOCIETY OF 
MEDICINE. 


Mr. President and Gentlemen, —The problem, “What 
is Cancer ! ” is hoary with antiquity, yet, nevertheless, it is 
of perennial interest. On two previous occasions I have had 
the honour of addressing you upon this subject; once on its 
“Etiology,"' and again on its origin by “Exogenesis.”* 
To-night 1 desire to direct your attention to certain points to 
which I have not previously referred, and to others already 
mentioned, but whioh 1 wish to enlarge upon and emphasise. 
That the importance of the problem is vital will be admitted 
by all, for, although many other diseases are just as in¬ 
curable, and exact even a greater tale of victims than cancer 
does, there is do disease which is so universally dreaded, or 
causes more mental distress, in addition to physical suffer¬ 
ing. This importance, moreover, becomes still greater when 
it is realised that the disease is becoming more and more 
widely diffused—that it is unquestionably increasing. 

The Increase of Cancer. 

An appeal to statistics leaves it in doubt whether the 
percentage ratio is or is not increasing, although the con¬ 
sensus of expert opinion is in favour of increase. No doubt 
the percentage ratio is affected by the greater accuracy in 
diagnosis and by the fact that the average duration of life is 
markedly increased, but it must not be overlooked that many 
deaths have been certified as due to malignant disease 
which have not been confirmed by sectio cadaveris. Even, 
however, if the percentage ratio is not increasing but 
remains stationary, it is still evident that cases of cancer 
must increase in number, pari pas tv with the increase in 
population. When, therefore, the population of a given 
place doubles itself, as it does in x years (Vienna, e.g., has 
doubled itself in 25 years), then the number of cases of 
cancer must likewise, at the end of this period, be double 
what it was at the beginning. 

Dr. S. Monokton Copeman states 3 in the Guthrie lecture, 
delivered in 1907 at Westminster Hospital, presumably from 
reliable data, that of individuals at present living above the 
age of 35 years, 1 in 8 women and 1 in 12 men will 
eventually die from cancer. This means that cancer will 
decimate those of an age above 35 years—truly an appalling 
prospect 1 

I regret that I am able to corroborate this estimate of Dr. 
Copeman from statistics supplied by my own practice. 
During the last five years there have been 389 deaths 
certified, of which 44 have been due to cancer (17 males and 
27 females), and this yields an annual average of 11'3 per 
cent, of deaths due to malignant disease. The actual figures 


are:— 







Due to Cancer. 



1903 .... 

..66 deaths . 

5 (4 females, 1 male) . 

7'5 per cent. 

1904 .... 

... 78 „ . 


14-1 „ 


1905 ... 

... 99 . 

8 (5 females, 3 males) . 

80 „ 


1906 .... 

... 72 . 

7 (6 females, 1 mate) . 

9*7 


1907 ... 

... 74 . 

13 (6 females, 7 males) . 

17-56 ,. 




Age. 



Between 40 and 50 years 

... 2 

Between 80 and 90 years... 

5 


50 60 

... 11 

Above 90 years 

... ... ... 

1 

„ 

60 „ 70 „ 

... 12 



_ 

„ 

70 80 „ 

... 13 

Total 

... ... ... 

44 


Youngest, 48 years ; oldest, 94 years. 


Region . 

Internal (mouth—rectum) . 24 

Breast . 9 

Genito-urlnary . 6 

Intracranial . 1 

Face and groin . 4 

Total. _, ... 44 

Under observation, 5. 


* The superior figures refer to the bibliography at the end. 


Cancer Hypotheses. 

Since the causa causans of cancer has not yet been demon¬ 
strated, it is not remarkable that many causes should have 
been suggested and many hypotheses propounded. Indeed, 
such causes and hypotheses are countless, and while their 
attempted recapitulation would doubtless be of great interest 
such wonld be but vain iteration. Suffice it to say that all 
these alleged causes and suggested hypotheses crystallise out 
into two classes : (1) intrinsic, of which the number is 
“legion”: and (2) extrinsic, of which there is but one. 
Autogenesis or Exogenesis.' “that is the question.” No 
doubt the calm, philosophic, and scientific attitude to main¬ 
tain npon a subject which cannot be proved to demonstration 
is that of “the open mind ” ; bat even the calmest, unless he 
is a disinterested Gallio, must find it hard to remain in a 
state of passive imperturbability when so much is at stake. 
Hence it is that there are warm advocates of both these views. 
The exponents of exogenesis believe that the evidence in 
favour of the extrinsic origin of cancer is overwhelming, and 
that this hypothesis will satisfactorily account for tbe 
incidence of cancer in every case, and they acknowledge 
only one possible cause—viz., parasitism. The believers in 
autogenesis, on tbe other band, chiefly maintain a negative 
attitude, denying tbe possibility of an extrinsic cause, bnt 
fail to formulate any practicable hypothesis which will 
explain the origin of the disease in every case. They suggest 
theory after theory, continually shifting their ground, and 
nohow can they suggest satisfactorily why cancer should 
arise, apparently do novo, in any single case. 

Again, the supporters of exogenesis hold that if cancer has 
an intrinsic origin—e.g., “running to seed”—it would not 
only be very much more prevalent than it is, but that 
few, if any, could escape from it. They also hold that 
an extrinsic origin would satisfactorily account for the pro¬ 
portion of individuals attacked, and believe that the wide¬ 
spread occurrence of the disease among vertebrates indicates 
the omnipresence of a specific parasite, and that those who 
are attacaed are simply those whose vulnerability, from what¬ 
ever cause, has permitted its access to the host and favoured its 
development. The opponents of exogenesis urge that the 
extrinsic origin of cancer is impossible because it is not 
entirely analogous to any known infectious disease. Tbe 
reply to this is that it is most unreasonable and illogical to 
presume that pathological processes can be in any way 
limited or even influenced by analogy ; and, furthermore, 
that analogy is quite incapable of proving anything. At the 
most, analogy can suggest mere probability, and is, after all, 
only a very convenient method of comparison between pro¬ 
cesses which resemble one another. 

The following may be cited as a concrete example of tbe 
futility of trusting to analogy to establish a conclusion. 
When Farmer, Moore, and Walker announced their interest¬ 
ing discovery that the karyokinesis of the cells forming a 
malignant neoplasm is heterotype in character, and that tbe 
karyokinesis of the cells of normal reprodnetive tissue is 
also heterotype, the director of the Imperial Cancer Research 
Institute ' hastened to emit the extraordinary declaration, 
ex cathedra, that “malignant new growths were virtually 
reprodnetive tissue arising in abnormal situations ” 1 

Now, which hypothesis is most probably right—autogenesis 
or exogenesis 1 It is difficult, and even impracticable, to 
disenss tbe former, since the various Intrinsic hypotheses are 
too numerous and too elusive, while their very multiplicity 
testifies to their inadequacy, but exogenesis, having only 
one string to its bow—viz., parasitism—can be considered. 
If further information regarding these numerous intrinsic 
hypotheses and suggested causes of cancer iB desired, I 
wonld refer yon to a work recently written by Dr. Jacob 
Wolff of Jena, entitled “ Die Lehre von der Krebskrankheit 
von den aeltesten Zeiten bis Gegenwart ” (“ The History of 
Cancer from Ancient Times to the Present ”). It was pub¬ 
lished in 1907 by Gustav Pischer and consists of 747 octavo 
pages. 

Since cancer is admittedly a specific disease which runs 
a definite course of attack, extension by dissemination 
similar to that of many other diseases, such as tubercle, 
syphilis, malignant endocarditis, Ac., constitutional intoxica¬ 
tion, and ending only in death, believers in exogenesis 
cannot admit the possibility of any somatic cell spon¬ 
taneously developing specific malevolent action. They are 
constrained to believe that a specific disease can no more 
originate without the presence of a specific morbific agent 
than that parthenogenesis can ocenr in tbe vertebrata. This 
specific agent, they consider, cannot be other than an 
extrinsic parasite, either a microphyte or a microzoon. 






























The Lancet,] 


DR. A. T. BRAND: THE INFECTIVITY OF CANCER. 


[Jan. 11, 1908 . 81 


Parasitism. 

It may truly be said of parasitism what Shakespeare ' says 
of Cleopatra, by the mouth of Enobarbus. “Age cannot 
wither her, nor custom stale her infinite variety.” The 
universality of parasitism is quaintly but concisely expressed 
in the quotation from Professor Russell Lowell 

“ Great fleas have little fleas 

Upon their backs to bite ’em ; 

And little lleas have lesser fleas, 

And so ad infinitum." 

What is true of the pulex irritans is equally true of all 
creation. The diseases which we already know to be caused 
by parasites are very numerous, and so many more are 
becoming suspected of a like origin that presently one will 
be driven to conclude that all the ills to which fiesh is heir, 
excepting accidents, are due to parasitism. Organic chemistry 
has been defined as “The continued history of carbon,” It 
appears that we shall soon be justified in defining all 
disease (apart from accidents) as "The continued history of 
parasitism.” 

Is Cancer Infectious? 

If cancer is caused by a parasite it comes under the 
designation of “infectious." Is oanoer infection*/ Before 
answering this question, which is the theme of this essay, it 
were well to define what I mean by the terms “ infection ” 
and “infectivity.” “Infection” iB a comprehensive term 
and may be defined as the transmission of a disease from 
one individual to another, directly or indirectly, by the 
agency of a specific micro-organism, either a bacterium or a 
protozoon. I believe cancer to be thu* transmissible. Infec¬ 
tion varies greatly in degree, and cancer is evidently not 
infectious to the same extent as many other diseases— 
e.g., variola. It is probably acquired much as enterics is by 
introduction through the mouth; or as syphilis is, by 
contact; or as tetanus is, by access of the germ to any 
vulnerable part; or it may be through the agency of an 
intermediate host, as is the case in malaria or trypano¬ 
somiasis. 

It has long been maintained, and many concrete instances 
have been quoted to prove, that cancer is transmissible by 
direct contact, ae in “cancer-iVdeux,” of which “coition- 
cancer” is an example. Such transmission, however, has 
been generally denied and accounted for by fortuitous 
coincidence ; but as transmission by implantation from one 
lower animal to another of the same species has been 
successful, and freely admitted to be so by all, the trans¬ 
mission in the case of “ cancer-i-deux ” has had reluctantly 
to be admitted as at least possible. This transmission has 
been designated “transplantation” and not admitted to be 
the successful and genuine inoculation of a specific disease. 
Now, if the “transplanted” cancerous tissue resembled a 
skin graft, always remaining local and forming no tumour, 
or if it merely continued to grow locally by proliferation 
without the usual metastatic dissemination and constitu¬ 
tional intoxication, and never caused death, then the term 
“transplantation ” might be justified ; but when the charac¬ 
teristic evolution of malignant disease follows, terminating 
the life of the invaded host, one can only regard the case as 
one of genuine inoculation of a specific disease by a specific 
agent—i.e., that it is the result of true “infection.” 

In connexion with the successful inoculation of cancer in 
the lower animals of the same species, and also as bearing on 
the question of “cancer houses and rooms,” an interesting 
communication was made by Dr. Gaylord of Buffalo entitled, 
“Evidences that Infected Cages are the Source of Spon¬ 
taneous Cancer developing among small Caged Animals.” 8 
I regret that the time at my disposal is too short to permit 
of reference to this paper at length, but I am sure you will 
find it well worthy of perusal. Dr. Gaylord first refers to 
the endemic occurrence of cancer of the thyroid in brook 
trout hatcheries in Germany, recorded by Pick. Pick states 
that his investigations show that certain hatcheries are 
entirely free from this affection and that where the fish are 
affected the disease is confined to individual tanks or pools 
in which the fish are kept; that wild fish introduced into 
those ponds to replenish the stock acquire the disease, and 
this, to his mind, eliminates heredity as a factor in the 
development of the disease. The nature of the affection 
is true carcinoma, and he concludes that this endemic 
occurrence of cancer among trout in certain tanks only 
indicates that the water of these tanks contains the agent 
which is the cause of the disease. Dr. Gaylord tten pro¬ 
ceeds to narrate many instances of cancer occurring in rats 


which developed the disease after occupation of cages pre¬ 
viously occupied by other rats suffering from cancer. These 
instances are quoted by several observers, both medical and 
lay, in the latter case by the man who supplied rats to the 
laboratory for experimental purposes. It was found that 
when the infected cages were thoroughly disinfected no 
further infection occurred. 

Auto-inoculation of Cancer. 

To my mind, the strongest argument which can be adduced 
in favour of the exogenesis of cancer is one of its most dis¬ 
tinguishing characteristics—viz., its undeviatiDg method of 
growth and dissemination by proliferation and metastasis 
and auto-inoculatioD. Although cancer is unquestionably 
purely local at the outset, unfortunately it does not long 
remain so. Indeed, it would be completely under the con¬ 
trol of the surgeon’s knife and would lose all its terrors were 
it not for the fatal metastases which are invariably formed 
and that with a startling rapidity which is not sufficiently 
realised. 

Mr. C. B. Lockwood 7 has drawn attention to this rapid 
extension of the disease in a communication entitled, 
"Carcinoma of the Breast and its Spread into the 
Lymphatics.” He points out that in malignant growths of 
organs which have no capsule—e.g., the mamma, tongue, or 
pharynx—hardly any interval of time exists between the 
onset cf the disease and its spread into the lymphatics. He 
says, “ In the smallest carcinoma of the breast that I have 
seen the neighbouring lymphatics were already cancerous.” 
It is this inevitable and rapid metastasis which is responsible 
for the equally inevitable failure of the great majority of 
operations for the removal of malignant neoplasms. 

Mr. H. T. Butlin," in his recent address in surgery at the 
annual meeting of the British Medical Association in 1907, on 
"The Contagion of Cancer in Human Beings and Auto¬ 
inoculation,” says : " The key to the problem of communica¬ 
bility of cancer in human beings must surely lie in the study 
of auto-inoculation. If auto-inoculation can be proved on 
such evidence as would be admitted in a court of law there 
is a prima facie case for contagion.” He then goes on to 
say : “ If the proof of auto-inoculation falls through from 
the lack of sufficient evidence it is no longer worth while to 
pursue the study of contagion from individual to individual.” 
Granted, but auto-inoculation of cancer requires no proof. 
Unfortunately for mankind it is indisputable ; it is a marked 
and only too self-evident characteristic feature of the 
malady. Every metastasis is a true auto-inoculation. So, 
also, is every so-called " recurrence.” There is obviously no 
such process as recurrence. That which has been removed 
cannot recur, but what has been left behind continues to 
grow. Worse still, what has been set free from divided 
lymphatics and the tumour itself by tbe surgeon's knife, and 
what that infected knife has itself inoculated in and about 
the wound infallibly grows also. Mr. Bntlln's conception of 
“ auto-inoculation ” appears to be a very limited one, applying 
only to the inoculation of an adjacent healthy surface by an 
affected one. Although it is well known that this auto¬ 
inoculation of adjacent structures not infrequently happens 
its absence or presence is merely of academic interest. Its 
presence is confirmatory, but its absence cannot in tbe 
slightest degree invalidate the obvious fact that auto-inocula¬ 
tion is one of the most marked characteristics of cancer. 
Mr. Butlin's " key ” is therefore ready to his hand, for the 
condition he considers necessary to establish a primd facie 
case for contagion is, only too clearly, already in evidence. 

Mr. But-lin further says : “ Experiment has proved that 
successfully implanted carcinoma invariably presents, both 
in the grait and its metastases, the characters of the car¬ 
cinoma from which it was implanted ”; also that, “no trans¬ 
formation has yet been observed of one variety into another 
variety.” Then, as a corollary to this, he adds, “all cases of 
reputed contagion of cancer, in which the disease is not of 
the same variety, must be unhesitatingly rejected.” With 
regard to his first point, that grafts and their metastases 
always present the same characters as the parent carcinoma, 
it could not possibly be otherwise. It is another character¬ 
istic of cancer that “breeds true,” and every metastasis, 
wherever situated, is an actual fragment, or graft, of the 
original neoplasm, and a cancerous graft implanted success¬ 
fully In another individual Is, to all intents and purposes, a 
metastasis of the tumour supplying the graft. Consequently, 
all implanted carcinoma grafts and their metastases must be 
of the same variety as the original growth. As regards 
the second point, Mr. Butlin must be unaware of the 




S2 Tbh Lancet,] 


DR. A. T. BRAND: THE INFECTIVITY OF CANCER. 


[Jan. 11, 1908. 


recent experiments of Ehrlich and Apolant • which have 
demonstrated beyond doubt that even a carcinoma can, 
under given conditions, lead to the development of a sarcoma 
in connective tissue immediately adjacent to it. If, then, a 
carcinoma can give origin to a sarcoma, it is obviously even 
more probable for one variety of carcinoma to originate 
another variety of carcinoma. It does not, therefore, 
appear necessary, after all, to reject the cases of reputed 
contagion in which the disease iB not of the same variety. 
Farther on I shall endeavour to show that any one variety of 
malignant neoplasm may originate any other variety. The 
reason for Mr. Bntlin’s rejection of these cases is entirely 
consistent with his belief, which is that, although he con¬ 
siders cancer to be a parasitic disease, he is not apparently 
able to admit the logical sequitur that a specific parasitic 
disease must be necessarily caused by a specific extrinsic 
parasite. In the Bradshaw lecture 10 delivered by him in 
1905 Mr. Butlin maintains that “cancer is a parasitic 
disease,” but that the “ carcinoma cell ” itself is the parasite 
and ‘ 1 acts as an independent organism like many a 
protozoon.” 

Is the Cancer Cell Itself tub Parasite? 

Imprimis , there is no such entity as a special “carcinoma 
cell.” Professor D. J. Hamilton" of the University of 
Aberdeen says, with reference to carcinomata: “The old 
notion that there was a special cell indicative of cancer is 
erroneous. The only point which is typical about the cells of 
the tumour is that they are always epithelial ; they have no 
constant morphological features beyond this.” The elements 
of any malignant neoplasm are simply ordinary somatic cells 
which have undergone abnormal, exuberant proliferation 
under a specific stimulus. Transmitted by the lymphatics and 
blood-vessels, or implanted deliberately by artificial means, 
these cells certainly appear to act like independent 
parasites, but they act in this manner not voluntarily but 
only by virtue of the intracellular malignant stimulus which 
is clearly the micro-parasite. 

It is impossible for the “carcinoma cell" to be the true 
parasite. 

Let it be supposed for a moment that the “carcinoma 
cell” could be the parasite, then—1 There must have been 
an original neoplasm for it to come from. How, then, did this 
original growth arise ? Certainly not from any pre-existing 
“carcinoma cell,” since "ex nihilo nihil fit." 2. All 
cases of cancer would also of necessity be due to 
direct contact. 3. All cases of cancer would be of 
only one variety—viz., the same variety as the original 
neoplasm from which the “carcinoma cell" emanated. 
Now, we know that comparatively few cases of cancer are due 
to direct contact ; so few, indeed, that they are not generally 
accepted as genuine, and the “cell parasite ” would account 
for them only. The great majority of malignant neoplasms 
arise apparently spontaneously and sporadically ; also it is 
a characteristic of cancer that its variety is very great. It 
is obvious that the origin of cancer and its great variety must 
be explained in some other way than by the direct implanta¬ 
tion of a “ carcinoma cell ” or by the preposterous sug¬ 
gestion that any somatic cell by any intrinsic stimulus can 
possibly develop de novo a specific disease such as cancer. 
We may as well be asked to believe that tuberculosis, for 
example, can be originated by the agency of an intrinsic 
stimulus. I beg to submit that the living implanted cell 
which may be the starting point of any malignant neoplasm 
must have been derived from a pre-existing neoplasm, and 
that its malignant influence is due to an intracellular micro¬ 
parasite endowed with extraordinary and most malevolent 
powers. It is this intracellular entity which is the “ dais ex 
maohind" or, as it might be more appropriately designated, 
the “ didbolus ex machina" of Mr. Butlin’s “carcinoma-cell 
parasite,” and this micro-parasite can, and does, exist 
independently of any cell. It alone is responsible for the 
original of all neoplasmata. 

With regard to his “carcinoma cell,” Mr. Butlin states 12 
that it exhibits a singular tenacity of life, for such cells have 
been kept for many days at a temperature below 27° F. or 
have been placed in sterilised glass flasks and sent across the 
sea by post and yet have in each case been inoculated with 
as good a result as if they had just been transplanted from 
one individual to another. Later, however, he adds that 
all experiments made with the object of cultivating the 
• * carcinoma cell ” outside the body of the host have resulted 
in failure, and that Ballance and Sbattock have reported that 
they have been unsuccessful even in keeping these cells alive 


outside the host. These statements are contradictory. It is 
impossible for living cells of any kind, malignant or other¬ 
wise, to retain their vitality for any length of time after 
removal from their natural environment. Everyone knows 
that any cells can, by sterilisation, be preserved from de¬ 
composition for an indefinite time, but this preservation is 
not synonymous with vitality. How, then, can these con¬ 
flicting statements be reconciled, and how was it that these 
dislocated “carcinoma cells” were successful in inoculating 
fresh hosts as alleged ? Their success was clearly due to the 
vitality of the intracellular parasite itself and not of the 
encapsuling cells. The vitality of the intracellular parasite 
is of paramount importance for the perpetuation of its 
species and is very great, whereas the vitality of the dis¬ 
located 1 ‘ carcinoma cells ” is of very brief duration and of 
only secondary importance. Although the cell itself is dead 
it can still originate a neoplasm by virtue of the living intra¬ 
cellular parasite, but the resulting neoplasm is, as I shall 
presently show, of a different type from that originated by a 
living cell. 

Classification of Neoplasmata. 

All neoplasms may be divided, clinically, into : (1) benign ; 
and (2) malignant. 

The benign are, for the most part, simply local hyper¬ 
trophies of normal tissue and remain so unless they become 
infected like any other normal tissue, in favourable 
circumstances, and they do not form metastases. These 
benign tumours do not require any specific stimulus to 
originate them, simple stimulus of a mechanical nature 
being quite sufficient in many cases for tbe purpose. They 
are comparable to the pearl of an oyster which is simply the 
deposit of a normal substance around a foreign body. 

Malignant neoplasms are divided into : (1) epitheliomata ; 
and (2) sarcomata. Epitheliomata arise from epithelium, 
originally derived from the epiblast and hypoblast. They 
disseminate themselves chiefly by the lymphatics but also, to 
some extent, by the blood-vesselB. Sarcomata arise from 
connective tissue, originally derived from the mesoblast. 
They, on the other hand, chiefly utilise the blood-vessels for 
propagation but they also utilise the lymphatics. Malignant 
neoplasms cannot arise without the agency of a definite 
specific stimulus. These two great classes are further sub¬ 
divided into very many varieties as regards structure but in 
all other essentials they are practically the samo in each 
case. This great variety is, simply and entirely, due to the 
anatomical diversity of the tissues in which they occur and 
their environment. As Professor Hamilton 11 points out, all 
such subdivisions as osteoid, villous, colloid, chondroid, 
encephaloid, fcc., are " useless and misleading.” 

With regard to their method of origin in the tissues, 
malignant neoplasms are of two distinct types: (I) primary ; 
and (2) secondary. The primary are those formed by the 
proliferation of tbe cells of the local tissue invaded by the 
parasite itself. When the parasite is in a free state or 
encapsuled in a dead cell thrown off from the surface of a 
neoplasm (which practically amounts to the same thing, for 
a cell devoid of vitality is obviously incapable of pro¬ 
liferating and so originating a tumour composed of its own 
elements), and when it gains access to the host, then tbe 
resulting neoplasm will consist of the proliferated elements 
of the local tissue cells invaded. Thus the free parasite 
emanating from a glandular-celled carcinoma may originate 
a squamous-celled carcinoma in another individual if it 
invades such tissue, or the free parasite from a squamous- 
celled carcinoma—of, e.g., the tongue—may give rise to a 
columnar-cell carcinoma of tbe stomach or rectum, or to a 
spheroidal-oelled carcinoma of the mamma, or to any other 
variety of carcinoma, according to the structure of the tissue 
invaded. The great majority of malignant neoplasmB which 
arise, apparently de novo, are of this primary type. They are 
originated directly by the parasite itself and indirectly by the 
tumour from which the parasite is set free. Thus the great 
variety of cancer is accounted for and to the free parasite are 
we indebted for the original neoplasm. 

The secondary are formed of alien cells by the proliferation 
of the directly implanted infective tissue cells themselves, 
acting under the stimulus of intracellular malignant in¬ 
fluence, the micro-parasite. When the parasite is encapsuled 
in a living cell and this cell gains access to any host the 
resulting neoplasm will be of the same variety as the invad¬ 
ing cell, being formed by its proliferation in its new situa¬ 
tion and not by the proliferation of the cells of the local 
tissue invaded, as in the primary type. All that the invaded 





Thb Lancet,] 


DR. A. T. BRAND : THE INFECTIVITY OF CANCER. 


[Jan. 11, 1908. 83 


tissue cells do is to provide ordinary nutriment for the pro¬ 
liferating invading cells. Thus, the parasite-bearing living 
cell from, e.g., a columnar-celled carcinoma will originate 
another columnar-celled neoplasm by its own proliferation, 
quite irrespective of the structure or situation of the tissue 
invaded. Such infection is immediate and direct as regards 
the implanted cell and indirect as regards the inclosed 
parasite. All metastatic growths and all auto-inocuiations 
are of this secondary type. For example, the metastasis 
from a neoplasm of the rectum established in the liver or 
lungs consists of proliferated rectal epithelial cells. All 
cases of “ cancer-ii-deux" and all cases of deliberately 
implanted cancerous growths are also of this type. So great 
are the activity and vitality of these malignant parasite¬ 
hearing cells that even one such left behind after an opera¬ 
tion for the removal of a malignant neoplasm is able to 
reproduce it. Thus, the infection of invaded tissues by a 
parasite-bearing living cell, with subsequent proliferation of 
the latter, corresponds to what occurs after an unsuccessful 
operation. Now we see that Mr. Butlin’s “ carcinoma cell ” 
parasite could only originate this secondary type of neoplasm 
while the origin of the enormous majority of malignant new 
growths is left unaccounted for by his hypothesis ; but the 
primary type of origin accounts for this majority and supplies 
the original neoplasm from which the living cell, apparently 
acting as an independent parasite, emanates. It also 
accounts for the great variety of malignant neoplasms, a 
variety only limited by the anatomical diversity of tissues. 

All this demonstrates how true a parasite the micro¬ 
organism responsible for cancer is. In the secondary type 
we find it comfortably ensconced in a living cell which it 
compels to slave for it, when implanted in any situation, 
stimulating it to proliferate and so provide accommodation 
for its numerous progeny. It exerts no personal influence 
whatever on the surrounding local tissue cells, which are 
generous enough to furnish the invaders with food supplies. 
It is only when death of the host occurs, or if perchance a 
cell dies and becomes detached from the colony, that its 
tyranny ceases for a time. Now it must make personal 
exertion and endeavour to find a fresh victim in the cell of 
the nearest available living tissue. Having succeeded in 
gaining a footing it proceeds to induce the selected 
invaded cell to commence work by proliferating, and the 
process progresses as before except that this time it is the 
cells of the local tissue which have both to increase in 
number and find their own food. This is the primary type. 

In all other parasitic diseases the micro-organism of 
causation remains free and active personally, but the cancer 
parasite is the trueit parasite of them all, for it never exists 
free if it can avoid it, but clings to its cell-host with 
indomitable pertinacity. 

The Parasite of Cancer. 

Although its presence is proved by induction, as is also the 
existence of, for example, the micro-parasite of variola, the 
parasitic agent of cancer is, as the Germans say, “ nock nickt 
lionstatirt ” (it has not yet been conclusively demonstrated). 
Doyen of Paris believes that the bacterium known as “ micro¬ 
coccus neoformans ” is the germ responsible for cancer. This 
belief appears to be corroborated by the researches of 
Dr. C. Jacobs and Dr. Victor Geets, the result of which was 
communicated by them to the Royal Belgian Academy of 
Medicine at Brussels in January, 1906. 13 These observers 
report that it is practicable to immunise the human organism 
by means of a series of inoculations of the micrococcus 
neoformans vaccine, provided that these are properly con¬ 
trolled by examination of the opsonic power of the blood. 
They cultivated the micro-organism from 90 per cent, of 
tumours examined and succeeded in producing localised, or 
generalised, neoplasmic lesions in 30 per cent, of the cases, 
by inoculating young and vigorous cultures of the micro¬ 
organism into mice and white rats. They prepare the vaccine 
in exactly the same manner as Koch prepares his tuberculin 
T.R. and treat their patients in a similar way to the vaccine 
treatment of tuberculosis. They allege that in some cases 
they obtain cures, but point out, however, that as tuber¬ 
culin does not cure all cases of tuberculosis, cancer vaccine, 
too, cannot cure all cases of cancer. Success or failure 
depends entirely upon the reserve of vital energy and capacity 
for reaction which each patient possesses, and these differ in 
each case. Other observers—e.g., Wright—have failed to 
confirm these results and they are, I believe, now dis¬ 
credited. 

Roswal Park, Gaylord, 11 and others in America believe 


that cancer is caused by an organism of the same nature as 
the plasmodiophora brassicic. Their observations seem to 
prove that minute plasmodiophorse are present in carcino¬ 
matous tumours and that they can be grown from such 
tumours through a definite stage in their life cycle. In 
summarising their results and conclusions Dr. W. Ford 
Robertson and Mr. Henry Wade 11 state that they had been 
able to recognise in carcinomatous tumours bodies which, in 
their form and in their reaction to the platinum and silver- 
gold methods, are identical with the plasmodiophora 
brassiest but from th to ,’ 0 th of the size. They had 
succeeded in growing from three carcinomata an organism 
which accurately represented the post-spore or pre-amoeboid 
stage of a plasmodiophora. If plasmodiophora; were present 
in carcinomatous tumours it was hardly open to doubt that 
they had the same relation to the morbid growth as the 
plasmodiophora brassicm had to “club-root,” that was to 
say, that they were the determining etiological factor. 

In a later communication (August, 1907) Dr. Ford 
Robertson 16 claims that he has obtained much new evidence 
which he considers confirmatory of this view, evidence 
derived from cultural and histological observations of the 
occurrence of special intranuclear bodies of the nature of 
those previously described, to show that structures morpho¬ 
logically identical with the spirochteta microgyrata can be 
demonstrated in human carcinomata. Gaylord and Calkins 11 
have also described a special spirochmta in primary and 
transplanted carcinoma of the breast in mice. The con¬ 
firmed discovery that spirochseta pallida is the etiological 
factor in syphilis is analogically suggestive of a spirochaetan 
cause of cancer. Much undoubtedly remains to be done, 
however, before the elusive parasite can be demonstrated to 
the satisfaction of all ; but these discoveries tend to show 
that the net is gradually, but surely, closing around it. 

I offer the suggestion that the examination of fresh, living, 
carcinoma cells on the warm stage of the microscope would 
result in much additional and valuable information ; also 
that the employment of high power microscopy would be a 
great aid to investigation. The objective of a microscope 
reaches the limit of its useful development in the direction 
of increasing magnifying power as soon as, by reason of the 
shortening of the focal length, the diameter of the object 
glass, in its principal plane, is reduced to something not 
much less than the diameter of the pupil. Added power, 
however, to any required extent can be obtained by high power 
oculars, but the image thus obtained is rendered defective 
by the blurring of the image from dust and obstructions in 
and on the lenses, and by the observer’s eyelashes, tears, and 
muscat volitantes ; but, quite recently, the image has been 
rendered perfectly clear and very high magnifying power 
obtained by the skill and ingenuity of an expert in micro¬ 
scopy. In February, 1905, at a meeting of the Royal Institu¬ 
tion of Great Britain, Mr. John W. Gordon 1# described a 
device by which a magnification of 7000 diameters could be 
obtained as well as a perfectly clear field of view. Mr. 
Gordon substitutes for the eyepiece a compound microscope 
with a half-inch objective and an ocular magnifying eight 
times. A ground-glass screen is held in the image plane of 
the principal microscope, and this screen is made to revolve 
and also at the same time to oscillate eccentrically. The 
screen abolishes the intrinsic images of dust and foreign 
matter and the eccentric rotary motion renders the screen 
invisible. 

Quite as important as high magnification of the image is 
good field illumination. Dr. Siedentopf ” has devised a 
system of dark field illumination, applicable to objectives of 
the widest possible aperture, which renders visible objects 
so minute and clustered so close to one another that by no 
other known contrivance can they be rendered separably 
visible at all. I must not further occupy time in describing 
this system of illumination and would refer those interested 
to the Proceedings of the Royal Institution of Great Britain, 
Vol. XVIII. 

There is another desideratum of the greatest importance in 
the histological investigation of cancer which, I fear, is 
more likely to be sought for than found, and that is a specific 
staining reagent which will act on cancerous tissue in an 
analogous manner to the selective action of iodine upon the 
diseased areas in amyloid disease which renders them 
clearly distinct even to the naked eye. It is true that there 
is such a selective stain, but it acts only in oue species of 
malignant neoplasm. I allude to the staining by melanin in 
melanotic cancer. Its presence makes it possible not only 
to detect every particle of original and metastatic growth in 


84 The Lancet,] 


DR. A. T. BRAND: THE INFEOTIVITY OF CANCER. 


[Jan. 11, 1908. 


this variety, both macroscopically and microscopically, but 
it also permits optical demonstration of the method of dis¬ 
semination by the blood-vessels and lymphatics. This has 
been most ably demonstrated by Mr. W. Sampson Handley 17 
in his Hunterian lecture on the Pathology of Melanotic 
Growths in Relation to their Operative Treatment. 

Tub Condition Precedent. 

Since perfectly healthy tissues are probably immune from, 
or invulnerable to, the attack of the cancer parasite, there 
must be causes predisposing to the acquisition of the disease, 
and these go to form what I have called the “condition 
precedent.” This condition is induced by whatever lowers 
or impairs the power of resistance of the body to infection. 
In the case of cancer the chief factor in producing this 
vulnerability is degeneration of tissue from any cause, but 
more especially that due to obsolescence of organs, senes¬ 
cence, and senility, for cancer is, par excellence , the disease 
of advanced age, though by no means confined to it. This 
is obviously due to the fact that in those of middle and 
advanced age decay is in marked and increasing excess over 
repair (the reverse being the case in youth), and the tissues 
are less equal to the strain of resisting the attack of the 
aggressive parasite, especially when this degeneration exists 
in conjunction with the other predisposing factors of this 
condition, which are chronic disease, continued irritation, 
traumatism, and congenital susceptibility. In my opinion, 
it is the failure to realise the invulnerability of young and 
healthy subjects which is one of the causes of so many un¬ 
successful inoculation experiments. I have discussed this 
point fully in another paper. 2 

Channels and Mode of Infection. 

I have elsewhere 1 * fully considered the channels of 
infection and it remains to consider how one becomes 
exposed, unknowingly, to the risk of attack by the parasite. 
This evil agent appears to be practically omnipresent, as so 
many other pathogenic micro organisms are, such as the 
bacillus tuberculosis, the bacillus tetani, and the malevolent 
legion of micrococci, and it is ever ready to act aggressively 
as opportunity arises and circumstances favour. One hardly 
appreciates how very close the relationship is, if only in¬ 
directly, with our neighbours, including those suffering 
from cancer. All our food, both cooked and uncooked, 
passes through the hands of many individuals, and the only 
safeguard, cleanliuess, on their part is practically beyond 
our control. As evidence of this I give you an instance 
from personal experience. A widespread epidemic of enteric 
fever which occurred in a village near Driffield, in which I 
had several patients, was easily traced to an imported case 
which was nursed by a woman who supplied milk to all those 
attacked. This woman, though altruistic, was a most un¬ 
cleanly person and made it her practice to milk her cows 
without even washing her hands, and that immediately after 
attending to the discharges and soiled linen of her patient. 
Much vegetable food, e.g., salads and fruit, is eaten un¬ 
cooked. Each strawberry, for example, we eat is gathered 
by the unwashed hands of the gatherer. Strawberries also 
lie very near the ground, as do lettuces, &o., and are 
readily accessible to domestic animals, such as the dog and 
cat, which also suffer from external cancer as well as 
from intestinal worms. There is an article published in 
Tiie Lancet of July 16th, 1904, entitled “Fruit and 
Filth,*' 1 '* which will well repay anyone’s perusal, provided 
the reader is nob too greatly under the dominance of his 
nerves, or has not too lively an imagination, for anyone who 
reads that article is not likely to touch strawberries again 
unless he picks them himself from plants above suspicion of 
defilement. 

Far be from me the desire to harrow your feelings too 
deeply, bub how, let me ask, is one to know that the common 
house-fly, which crawls all over our bread and butter, or 
other article of food, was not, immediately before, disporting 
itself on the surface of a cancerous wound ? Flies are well 
known to carry tubercle and typhoid bacilli, as well as other 
pathogenic micro-organisms, on their feet, and in the 
stomach, and it is al-o well known that they have infected 
food and drink with these germs, with disastrous results. I 
would refer you to a very ab’e and suggestive communication 
published in The Lancet of July 27oh, 1907, under the title 
of “The Carriage of Infection by Flies.” 10 This article gives 
the result of experiments made by Dr. R. M. Buchanan, 
bacteriologist to the corporation of Glasgow, with the object 
of demonstrating this fact. I wrote to Dr. Buchanan to 
inquire if he had made any experiments as to the 


cancerous contamination of food by flies and received the 
following reply: “I have not yet tried the experiment yo*» 
suggest with reference to cancer, but hope to do so as soon 
as I can obtain material. The same problem presented itself 
to me in connexion with the death of a friend some years ago 
from intestinal cancer.” 

One’s own footgear must bring much dust, laden with all 
kinds of pathogenic micro-organisms and, on occasion, dust 
from a cancer sufferer’s room, into one’s house, and it 
may easily find its way to one’s food, &c. In this con¬ 
nexion the Eistern custom of leaving the outside shoea 
at the entrance of the house has, truly, much to com¬ 
mend it. Another risk to which we are exposed is 
eating the flesh of animals which have been suffering 
from malignant disease when killed. In December, 1904, 
according to press cuttings in my possession, a man was 
fined £50 and £7 costs at the Guildhall, London, for sending 
meat to Smith field which on examination was fonnd to be 
sarcomatous, lb cannot be assumed thAt this is a solitary 
instance, only it happened to be discovered. Cooking ia 
said to minimise risk, but underdone meat is not unpopular. 

I once knew a dentist who suffered from cancer of the 
prostate, from which he eventually died, and who followed 
his occupation during his illness. One of the physical sign* 
of his malady was a urethral discharge, which necessitated 
frequent manual attention. I have no reason to doubt that 
he occasionally washed his hands! In my own practice 1 a 
patient suffering from a fungating cancer of the mamma 
was nursed by a woman who frequently had occasion to 
remove soiled dressings and who was nob particularly cleanly 
in her habits, and did not always wash her hands before meals. 
Within a year of her patient’s death the nurse developed 
cancer of the stomach and died. This may have been a 
coincidence but I believe it to have been a case of indirect 
infection, a neoplasmic disease of the primary type. 

I have thus indicated a few possibilities ; some may be- 
considered far-fetched, still they are possibilities, and 
unpleasant ones; doubtless many more will occur to your¬ 
selves. 

Prophylaxis. 

From the foregoing it is obvious that the only reliable 
prophylactic against cancer as well as other filth diseases, 
and it is an efficient one, is cleanliness in its widest sense. 
Earth burial, with all its hideous possibilities, should be 
superseded by cremation of all who die from infectious 
disease, and especially from cancer. Cremation would deal 
with the disease at its source. All soiled dressings and dis¬ 
charges from cancerous subjects should be destroyed by fire 
and all rooms inhabited by them should be most thoroughly 
disinfected both during the illness and after death. No food 
should be prepared or consumed with unwashed hands. 

New Facts about Cancer. 

Within recent years several new facts have been discovered 
about cancer. 1. The mitosis of the cells of malignant 
neoplasms has been found to be heterotype in character, 
whereas the mitosis of all somatic cells with one exception, 
and of the cells of benign tumours, is homotype. The 
mitosis of normal reproductive tissue is also heterotype. 
2. It has been discovered that cancer is not restricted to the 
higher vertebrata, e.g., man and the domesticated animals, 
as was at one time supposed, but that it occurs in all 
vertebrata, with the possible exception of certain reptilia. 
The malignant growths occurring in other vertebrata are 
identical with those found in man, clinically, pathologically, 
anatomically, and microscopically. 3. The transmissibility 
of malignant new growths from one lower animal to another 
of the same species has been demonstrated. 

With regard to the first of those discoveries it was the 
resemblance between the mitosis of malignant cells and that 
of normal reproductive tissue cells which led to the 
enunciation 4 by the director of the Imperial Cancer Research 
Fund of the famous analogical fallacy that malignant new 
growths are merely reproductive tissue in abnormal 
situations. The heterotype character of the mitosis of 
malignant cells and the homotype character of somatic and 
benign tumour cells are, indeed, of academic interest but of 
little or no practical importance beyond affording a possible 
means of differential diagnosis in some doubtful cases which, 
however, would signally fail in the case of tumours of the 
reproductive tissues, since the mitosis is heterotype in either 
case, whether benign or malignant. It has been suggested 
to me that the fact of the mitosis of malignant and 
generative tissue cells being heterotype in both cases was 
important as showing that generative tissue cells, like those of 



The Lancet,] DR. MACLEAN : ANOMALOUS REACTIONS OBTAINED IN TESTING URINE, ETC. [Jan. 11,19C8. 85 


cancer, have the power of proliferation. Of course, this fact 
cannot prove any such power, since analogy can prove 
nothing, but can merely suggest; still, if it oould prove it 
it would not be necessary to corroborate the power of pro¬ 
liferation of generative cells, since the first infant one comes 
across is ample and convincing proof of that! At the same 
time there is a very suggestive parallel between the two 
proliferations. Neither generative tissue nor other normal 
tissue ceils can proliferate without a specific st imulus. In the 
case of generative tissue the ovum only commences to pro¬ 
liferate when it has been invaded by the spermatozoon, 
which acts practically as an extrinsic specific protozoan 
parasite. The proliferation is enormous and rapid. The 
resulting tumour is benign, though some might consider it to 
be a malignant tumour in a normal situation ! It is easily 
got rid of, and ‘' recurrence ” does not take place unless 
there is reinfection In the case of somatic cells proliferation 
only commences when they are attacked by the cancer 
parasite. Mitosis becomes heterotype, proliferation goes on 
apace, and the tumour is malignant and impossible to 
eradicate. Nothing is known of the method of the influence 
of the cancer parasite on the somatic cell, any more than the 
influence of the spermatozoon on the ovum is understood, but 
it will be admitted that the one process is equally as 
marvellous as the other. 

With regard to the second of these facts, among the verte- 
brata in which cancer has been discovered to exist are certain 
fi-hes, found both in rivers and in the ocean round our coasts. 
This fact has induced the director before mentioned to state" 0 
that “the wide zoological distribution of malignant new 
growths indicates that the cause of cancer is to be sought in a 
disturbance of those phenomena of reproduction and cell-life 
which are common to the forms in which it occurs.” Thus he 
makes another statement of opinion which clearly indicates 
how little is the help towards solution that may be expected 
from intrinsic hypotheses and their advocates. To the 
“man with the open mind,” however, it might probably 
occur, as it certainly does to me, that this wide distribution 
of cancer throughout the vertebrata, with the resulting great 
diversity in environment, food, and conditions of life 
generally, was suggestive of the omnipresence of a specific 
malevolent agent of great vitality ; that, with regard to the 
fluvial and marine fishes found bearing cancerous growths, 
this fact might well suggest that the specific cause of cancer 
is water-borne and, like the bacillus typhosus, it is not 
injuriously affected by sea water ; and, finally, that since 
the neoplasms found in fish are identical in every way with 
those occurring in man, infection may well have arisen 
through the agency of parasite-bearing sewage polluting 
both the rivers and the ocean into which they flow. 

Regarding the third discovery of the trauBmissibility of 
cancer from one individual to another of the same species, 
although this has had to be admitted, it is qualified by the 
assertion that such transmission is merely a transplantation of 
a graft of a malignant tumour and not the genuine inoculation 
of a specific disease. It would be more graceful to concede 
that since transmission between individuals of the same 
species is proved to be possible it may be eventually found 
that transmission between animals of different species, and 
even the development of one variety of malignant growth 
from another, is possible also. 

An admission which may be looked for sooner or later is 
that a carcinoma of epithelial origin has been observed to 
give rise to a sarcoma in the adjacent connective tissue. 
Then will be confirmed the dictum that cancer is a specific 
infective disease and that one specific micro-organism is 
capable of originating every variety of malignant neoplasm, 
the variety depending upon, and only limited by, the 
anatomical diversity of the structure and the situation of the 
tissue invaded. 

Deductive Evidence. 

As it is necessary to apply the striotest canons of logic to 
the arguments brought forward in support of any hypothesis 
I beg to submit the following, which to my mind fulfils this 
postulate. Every specific disease is infectious to the indi¬ 
vidual. By this term, “infectious to the individual,” I 
mean the gradual evolution of disease, more or less rapid, 
locally and constitutionally, over the body from the point of 
origin of the disease. Specific diseases infectious to the 
individual are very numerous and are caused by the agency 
of some extrinsic 'parasite, either a microphyte or a micro- 
zoon. These diseases are communicated to others, directly 
from individual to individual, or indirectly by inanimate 
objects, or through an intermediate host. 


Now cancer is, emphatically, a specific disease, and it is 
intensely infectious to the individual ; therefore, the only 
logical conclusion that can be drawn is that cancer is both 
transmissible to others and that it is caused by an extrinsic 
agent. Except for the solitary fact that the elements of a 
malignant neoplasm—i.e., its cells—are themselves trans¬ 
ported, in addition to the infective agent (which is the 
peculiar and characteristic idiosyncrasy of cancer), this 
disease very closely resembles in its origin and evolution a 
chronic infectious disease. 

My argument may be condensed into two syllogisms— 
viz : 1. All diseases which are infectious to the individual 
are transmissible to others. Cancer is infectious to the 
individual. Therefore cancer is transmissible to others. 
2. All diseases which are infectious to the individual have an 
external origin. Cancer iB infectious to the individual. 
Therefore cancer has an external origin. 

Bibliography. — 1. Brit Med. Jour., July 26th, 1902. 2. Quarterly 
Medical Journal. May. 1905. 3. Practitioner. August, 1907. 4. Brit. 
Med. Jour.. Jan. 30lh. 1904. 5. Antonv and Cleopatra. Act II., Scene ii. 
6. Brit. Med. Jour., Dec. 1st, 1916. 7. Ibid.. Jan. 27th, 19U6. 8. Tat: 

Lancef, August 3rd, 1907. 9. Brit. Med. Jour., Dec. 1st, 19C6. Ehrlich 
uud Apoimit: Centralblatt fur Allgcmtlne Pathologic tins Pathologische 
Auatomie. Band aril.. No. 13, IsCS. Apolaat und Ehrlich : Arbetten 
aus dem Khnlgllchen institut ftir Kxperimcntello Therapie zil Frank¬ 
furt A /M., Heft 1 (Aus der Abtellung iiir Ktebsforschnngl. Ehrlich : 
Experimentelle Studlen an Mauaetumoren, Zritschrlft tttr Krebafor- 
schung, Band v., Ileft 1/2, 1907. 10. The Lancet, Dec. 16ih, 1906. 
11. Hamilton's Text-book of Physiology, vol. i. 12. The Lancet, 
Doc. 16th. 1906. 13. The Lancet. April 7th. 19C6. p. 964. 14. The Lancet, 
August 13th. 1904, p. 469. 16 The Lancet. August 10th. 1997. p. 358. 

16. Proceedings of the Itoyai Institution of Cireat Britain, vol. xviii. 

17. The Lancet, April 6th, 1907, p.927. 18. The Lancet. July 16tb, 
1904, p. 167. 19. The Lancet, July 27th, 1907, p.216. 20, Brit. Med. Jour., 
Jan. 30th, 1204. 


ON ANOMALOUS REACTIONS OBTAINED 
IN TESTING URINE FOR SUGAR 
WITH FEHLING’S SOLUTION. 

By HUGH MACLEAN, M.D. AnERD , 

I.KCTEKEH ON CHEMICAL PHYSIOLOOV IN THE UNIVERSITY OP 
ABERPEEX. 

(From the l‘hy*iologioa l Laboratory.) 


The application of FehliDg’s test for the detection of sugar 
in urine is both simple and reliable in the presence of a fair 
amount of sugar. Urines in which a distinct reaction is 
obtained when boiled for a short time with an equal amount 
of Fehling’s solution may, in almost all cases, 1 be held to 
contain excess of sugar, and such urines present bo further 
difficulties. Practical experience, however, as well as an 
examination of the plentiful references to the reaction in 
clinical and other text-bocks, &c., show that the test as 
applied to urine in general Is complicated by many difficulties 
and ambiguities. Different authorities seem to hold very 
divergent views with regard to the exact significance of 
certain results obtained with Fehling’s te6t when the reaction 
is somewhat modified either with regard to the general 
appearance of the precipitate or the time taken to produce 
it. Thus on testing urine it is sometimes found that no 
result is evident after a good deal of heating with Fehling’s 
solution, but that some time after standing an opalescent 
mixture is found to have taken the place of the blue solution, 
or perhaps there is a fairly definite yellowish-green pre¬ 
cipitate. In other cases it is found that the mixture of urine 
and Fehling’s solution gives on boiling for tome time a dirty 
opalescent greenish milky liquid without aDy sign of a 
definite precipitate ; at other times a more yellowish-green 
solution is in evidence ; and all stages from a faint dirty 
greenish opalescence to a definite yellowish mixture exhibit¬ 
ing undoubted evidence of a precipitate may from time to 
time be seen in clinical work. 

The significance of these ambiguous reactions has not been 
thoroughly dealt with in the literature of the subject and at 
present the general tendency is to explain them in a con¬ 
venient, but not very helpful, way by reference to some dis¬ 
turbance by “interfering" substances. How these latter 
substances are supposed to interfere with the test is generally 
not very plainly indicated, bnt the general impression con¬ 
veyed seems to be that they act in virtue of their direct 
reducing action and thus simulate sugar, though giving at 

l Possible complications with glycuronic add, Ac., are not discuaasd 
here. 



86 The Lancet, ] DR. MACLEAN : ANOMALOUS REACTIONS OBTAINED IN TESTING URINE, ETC. [Jan. II, 1908 


the same time a result somewhat different from that obtained 
from sugar, insomuch as the reaction is often modified, the 
result being a greenish and greenish yellow mixture, as 
mentioned above. 

Causation of the Anomalous Reactions. 

Some years ago the writer undertook an investigation into 
this subject in order if possible to elicit the causation of 
these ambiguous results and the clinical significance to be 
attached to them. The results of this investigation were 
published in extenso in the Bioohemioal Journal , a but as the 
subject is exceedingly important from the standpoint of 
practical medicine I propose to deal here with the part of 
greatest interest to the clinician. 

If we take a normal urine giving no reaction with Fehling’s 
solution and add to it a trace of sugar it will generally be 
found, on subsequent testing in the usual way, that no 
evidence of the presence of the added sugar can be detected ; 
that this is not due to any lack of delicacy on the part of 
Fehling’s solution is evident from the fact that this reagent 
will readily detect such a small quantity of sugar as 1 part 
in 126,000 parts water (0 0008 per cent.). Now since several 
times this amount of sugar often gives no result when added 
to normal urine and tested as usual we at once arrive at the 
conclusion that normal urine contains something which 
prevents small quantities of sugar giving a reaction with 
Fehling’s solution. According to Dr. F. W. Pavy this 
inhibition of precipitation of cuprous oxide is due to the 
ammonia evolved by the action of the alkali of Fehling’s 
solution on the nitrogenous constituents of the urine holding 
the suboxide in solution. In this way, of course, precipita¬ 
tion might be prevented provided the ammonia were present 
in sufficient abundance, but it will be shown later that the 
quantity of ammonia actually present is much too small to be 
of any account in this respect. 

An examination of all the ordinary constituents of urine 
resulted in disclosing the fact that the substance which 
causes this inhibition of precipitation is kreatinin. Kreatinin 
has the power of holding in solution the reduced suboxide 
and so the mixture gives no evidence, so far as precipitation 
is concerned, of the presence of sugar. Now, since normal 
urine always contains a certain amount of sugar every urine 
would give a reaction with Fehling’s test were it not for the 
kreatinin. The normal sugar of urine, of course, reduces its 
equivalent amount of Fehling’s solution in the ordinary way 
but since the reduced suboxide is held in solution by 
kreatinin we get no evidence of the presence of sugar and 
thus with Fehling’s solution average normal urine gives no 
apparent reaction. It will be seen that this action of 
kreatinin is more beneficial than otherwise, for it prevents 
mistakes being made with urine containing very little sugar 
—sugar of normal amount and only of physiological 
importance. The first effect therefore of kreatinin is to 
prevent a reaction with small amounts of sugar. 

Nature of the Precipitate. 

Kreatinin, however, possesses another very marked pro¬ 
perty—that of materially modifying the nature of the pre¬ 
cipitate when there is a slight excess of sugar present. It 
will be shown later that this characteristic of kreatinin is a 
most marked one and exceedingly important in affording an 
intelligible explanation of the various different-coloured 
solutions and precipitates described above. In a paper pub¬ 
lished in the above-mentioned journal for April, 1907, I 
entered fully into the phenomenon and showed that the 
different-coloured precipitates obtained in urine testing were 
associated with, and dependent on. a difference in the degree 
of granularity of the particles of the precipitates. Thus, in a 
urine giving, after boiliDg for some time, a dirty greenish 
opalescent solution, the modified colour is due to the fact 
that the precipitate of cuprous oxide is present in an 
exceedingly finely divided state ; in the case of a greenish- 
yellow precipitate the particles are still very fine but rather 
coarser than in the last ; with a yellow precipitate they are 
still somewhat larger, and this increase in the size of the 
particles goes on until in a distinct red precipitate the size 
of the individual granules is much more marked. 

It is customary to state that the red precipitate seen in 
testing distinctly diabetic urine is cuprous oxide, whereas the 
yellow precipitate in evidence when urines containing com¬ 
paratively small amounts of sugar (say from 1 to 2 per cent.) 
are tested is cuprous hydrate. The difference in colour, how¬ 
ever, is not dependent on the chemical nature of the precipi¬ 
tate present but on the state of subdivision of the particles, 

2 February, 1906, and April, 1907, 


and it is likely that all urines really give a precipitate of 
cuprous oxide and that the statement to the effect that the 
yellow precipitate is cuprous hydrate is incorrect. The 
lower hydrate of copper, Cu a (OH) u , is such an unstable 
chemical body as immediately to suggest a doubt whether it 
is possible for it to appear in urine testing in the form of a 
permanent precipitate. With regard to this difference of 
colour of the precipitates being associated with the state of 
subdivision of the particles of the cuprous oxide, it is of 
interest to observe that some months after the publication 
of my paper dealing with the above a paper by Dr. Pavy 
appeared in The Lancet 3 in which my general investiga¬ 
tions were repeated. It is satisfactory to note that the above 
authority has quite confirmed my observations concerning 
the relations of colour and state of subdivision. 

A consideration of the above facts enables us to under¬ 
stand the causation of modified results in urine testing. 
When the urine contains just a slight excess of sugar it 
reduces its equivalent amount of Fehling’s solution in the 
ordinary way, but the kreatinin present modifies the nature 
of the precipitate so that it separates out in exceedingly fine 
particles; these fine particles floating in the liquid give a 
dirty, milky, greenish appearance to the liquid. It is thus 
obvious that these ambiguous precipitates are just modifica¬ 
tions of the usual form, and are often (in fact generally) 
indicative of a slight excess of sugar above the amount 
present in normal urine. Of course, it is obvious that the 
presence of a sufficient amount of some other reducing body 
—e.g., glycuronic acid—would act in the same way, but 
observation shows that sugar is really the substance which 
most often gives these modified reactions. Again, it is 
sometimes necessary, in the case of those ambiguous pre¬ 
cipitates, to boil for some time before a result is obtained ; 
this is due to the fact that the kreatinin holds in solution 
the cuprous oxide formed during the initial stages of boiling, 
and it is only after the kreatinin can hold no more in solu¬ 
tion that the modified precipitate separates out. Since a hot 
kreatinin solution is a more effective solvent than a cold one, 
there is a consequent tendency for the precipitate to settle 
out after standing for some time. 

Reaction with Normal Urine. 

Even normal urine, when boiled long enough with 
Fehling’s solution, will give a distinct precipitate, and a 
consideration of what happens here will help us to make 
clear the processes involved in the case of urines with slight 
excess of sugar. With regard to this the following quota¬ 
tion from my paper may be of interest:— 

The chief reducing substances present in all normal urines are uric 
acid, carbohydrate material (of which the larger part seems to be 
dextrose), and kreatinin. Uric acid and sugnr, however, differ greatly 
from kreatinin in regard to the time required to cause reduction. 
Both substances, in the percentage in which they occur in normal 
urine, are capable of effecting reduction almost immediately on the 
boiling point being reached; in the process of reduction they undergo 
destruction. , , f . _ 

Kreatinin, on the other hand, reduces very slowly indeed. When a 
normal urine is boiled with Fehling'a solution, the uric acid and sugar 
present almost Immediately reduce their equivalent amounts of the 
solution; no effect is perceived owing to the fact that the reduced 
suboxide is held in solution by the kreatinin ; after boiling for a very 
short time t he full reducing effect of both uric acid and sugar is com¬ 
pleted. On continued boiling the kreatinin gradually causes further 
reduction, at the same time becoming grad uallv diminished in amount; 
part of it is probably converted into kreatin while part is destroyed. 

Ultimately a uoiiifc is reached, at which the suboxide reduced by the 
sugar and uric acid, added to that reduced by the kreatinin Itself, is no 
longer capable of being held in solution by the amount of kreatinin 
and its derivatives actually present in the'urine at that moment; at 
this point precipitation occurs. 

Thus it will be seen that the reaction obtained from a normal urine 
is very similar in character to that obtained from a urine containing 
more than the normal amount of sugar, the chief difference being that 
the more sugar present the quicker the reaction occurs. 

In the presence of great excess of sugar the effect of kreatinin is of 
course qu*to obscured and of no practical importance. It will be seen 
that the influence of kreatinin on Fehllng’s solution is very marked 
and important, though Bomewhat different from that Ascribed to it in 
the text-books where its action is generally considered in relation to 
its direct reducing power. This direct action occurs but slowly, and is 
therefore very insignificant w hen Fehling's test is used in the ordinary 
way; its direct inhibitory action, however, explains many points which 
are otherwise obscure, and for which no definite explanation has been 
forthcoming. 

Dr. Parry's Criticisms. 

In The Lancet of August 3rd, 1907, p. 290, Dr. Pavy 
in a paper advocating his own theory of the phenomenon 
takes exception to certain statements published by the 
writer in the Biochemical Journal for February, 1906, under 
the heading “ Observations on Fehling’s Test for Dextrose 
in Urine.” After satisfying myself as the result of prolonged 

a The Lxxcet, July 27th, 1907, p. 223. 



The Lancet,] DR. MACLEAN: ANOMALOUS REACTIONS OBTAINED IN TE8TING URINE, BTC. [Jan. 11,1908. 87 


experimental work that the quantity of ammonia evolved 
from the ordinary nitrogenous constituents—i.e., urea, nric 
acid, kreatinin, ice.—was quite incapable of giving rise to 
the reaction, I performed some experiments with a view to 
determine the possible effect of the ammonia always present 
in “loose” combination. By this, of course, was meant 
any ammonia that might be present in the form of salts as 
distinguished from ammonia generated from the nitrogenous 
constituents. All observers agree that a certain quantity of 
ammonia is always present in this form ; in order to get rid 
of this ammonia I boiled the urine for a short time with the 
alkaline part of Fehling's solution. It this way the action 
of any ammonia present in loose chemical combination was 
disposed of. With regard to this point the statement made 
in my paper was as follows : “Were the reaction due to 
ammonia present in loose combination boiling the urine with 
the alkaline part of Fehling's solution for a comparatively 
short time should be sufficient to remove it.” Dr. Pavy, 
however, seems to argue that my meaning was that the total 
ammonia of the urine—both the ammonia present as such and 
the ammonia generated from the nitrogenous constituents— 
would be evolved after boiling for a short time with the alkaline 
part of Fehling's solution. After quoting my statement as 
given above he proceeds as follows : “ Dr. Maclean surmises 
that boiling the urine with the alkaline part of Fehling’s 
solution for a comparatively short time should be sufficient 
to remove the ammonia. If he had ascertained by observa¬ 
tion the effect produced he could not have expressed himself 
as he has done. As a matter of fact it is difficult to get 
away from the evolution of ammonia,” &c. He then goes on 
to say that even if boiled to solidification ammonia is still 
freely evolved on the addition of water. That ammonia 
comes off after boiling urine and caustic alkali for a very 
long time I have often verified. This fact only adds further 
proof to the assertion that the amount given off in any given 
short period must be very small indeed. This ammonia, 
however, is generated from the nitrogenous constituents of 
the urine, and such ammonia could hardly by any play of 
imagination be referred to as ammonia in “ loose combina¬ 
tion." In quoting my statement (given above) Dr. Pavy 
italicises the words “should be sufficient”; if at the same 
time he had italicised the words “ loose combination ” all 
confusion would have been avoided. 

It is, of course, commonly known that sugar is easily 
destroyed by the action of boiling caustic alkali and this 
fact is often taken advantage of in physiological chemistry 
when we wish to destroy the sugar in any substance 
previous to certain processes—quantitative estimations, 
Jcc.—which would be interfered with by the presence 
of sugar. For instance, in Neumann's well-known 
method for estimating phosphorus, when the substance 
to be operated on contains sugar—eg., milk—it is 
first boiled with caustic alkali. This destructive action 
of caustic alkali towards sugar would, of course, destroy the 
sugar normally present in the urine when the latter is boiled 
with an alkali. Therefore after boiling urine with caustic 
alkali for some time in order to remove the loosely combined 
ammonia as described above it is necessary to add a little 
sugar to the boiled urine in order to test its inhibitory 
power when treated with Fehling’s solution, since the sugar 
normally present has been destroyed. When this was done 
it was found that the urine still possessed marked inhibitory 
power, proving, of course, that the loosely combined 
ammonia was not itself the cause of the inhibitory action. 
With regard to this point, my paper reads : “ Urines how¬ 
ever to which small amounts of dextrose have been added 
previously do not give any more indication of the presence 
of sugar after boiling than before.” “ Previously ” of course 
refers to the boiling of the urine with Fehling's solution. 
In other words, urines which have been boiled for some time 
with caustic alkali, and to which a small amount of sugar is 
added after the boiling is completed and previously to 
boiling with Fehling’s solution (to represent the sugar of 
normal urine destroyed by the boiling alkali) do not give any 
more indication of the presence of sugar than if they had not 
been boiled at all. It may be that the above sentence as 
given in the Biochemical Journal , is ambiguous as far 
as the mere wording is concerned, and that it is possible 
to assign to it the interprepation adopted by Dr. Pavy. 
With reference to this point, Dr. Pavy says that I seemed 
“to have overlooked the destructive action exerted by a 
fixed alkali on dextrose. Instead of their being more 
indication of the presence of sugar after boiling with 
the alkaline part of Fehling’s solution as is suggested should 
he the case through the expulsion of ammonia the actual 


effect that occurs is a disappearance of the sugar. It is easy 
for anyone to boil some dextrose-containing urine with the 
alkaline part of Fehling’s solution, then add the copper 
portion and see the effect produced. Even with as much as 
2 per cent, and over of dextrose present and boiling only for 
one minute sufficient destruction occurs to prevent any sign 
of reaction being obtainable, Ac.” It was, of course, to 
make up for the sugar destroyed that I added sugar to the 
boiled urine and while it is admitted that the sentence as it 
stands might possibly be interpreted as Dr. Pavy suggests 
such an interpretation would hardly have been expected from 
such an authority as Dr. Pavy. 

In the same journal (April, 1907) another article was 
published in which I incidentally emphasised the destructive 
action of caustic alkali on sugar not as something not well 
known already but in regard to the very rapid action of the 
boiling alkali on small amounts of sugar. In the course of 
my research work I happened to ascertain that in many cases 
this fact was not generally appreciated and so thought it 
worth while to draw attention to the point, stating at the 
same time that “while it is a well-known fact that boiling 
with hot alkali destroys sugar it would seem that the 
extreme facility with which this is accomplished is hardly 
appreciated.” With regard to the above Dr. Pavy sayB : 
“In this [article] Dr. Maclean shows that he has dis¬ 
covered the facility with which dextrose is destroyed by the 
agency of a fixed alkali and that he has learnt the caution 
that is required to be exercised in experimenting with sugar 
in the presence of an alkali to escape arriving at a fallacious 
conclusion.” It is obviouB from what has been said that the 
foregoing statement is inapplicable. 

Inhibitory Influence of Ammonia. 

In the same journal I gave the following table with 
regard to the inhibitory effect of ammonia on a weak 
dextrose solution :— 



£ 

<*-==: 



IS® 2 

- S 


— 

SiSa 

5 £ 

S =? £ bt 

Results. 


<, Ck 


- 



1 drop. 

15 

Immediate precipitate. 



2 drops. 

3-0 

„ 

1 cubic centi- 


4 

60 


metre of & 0 1 per 
cent, dextrose 


6 „ 

90 

Precipitate after a few seconds 

solution 




boiling. 

+ v 


8 „ 

120 


1 cubic centi - 


10 

150 

Precipitate after 6-10 seconds 

Fehling's solution 




boiling. 

boiled with— 


12 „ 

18-0 

Precipitate after 8-12 seconds 




boiling. 

i. 

16 ., 

240 

Precipitate after a little time. 


In these experiments the urine was boiled with the alkaline 
part of Fehling’s solution in a test-tube, just as ordinary 
urine is tested, in order to obtain a result as nearly as 
possible in harmony with the effects of the ammonia 
generated when urine is tested in the usual fashion. Dr. 
Pavy performed similar experiments but under materially 
modified conditions—the mixtuies being heated in a boiling 
salt solution and not boiled directly over the flame—and 
makes the statement that “viewed in this way the table 
given by Dr. MacLcan[does not supply a correct representation. 
It is not correct to represent no effect as being producible by 

one to four drops of dilute solution of ammonia. after 

four drops the interval amounted to seven seconds.after 

six drops of the ammonia solution the interval was observed 
to stand at 12 seconds ; after eight drops, 15 ; after 12 drops, 
20 : after 16 drops, 38,” &c. 

Now boiling the mixture rapidly over the flame is a very 
different matter from heating in a boiling salt solution and 
so no comparison can be drawn between the two sets of 
experiments, more especially since the intervals during which 
precipitation is prevented are, comparatively speaking, so 
insignificant when compared with the time taken for the pro¬ 
duction of a precipitate when normal urine is boiled with 
Fehling’s solution. Such a large amount of ammonia solu¬ 
tion as 16 drops is capable of preventing precipitation only 
for 38 seconds, and since urine (which would never contain 
this amount of ammonia per cubic centimetre) does not as a 
rule give a reaction until the boiling is continued for several 
minutes, I think that my table when viewed in comparison 







88 The Lancet,] DR. MACLEAN : ANOMALOUS REACTIONS OBTAINED IN TESTING URINE, BTC. [Jan. 11,1908. 


with what obtains in urine gives a fairly true idea of the 
relative action of ammonia as an inhibitor of precipitation. 
It is certainly not customary when testing urine for sugar in 
the ordinary way to apply heat by means of a boiling salt 
solution, and as my experiments were purposely so conducted 
as to coincide as nearly as possible with the methods adopted 
generally in urine testing it may fairly be claimed that these 
results are representative of the effects produced in urine. 
A urine which with Febling's solution would give a precipitate 
after, say, four minutes' vigorous boiling would require a 
longer period of heating before a similar precipitate would 
be given if the urine were immersed in a boiling salt 
solution; this can be very simply proved by simple com¬ 
parative experiments, using portions of the same sample. 

I think that the above explanations make it clear that 
in Dr. Pavy’s article in The Lancet of August 3rd my 
observations are unfortunately represented in a manner quite 
different from the true meaning assigned to them by me. 

Dr. Pavy refuses to accept the view that kreatinin is the 
chief substance in urine which gives rise to this inhibitory 
effect, and argues that the evolution of ammonia generated by 
the action of caustic alkali of Fehling’s solution on the 


Table III.— 15 Cubic Centimetre* of Urine B oiled _ with' ‘15 
Cubic Centimetrj* of Alkali for Five Minute*. 

No. 

Specific 

gravity. 

Total amount of 
ammonia evolved In 
milligrammes. 

Average amount per 
cubic centimetre iu 
milligrammes. 

1 

1015 

187 

124 

2 

1012 

21-2 

1*41 

3 

1022 

32-6 

2 17 

4 

1024 

22 1 

1 47 

5 

1018 

197 

1 31 

6 

1015 

205 

1-36 


Average of above experiments = 1'49 milligrammes NH 3 per cubic- 
een timet re in live minutes; ami the average of three sets of experiments 
from 18 different urines = 1'514 milligrammes NIL per cubic centi¬ 
metre evolved in tive minutes. 

The above specimens were obtained from different sources 
and give a fair representation of the amount of ammoDia 
evolved in a given time when urine is boiled with the alkaline 


nitrogenous constituents of the urine is sufficient to bold the 
reduced suboxide in solution when the latter is present in 
small amount. AVnile it is common knowledge that ammonia 
has the power of holding cuprous oxide in solution, my 
assertion was that ammonia “is ordinarily evolved in too 
small an amount to markedly interfere with the reaction ”— 
i.e., the precipitation of the cuprous oxide. In order to 
settle the point conclusively, however, I annex some experi¬ 
ments performed with ordinary urine in which a certain 
quantity of the urine was boiled with an equal volume of 
caustic alkali of the same strength as is present in ordinary 
Fehling's solution ; such a mixture, of course, contains the 
same percentage of alkali as urine when mixed with an 
equal volume of Fehling’s solution. The ammonia was 

N 

collected in the ordinary way by means of sulphuric acid, 

and the latter titrated against sodium hydrate solution. 

The total amount of ammonia given off from the urine could 
in this way be easily and accurately determined, and affords 
a direct and simple means of judging of the part played by 
ammonia as an inhibitor of precipitation of cuprous oxide. 
Different amounts of urine were used, and boiling continued 
for different periods, but the following tables deal with 
mixtures boiled for five minutes, as this space of time 
represents roughly the time required to produce a precipitate 
in many normal urines when boiled with Fehling’s solution. 

Table I .—25 Cubic Centimetres of l T rine Boiled with ~5 
Cubic CentimetreI of Caustic Alkali for Five Minutes. 


No. 

[ Specific 
gravity. 

Total amount of 
ammonia evolved in 
milligrammes. 

Average amount per 
cubic centimetre of urine 
in milligrammes. 

1 

1020 

265 

1-02 

2 

1026 

391 

1-56 

3 

1018 

24 6 

0-98 

4 

1025 

33-8 

1-35 

5 

1026 

40-1 

1-6 

6 

1018 

25-1 

1*004 


Tne average of the six experiments gives an ammonia evolution 
equivalent to 1 252 milligrammes .Nil, to each cubic centimetre of 
urine, this amount being evolved iu live minutes' boiling. 

Table II. — 10 Cubic Centimetres of Urine Boiled with 10 
Cubic Centimetres Caustic Alkali for Five Minutes. 


No. 

S peci fic 
gravity. 

Total amount of 
ammonia evolved in 
milligrammes. 

Average amount per 
cubic centimetre in 
milligrammes. 

1 

1020 

12*3 

1*23 

2 

1026 

168 

1*68 

3 

1015 

141 

1-41 

4 

1023 

201 

2 01 

5 

1020 

262 

2-62 

6 

1015 

18 5 

1 85 


centimetre evolved iu live minutes. 


part of Fehling's solution. Urines, therefore, may be con¬ 
sidered as capable of evolving from 1 • 5 to 2 milligrammes 
of ammonia per cnbic centimetre when boiled for five 
minutes with an equal volume of sodium hydrate containing 
the same percentage of caustic alkali as is commonly present 
in ordinary Fehling’s solution ; in other words, when urine 
is tested for sugar in the ordinary way with Fehling's solu¬ 
tion 2 cubic centimetres of the mixture if boiled for five 
minutes would generate from 15 to 2 milligrammes 
of ammonia in that time. Now since the ammonia 
formed in the boiling liquid must be quickly driven off the 
amount of this substance present in the mixture at any 
given moment must be exceedingly minute. If we assume 
that the ammonia is formed at an average fixed rate per 
second, then the average amouDt generated per second 
in the boiling liquid will be from 0 005 to O'007 
milligramme KH, per cubic centimetre of urine. Now Dr. 
Pavy Btates that with one cubic centimetre of urine mixed 
with one cubic centimetre of Febliog’s solution the addition 
of oue drop of pure (diluted 1 in 10) ammonia (O'880) 
solution just appreciably hinders precipitation ; observation 
proves that if there is any interval it is really exceedingly 
minute. If, therefore, such a comparatively large amount of 
ammonia as one drop which represents about 1'5 milli¬ 
grammes of ammonia has but the very slightest effect it is- 
obvious that the insignificant amount of ammonia evolved in 
urine testing with Fehling's solution has practically no effect 
in acting as an inhibitor of precipitation. 

Again, if for purposes of comparison we assume that all 
the urea present in one cubic centimetre of urine is changed 
into ammonia say in five minutes’ boiling, a simple calcula¬ 
tion gives the total amount of ammonia formed. Average 
urine contains about 22 milligrammes of urea per cubic 
centimetre. The total ammonia evolution of 22 milligrammes 
of urea is 12'4 milligrammes NH 3 . 

34 99 

CON.jHj = 2(NH,) = *- x ~ = 12'4 mgs. NH S . 

(mol. wt. fcO; (mol. wt. 34) cu A 

If we add another 2'6 milligrammes* for the ammonia 
generated from kreatinin and other nitrogenous bodies that 
may be acted upon, as well as for any ammonia present as- 
such in “loose” combination, the total ammonia evolution 
per cubic centimetre of urine would amount to 15'0 milli¬ 
grammes. Now the inhibitory effect of 16 milligrammes 
NH, is exceedingly small. This amount of ammonia corre¬ 
sponds to the amount present in ten drops of a 1 in 10 pure 
ammonium hydrate solution (0 1 880). 

According to Dr. Pavy’s results ten drops of ammonium 
hydrate of above strength added to a mixture consisting of 
one cubic centimetre of Fehling's solution and one cubic 
centimetre of a 0 1 per cent, solution of dextrose would 
prevent the ordinary reaction for about 17 seconds. 5 Since 
Dr. Pavy’s experiment was performed under conditions 
entirely different from those generally adopted in urine 
testing (heat being applied by means of a boiling salt 
solution) the above period of 17 seconds may be taken as 

* This ia of course ft very liberal allowance and does not represent 
the actual relationship between urea nitrogen and other nitrogen 
present; it is merely given for purposes of comparison. 

5 Ur. Favy's actual figures are : 8 drops = 15 seconds delay; 12 drops 
= 20 seconds delay. From this it is obvious that 10 drops would be 
equal to about 17 seconds. 




The Lancet,] DR. MACLEAN : ANOMALOUS REACTIONS OBTAINED IN TESTING URINF, ETC. [Jan 11,19C8. «9 


the maximum time. Here, then, according to Dr. Pavy, the 
total amount of nitrogen that can be evolved from one cubic 
centimetre of urine is capable of inhibiting the usual 
reaction when 0 1 1 per cent, of sugar is mixed with an equal 
volume of Fehling's solution only for about 17 or 18 seconds. 
Now as Dr. Pavy assumes that ordinary urine contains from 
0'3 to 0 • 5 par cent, sugar it is obvious that a reaction with 
urine would not be inhibited for so long a period as with a 
0'1 per cent, dextrose solution (seeing it contains more 
reducing substance). In fact, with a O’ 5 per cent, solution 
we might reasonably expect little or no inhibitory action. 
Experiment Bhows, however, that one cubic centimetre of 
ordinary urine may be boiled with an equal amount of 
Fehling's solution for anything from three to live minutes 
before a reaction is obtained. 

In the above experiments it is assumed for purposes of 
comparison that all the nitrogenous substances of the urine 
generate all their ammonia when boiled for five minutes 
with the caustic alkali. This, of course, is far from true, 
for it is proved by observation—as shown above—that but a 
comparatively small fraction of the total ammonia is evolved 
in this time. The following quotation from Dr. Pavy’s 
paper is of interest in this respect: “The boiling [of the 
mixture boiled with the alkaline part of Fehling's solution] 
may be carried on in any open capsule until solidification 
has begun to take place and then on adding water and trans¬ 
ferring to a test tube renewed boiling will be found to be 
attended with the free evolution of ammonia made manifest 
by moistened litmus paper introduced into the mouth of the 
tube.” Seeing, therefore, that but a portion of the total 
ammonia is generated after boiling for five minutes it follows 
that the total amount present in the urine at any given time 
must be exceedingly insignificant both in quantity and 
inhibitory effect; in fact, it is certain that the ammonia can 
count for little or nothing in preventing precipitation of 
cuprous oxide in urine. 

It might possibly be argued that the addition of ammonia 
as such to a mixture of sugar and Fehling's solution is not 
tantamount to the gradual production of ammonia in urine, 
and that after a few seconds’ heating the ammonia is driven 
off. This objection is not a valid one. for the usual tests dis¬ 
close the fact that ammonia when added to a solution of 
sugar boiled with Fehling's solution comes off in considerable 
abundance after the cuprous oxide has been precipitated ; in 
fact, it is obviously much more abundant after the addition 
of a drop or two of the above dilute solution, them it is in the 
case of urine where, though ammonia is continuously evolved 
during the process of boiling, the indications of its presence 
given by prepared test papers held over the boiling liquid 
suggest that it is present in comparatively small amount at 
any given time. Again, as above mentioned, an amount of 
ammonia amounting to about 1 • 5 milligrammes when added 
to one cubic centimetre of 0’1 per cent, dextrose with 
one cubio centimetre of Fehling’s solution and boiled, has 
but a very insignificant, if any, action as an inhibitor of pre¬ 
cipitation, and here the precipitate occurs before the 
ammonia could possibly be boiled off ; this is a case in 
which a fair amount of ammonia is present and yet there is 
little or no inhibitory action. 

Influence of Kreatinin in Association Kith Urea. 

Dr. Pavy again quotes from my paper the following 
observation:— 

Urea, in the percentage in whicti it occurs in urine, vioids much 
more ammonia than the kreatinin of an equal amount of urine, and vet 
it possesses no SDparent retarding effects: for s verv dilute solution of 
dextrose ideas than 001 per cent.l introduced into a 2'3 percent, urea 
solution and mixed with equal parts of Fehliug's solution gives quite a 
distinct reaction. 

He then proceeds to say that when kreatinin is associated 
with the ammonia-generatiDg product—urea—an effect is 
producible beyond that which is capable of being 
occasioned by kreatinin alone. Now, it is a fact beyond 
dispute that urea in the maximum percentage in which it 
ever occurs in urine produces no inhibitory reaction in a weak 
(say O'01 per cent.) solution of sugar when the test is 
performed in the usual way. Dr. Pavy, however, finds that 
one cubio centimetre of a 01 per cent, sugar solution 
containing/owv times the urea present in normal urine gives 
a precipitate slightly in arrear of a similar mixture without 
urea and so argues that urea has of itself an inhibiting effect. 
This statement conveys a wrong impression with regard to 
the real facts, for Dr. Pavy admits that urea in the percentage 
in which it occurs in urine, produces no inhibitory effect when 
boiled with sugar and Fehling’s solution, and it was urine— 


or mixtures equivalent in strength of urea to urine—that I 
had under consideration when I published the above. The 
statement that fonr times tbe amount of urea present in urine 
has a slight effect in inhibiting the reaction is practically 
irrelevant, seeing that urine never varies in its urea content 
to snch an extent as this. The urea of urine, therefore, 
though generating much more ammonia than kreatinin, hss 
no effect in preventing precipitation. 

Again, it is argued by Dr. Pavy that urea greatly enhances 
the inhibiting effect of kreatinin in virtue of the 
ammonia given off. Tbe statement is made that with 0 05 
milligramme of kreatinin 4- 1 cubic centimetre of Fehling’s 
solution +- 1 cubic centimetre of 01 per cent, sugar solution, 
the latter being mixed with two drops of 40 per cent, solution 
(i.e., twice the amount of urea for an equivalent amount of 
nrine), inhibition was delayed for 35 seconds. Now, if this 
inhibition was caused by ammonia it is obvious that a very 
small amount of ammonia must be capable of increasing tbe 
inhibitory effect of kreatinin. Shortly after the above, how¬ 
ever, Dr. Pavy makes the statement that with one or two 
drops of a 1 in 10 solution of strong ammonia there is no 
effect produced in inhibiting the reaction of the kreatinin 
when one cubic centimetre of a 0'1 per cent, solution of 
dextrose, one cubic centimetre of Fehling's solution, and one 
milligramme of kreatinin are heated. Now two drops of the 
above ammonia solution are equivalent to about three milli¬ 
grammes of ammonia, and since experiment proves that urea 
does not give up more than about one-fifth or one-sixth or so 
of its nitrogen when boiled for five minutes it is obvions that 
the amount of ammonia generated in 35 seconds must be 
very small ; the total possible evolution (assuming that all 
the N. of the urea is changed) is only 24 ’8 milligrammes 
of ammonia, and taking one-sixth of that amount we get 4 ’2 
milligrammes of ammonia for five minutes’ boiling. We are 
therefore justified in assuming that not more than three 
milligrammes of ammonia are generated in 35 seconds' boiling, 
and this amount of ammonia, according to Dr. Pavy’s second 
statement, produces no effect in augmenting the inhibitory 
power of kreatinin. Even the untenable assumption that ail 
the urea is changed in 35 seconds may be examined with 
profit; here 24 • 8 milligrammes of ammonia would be 
generated—an amount corresponding to about 16 drops of 
above ammonia solution, and we have it on Dr. Pavy's 
authority that 15 drops produce no effect. If, on the other 
hand, we assume that a good deal more than thiee 
milligrammes of ammonia is evolved, then, according 
to the same authority, this amount of ammonia should 
decrease instead of increase tbe inhibiting effect of 
kreatinin, for it is stated that over three milligrammes 
up to about 15 milligrammes of ammonia added (in solution of 
corresponding strength) to one cubic centimetre of a 0 • 1 per 
cent, sugar solution containing one milligramme kreatinin 
and heated with an equal amount of Fehling’s solution 
actually decreases the kreatinin inhibitory power. It is only 
after 15 milligrammes are added that an increased effect is 
noticed, and of course it is impossible to imagine that any¬ 
thing beyond 15 milligrammes NH 3 could be evolved from 
the urea in 35 seconds. 

Thus the statement by Dr. Pavy that urea increases the 
inhibitory effects of kreatinin in virtue of the ammonia 
generated is, according to his own observations, incapable 
of being accepted. Much more could be said with regard 
to the above, but it is the experience of the writer that urea 
in the percentage in which it occurs in urine neither 
inhibits the production of a precipitate in a weak sugar 
solution nor adds to any material extent to the inhibitory 
power of the kreatinin. Intervals of a few seconds are of 
no importance, and emphasising the importance of such 
short intervals tends only to produce an erroneous impression 
with regard to what actually happens in normal urine, where 
the time of boiling with Fehling’s solution necessary for the 
production of a precipitate usually extends to minutes 
instead of seconds. 

F.ffi ctiveness of Kreatinin. 

Dr. Pavy bases his objections to my statement that 
kreatinin is the substance responsible for the reaction on the 
argument that the amonnt of kreatinin present in urine is too 
small to be answerable to any material extent as an inhibitor 
of precipitation. Now, according to very exact determina¬ 
tions of the amount of kreatinin in urine made by Folin. 8 
it is estimated that the amount for average urin9 is from 


5 Zeltachrift fiir Physlologische Chemle, Band xli, S. 225. 




90 Thb Lancet,] DR. ARTHUR RANSOME: ON FERMENTS AND THEIR MODE OF ACTION. [Jan. 11, 1908. 


1'5 to 2 milligrammes per cubic centimetre. The following 
table taken from his paper is of interest:— 


Urines. 

Amount of 
kreatinin in 
milligrammes 
per 10 cubic 
centimetres 
of urine. 

Amount of 
kreatininin 
milligram met 
per cubic 
centimetre. 

Urines. 

Amount of 
kreatinin in 
milligrammes 
per 10 cubic 
centimetres 
of urine. 

Amount of 
kreatinin in 
milligrammes 

per cubic 
centimetre. 

1 

6-15 

0 -6). 

6 

17*4 

1-74 

2 

12-5 

1 25 

7 

21-3 

213 

3 I 

19-1 

1*91 

8 

16 6 

1-66 

4 i 

11*6 

1-16 

9 

131 

i 1-31 

5 

20-26 

2 025 

10 

1 19 8 

1-98 


Now one cubic centimetre of a 01 per cent, dextrose 
solution when mixed with one cubic centimetre of Fehling's 
solution is on boiling prevented from giving the usual 
precipitate of cuprous oxide for a considerable time by the 
addition of such a relatively small amount of kreatinin as 
one milligramme. Now, since normal urine generally con¬ 
tains, according to the above authority, from 15 to 2 
milligrammes of kreatinin per cubic centimetre, it is obvious 
that urine, if it contains about 0 • 1 per cent, dextrose, would 
be prevented from giving a reaction for a considerable 
time by the amount of kreatinin normally present. Now 
average urine may be said to contain generally about 0 • 1 per 
cent, sugar, or at any rate to have an average reducing 
action due to carbohydrates equivalent to that exerted by a 
0 • 1 per cent, solution of pure dextrose. This can be shown 
by various reagents which are not acted upon by the so-called 
“interfering” substances of urine. Such reagents are 
safranin and sodium-nitro-phenyl-propiolate. With safranin 
as an indicator the following examples of the results 
obtained by the writer may be cited :— 


Urine. 

Specific 1 
gravity. 

Percentage of 
sugar calcu¬ 
lated as 
dextrose. 

1 

Specific 

gravity. 

Percentage of 
sugar calcu¬ 
lated as 
dextrose. 

1 1 

1020 

Oil 

6 ! 

1025 

013 

2 I 

1014 

008 

7 1 

1023 

0X95 

3 

1023 

010 

8 1 

1024 

014 

4 

1021 

0-125 

9 

1016 

0-09 

5 

1022 

0-08 

10 | 

1026 

0-115 


Here, then, it is seen that the average amount of sugar cor¬ 
responds roughly to about O'09 to O'11 per cent. The 
examination of several hundred normal urines gave on an 
average a reducing power equivalent to 0 • 08 to 0 • 1 per cent, 
glucose—due to urinary carbohydrate. 

The statements made by some observers that average urine 
contains anything up 0 3 per cent, or bo of sugar are not 
borne out by observation, for if this were the case such 
an amount of sugar could be easily detected by Fischer's 
phenyl-hydrazin test. Normal urine does not, as a rule, give 
anything corresponding to a typical reaction with the test; 
this fact and various other tests show that sugar is seldom 
present in an average urine to this extent. That a urine 
may contain occasionally 0 • 2 or 0 ■ 3 per cent, of sugar and 
still be obtained from a healthy or “ normal ” subject is 
quite a different matter, but it is certain that average 
normal urine does not contain in general more than about 
0 • 1 per cent, of sugar. Thus it is seen that the amount of 
kreatinin present is quite sufficient to act in a very effective 
manner as a retarder of cuprous-oxide precipitation when 
minute amounts of sugar are in question. Dr. Pavy, how¬ 
ever, reasons as follows: “Kreatinin dealing with the 
quantity existing in healthy urine has but a limited power in 
delaying suboxide precipitation, and the power is only made 
manifest when the amount of suboxide being dealt with is 
exceedingly small. In the case of one cubic centimetre of a 
1 per 1000 solution of sugar, one cubic centimetre of 
adjusted Fehling’s solution, and one milligramme of 
kreatinin, compared with the counterpart without the 
kreatinin, marked delay is seen to occur. With a large 
quantity of suboxide, however, brought into the question, as, 
for instance, when a 5 per 1000 solution of sugar is used 
with the ordinary Fehling’s solution, it may be said that 
practically no material indication of delay is perceptible. 


In urines giving the anomalous reaction it may be considered 
that somewhere about 3, 4, or possibly 6 per 1000 of sugar 
may be reckoned to be present, from which it follows that 
the kreatinin constituent cannot be regarded as answerable 
to any material extent for the delaying effect that may be 
noticed to occur.” 

Now the admission that one milligramme of kreatinin per 
cubic centimetre causes considerable delay is tantamount to 
saying that this amount would cause considerable delay in 
urine. As above stated, the amount in urine is generally 
considerably above this (from 1-5 to 2 milligrammes per 
cubic centimetre), and since the sugar generally corresponds 
to about 0 ■ 1 per cent, it is obvious that the kreatinin present 
is answerable to a very material extent for the delaying 
effect that occurs. The statement that urines giving the 
“ anomalous reaction ” (if this really means, as judged from 
the context, delayed precipitation or, in other words, average 
normal urines) contain about 0 1 3, 0 4, or possibly 0'5 per 
cent, of sugar is. in the opinion of the writer, as the result 
of exhaustive experimental work, absolutely unfounded. It 
has been my constant experience that urines giving a sugar 
equivalent of such a comparatively small amount of sugar as 
about 0'25 per cent, (or even less) invariably gave the usual 
modified reaction with Fehling’s solution after boiling for a 
very short time, and never corresponded in their behaviour in 
this respect with average urine. Dr. Pavy then proceeds to 
argue that an increase in the alkali of Fehling's solution will 
prolong the interval prior to precipitation. With large 
amounts of alkali it is quite possible that some prolongation 
may be in evidence, but at most the difference does not 
amount to very much—at any rate, with moderate amounts 
of alkali—when considered in relation to the time taken by 
normal urine. Moreover, I have considered the reaction 
with ordinary Fehling’s solution in regard to which 
I have already shown that the action of the alkali 
on the urea, Ac., has little or no influence. Again, since 
Dr. Pavy admits that the amount of ammonia generated 
from kreatinin alone is not sufficient to inhibit the reaction 
it is obvious that, in solutions such as the above, in which 
there is no other product present to generate ammonia, the 
action must be brought about by some other means than by 
the evolution of ammonia. Therefore I think it is obvious 
that the above criticisms by Dr. Pavy can hardly be regarded 
as in any degree tending to invalidate my statement that 
“kreatinin is the substance in normal urine which most 
markedly interferes with Fehling’s reaction in the presence of 

small amounts of sugar.kreatinin directly inhibits the 

effect of small amounts of sugar when boiled with F'ehling’s 
solution by holding the reduced suboxide in solution and 
not indirectly by generating ammonia; the latter is not 
present in sufficient quantity to materially affect the re¬ 
action.” 

Xole. —For the full publications on the subject dealing with the 
points mentioned above see my paper in the Biochemical Journal for 
February, 1906, and April, 1907 ; also Dr. Favy's papers In Tar Lancet- 
of July 27th (p. 223) and August 3rd (p. 290) and 10th (p. 361), 1907. 


ON FERMENTS AND THEIR MODE OF 
ACTION . 1 

By ARTHUR RANSOME, M.D. Cantab., F.R.C.P. Lond., 
F.R.S., 

CONSULTING PHV8ICIAN TO TICK MANCHESTER HOSPITAL TOR 
CONSUMPTION ANP PISEA8HS OK THE CHEST. 


Th>: subject of F'erments has been chosen for our con¬ 
sideration this evening because I wish to point out the mode 
of action of organised and unorganised ferments and their 
relationship to one another. It is also not without its bearing 
upon some forms of disease. 

The analogy between fermentations of different kinds and 
the course of various eruptive fevers was indeed early 
recognjfejLby ancient medical writers. Thus Robert Boyle, 
England's grteflf philosopher, writing in the seventeenth 
century, says 3 : “liethat thoroughly understands the nature 
of ferments and fermentations shall probably be much better 
able than he that ignores them to give a fair account of 
several diseases (as well fevers as others) which will perhaps 
never be thoroughly understood, without an insight into the 


1 A paper rend before the Bournemouth Medical Society on Dec. 11th, 
3 Boyle'a Works, Edition 1744, vol. 1., p. 476. 


( 






Ths Lancet,] DR. ARTHUR KANSOME: ON FERMENTS AND THEIR MODE OF ACTION. [Jan. 11, 1908. 91 


doctrine of fermentation." He also realised that these fer¬ 
ments came from the outer air, for he says farther: “Those 
parts of the atmosphere which, in a stricter sense, may 
be called the air, are in some parts so intermixed with 
particles of different kinds, that among so great a number 
of various sorts of them, ’tie very likely there should 
be some kind of an uncommon or unobservable nature.” 
Again, a quaint writer, Mr. Place, speaking of the plague, 
sajs 3 : “ When we consider what avast deal of vapours a 
small thing sends ont, and what a large space of air it will 
fill with it, and diffuse itself through, we may conceive a 
city, thoroughly infected, to be as it were clouded in pesti¬ 
lential fumes, as it would be with smoak, if on fire ; and, if 
it come near such representation, ’tis vain to ask what way 
men, living amongst it, receive the infection ; whether they 
draw it in with the breath, or it gets into the stomach by the 
venom sticking to what they eat or drink, or directly climbs 
into the brain by the sensory of the nose, since it is much 
'tis all these ways.” 

In one of the early years of the registration of deaths the 
great master of statistics, Dr. William Karr, 1 crystallised all 
these imaginings into the one word “ zymotic ” as applied to 
various eruptive and other contagious complaints. As he 
said then: “The property of communicating their action, 
and affecting analogous transformations in other bodies, is 
as important, as it is characteristic of these diseases, which 
it is proposed therefore to call, in this sense, ‘ zymotic ’ (from 
(V/iiw: I ferment).” In another passage he says: 3 “The 
diseases of this nature are called Zymotic diseases; the 
peculiar processes, Zymoses: to distinguish them from 
fermentations, with which they have more points of contact 
than they have with combustion, or any common propagated 
chemical action.” 

It is scarcely necessary to point out how completely these 
anticipations of the old writers have been verified. A 
multitude of diseases have now been traced to the presence 
of micro-organisms similar in nature to the ferment of yeast 
and others to protozoa belonging to the animal kingdom. 
Toxins also and antitoxins of a specific character have been 
recognised, stored up, and used as prophylactics and 
vaccines. 

There is no need to go into further detail on the important 
facts thus far ascertained, but it may be interesting to 
discuss the nature of the fermentative actions concerned 
and to attempt to point out the several modes in which they 
bring about the physiological and pathological changes of 
which they are the causes. About the middle of the last 
century a fierce controversy raged as to the nature of fermen¬ 
tation. On the one hand, the late Baron Liebig, who may 
be regarded as the father of modern organic chemistry, 
defended a sort of physico-chemical theory which he derived 
from his observation of the unorganised ferments of bitter 
almonds and of mustard seed. On the other hand, Berzelius 
and Dumas regarded fermentative changes as due to the vital 
reactions of living micro-organisms similar to the then 
recently discovered “yeast plant.” Baron Liebig affirmed 
that fermentation was due to the communication of internal 
motion from the particles of a ferment to the particles of 
the fermenting substance, this movement causing an atomic 
change and consequent decomposition. The action was 
supposed to be usually started by oxygen and to be analogous 
to that of heat. 

More than 40 years ago I-ventured to point out that this 
theory is identical with that propounded by Sir Itaac 
Newton about 200 years before. With his marvellous in¬ 
tuition he thus Bpeaks of fermentation in his treatise on 
Upticks ” 11 “The air abounds with acid vapours (oxygen) 
fit to promote fermentation, as appears by the rusting of iron 
and copper in It, the kindling of fire by blowing, and the 
beating of the heart by means of respiration. Now, the 
above-mentioned motions are so great and violent as to show 
that in fermentations the particles of bodies, which almost 
rest, are put Into new motions by a very potent principle 
which acts upon them only when they approach one another, 
(onr molecular force), and causes them to meet and clash 
with great violence, and grow hot with the motion, and dash 
one another into pieces, and vanish into air and vapour and 
ilame.” Pat this into modern terminology and it exactly 
gives Liebig’s theory. Is it not a wonderful instance of 
philosophical insight ? A little later also, Mr. Place, whom 


3 Hypothetical Notion of the Plague, p. 12. 
* Vital Statistics, 1885, p. 246. 

3 P.327. 

• Second edition, 1715, vol. 11., p. 355. 


I have already qnoted, writing in 1721, says : “ Infection is 
a communication of motion by activity”; and again, “All 
contagions operation is of the same quality as that of fire 
and differs from it only in degree." 

As I have said, these views of Baron Liebig were not 
allowed to go unchallenged, and the controversy was not 
always carried on with appropriate scientific calmness. 
Hard things were said on both sides, and Liebig justly 
pointed out that Dumas and others, in invoking vital action, 
as an explanation of the phenomena of fermentation, were 
in no way doing anything to explain it, as they could not 
show how the micro-organisms acted. In an open letter to 
Dumas Liebig made fun of this view and gave a humorous 
account of a supposed experience of his own. He declared 
that as he was one day watching under the microscope the 
cells of the yeast plant he saw them suddenly take on an 
elongated appearance which presently caused them to assume 
the exact shape of miniature champagne bottles, at first 
well corked, but, by-and-by, the corks flew out and the 
stage was soon flooded with excellent sparkling wine. 

Liebig’s own theory was, however, open to several strong 
objections. 1. In the first place, oxygen is certainly not 
essential to the process. 2. The decomposition of the 
ferment does not necessarily take place, though there is 
probably some modification in its nature. 3. On the con¬ 
trary, the preserving power of the gastric juice and the fact 
that many fermentations will go on in the presence of 
powerful antiseptics would lead us to the conclusion that 
the decomposition of the ferment is certainly not essential. 
4. When ferments putrefy they lose their power. 5. The 
action of most ferments is specific ; each ferment will only 
act upon its appropriate material. 6. The result, in many 
cases, is not decomposition or lysis, but synthesis. 7. Lastly, 
in many instances the presence of living organisms is 
necessary to the action. 

Fermentations may, indeed, be grouped under two heads : 
first, those in which micro-organisms are always present ; and 
secondly, those in which the specific agent is unorganised. 
The Germans call them “formte” and “ungeformte 
Fermente,” respectively. In the first group are included : 
(I) all the organisms concerned in the production of 
fermented liquors ; (2) the micro-organisms producing 
various eruptive, contagious, and non-contagious diseases, 
such as scarlet fever, measles, and the like, whooping-cough, 
diphtheria, ague, sleeping sickness; and, lastly, the various 
epizootics. In the second group are : (1) all the physiological 
ferments ; (2) those bringing together the components of 
essential oils and of dyes ; (3) those which assist in the 
ripening of fruits; and (4) the unorganised derivatives of 
living ferments. At first sight these two groups of ferments 
would seem to be quite distinct not only in their form but 
also in their mode of action. Yet it may be that this is not 
the case. 

In truth, little is known as yet as to the exact nature of 
fermentative action. It is certainly not due simply to 
chemical affinity, though it affects the chemical affinities of 
other substances. A true ferment, such as diastase, will 
change successive portions of the substance, starch, upon 
which it has a specific action ; and its power is only slightly 
lessened after each fresh admixture. Moreover, it never 
enters into chemical combination with the object of its 
attacks. Its closest analogues are rather such inorganic 
bodies as spongy platinum and animal charcoal, which owe 
their power to surface condensation, and are hence called 
“catalytes" or “catalysts.” These bodies, by their very 
inability to enter into chemical combination, permit their 
surfaces when cleansed by heat, or in other ways, to come 
into such close contact with gases or liquids as to enable 
what are called molecular forces to come into play. 

It appears, then, that we have to attempt to explain 
fermentative action, of which we know little, by means of 
molecular force, of which we probably know less. It will be 
well, however, to recall what is known about it. We may 
with safety affirm the following propositions with regard to 
molecular influence : I. That molecular influence depends 
essentially upon the elementary molecular constitution of 
bodies. 2. That it acts without regard to mass. 3. That it 
increases inversely as the distance, at some enormous ratio, 
being excessively powerful within molecular distances, and 
utterly insensible beyond them. 4. That its action is in 
some way affected by calorific, electric, and probably by 
luminous vibrations and by chemical affinity. 5. That it 
does not seem to differ in kind from the attraction of cohesion, 
which binds together the molecules of tlje same substance 




92 The Lancet,] DR. ARTHUR RANSOME: ON FERMENTS AND THEIR MODE OF ACTION. [Jan. 11, 1908. 


6. That chemical affinity may be similar in kind, but that it 
differs from molecular attraction in the power of producing 
chemical combination of the molecules between which it acts. 

When molecular operations take place between the particles 
of bodies of dissimilar composition the following conditions 
are found to favour the production of molecular changes : 
1. That two or more of the substances submitted to molecular 
influences should have a more or less powerful attraction for 
one another. 2. That their physical condition be favourable 
to molecular action. 3. That the molecular agent or 
“ catalyte ” should have very low chemical affinities for the 
substances acted upon. 4. That the molecules of the 
catalyte be free—i.e., that their surfaces be clear of any 
contamination by other liquids or gases. 6. That the 
catalyte be freely permeable by other substances. All these 
conditions are fulfilled by typical catalytes such as “ platinum 
black and animal charcoal.” 

In his work on Electrons Sir Oliver Lodge 7 attempts to 
account for some of the phenomena of molecular action. 
Thus (p. 155) he says: “There is another kind of adhesion 
or cohesion of molecules, not chemical, but what is called 
molecular. This occurs between atoms not possessing ionic 
or extra charges, but each quite neutral, consisting of paired- 
off groups of electrons. At any moderate distance the force 
of attraction between paired electrons will be next to 
nothing, but at very minute distances it may be very great, 
ultimately becoming almost indistingnishable from chemical 
combination, except that the cling will be a weak cling at a 
multitude of points, instead of an intense cling at only one.” 
He gives diagrams illustrating his theory and then continues: 
“Molecular forces on this view are electrical, just us much 
electrical as are chemical forces; but they occur between 
chemically saturated molecules and are due to the interaction 
or distant influence of paired electrons on each other across 
molecular distances. It may be said to be a result of 
residual affinity.” 

There are probably other conditions governing the 
molecular action of “catalytes,” whether inorganic, organic, 
or organised, but on further examination they may perhaps 
suffice to show the intimate relationship that exists between 
all kinds of ferments. Let us take first the action of our 
Becond group, the “unformed” ferments, such as diastase, 
pepsin, trypsin, erythrozyme, synaptase, and the like; and the 
various products of organised forms, such as are secreted by 
yeast, and by divers other micro organisms. 1. These bodies 
all possess the characters which, as we have seen, belong to 
“catalytes.” They are all nitrogenous substances and thus 
contain one of the most chemically inert bodies in nature. 
These compounds are also among the most unstable bodies 
in nature—eg., nitroglycerine, kc. 2. They are all 
“colloidal” in structure and are thus themselves chemically 
inert. 3. Owing to this structure they are bodies in a state 
of continual molecular change, and their particles are 
constantly being presented to substances in their immediate 
neighbourhood in a fresh, clean, and nascent condition. 
They are thus able to exert to the uttermost any molecular 
power which they may possess. 4. They are all specific in 
their action ; in other words, they only affect substances 
with which they have special molecular affinities. 5. They 
readily permit the diffusion among their particles of other 
bodies, especially those of a crystalloidal character. 

Let us consider for a moment this physical power of 
colloids. Though chemically inert, in the ordinary sense, 
colloids possess a compensating activity of their own, arising 
out of their physical properties. Thus, notwithstanding 
their apparently feeble affinity for water, anhydrous colloids 
can decompose certain crystalloid hydratics, such as hydrated 
alcohol. Further instances of their physical power are to be 
seen in their adhesiveness and in the phenomena of cementa¬ 
tion. The adhesion of colloid to colloid appears to be more 
powerful than that of colloid to crystalloid ; thus, two pieces 
of plate glass left in contact will after a time adhere so 
closely that no division can be detected between them and 
they may be cut and ground without separating ; and, again, 
the intense symoresis of isinglass, dried in a glass vessel 
over sulphuric acid, in vacuo, enables the contracting gelatin 
to tear up the surface of the glass. Colloids also, like 
platinum black and animal charcoal, are extremely per¬ 
meable, and the diffusion of a crystalloid appears to take 
place through a firm jelly with little or no abatement of 
velocity. 

All ferments then are easily penetrated by the material 
upon which they act. Their molecules are loosely aggregated 


7 See Lodge in Nature, 1904, vol. lxx„ p. 176. 


together, thus presenting a large surface and a series of 
points of force from each of which any peculiar molecular 
influence (whatever it may be) can act without perturbation 
from other surrounding molecules. They are all, agaiD, like 
their inorganic congeners, chemically indifferent. This 
character, in fact, is essential to substances acting by 
contact. Although so little is known of molecular forces it 
is certain, as I have before said, that they require extreme 
approximation of the particles influencing each other and 
that their power increases, in some enormous ratio, inversely 
as the distance. It may easily be conceived, therefore, that 
this chemical indifference of ferments will enable their 
ultimate particles to come into close contact with other 
substances without uniting chemically with them and in 
consequence destroying the molecular power of the ferments. 
Chemical inertness is characteristic of the whole range of 
bodies exercising fermentative power. Furthermore, as 
platinum black and its congeners act with the greatest energy 
when their surfaces have been freed from all taint of vapour 
or impurity other than that upon which they are about to act, 
so organic ferments are most active when they are in a nascent 
condition, their particles freshly formed, or at least freshly 
arranged and free to attach themselves to the material 
which is appropriate to them. To come down to concrete 
examples, 1 venture to think, for instance, that the changes 
produced during digestion by the unorganised ferments are 
brought about chiefly by purely molecular influences 
analogous to the so-called catalyses wrought by many 
inorganic substances. On this hypothesis it is not difficult 
to understand why a very small proportion of a ferment 
suffices to act upon large masses of suitable material; for 
the molecular action once completed upon one part of the 
mass is not necessarily exhausted or neutralised thereby. If 
the substanoes formed by the action of the catalyte have less 
molecular affinity for it than the original material had they 
will at once be released ; the original energy of the ferment 
persisting, because the ferment experiences no transforming 
molecular reaction, it will attract fresh portions of the 
more appropriate material, and the action will go on almost 
indefinitely. 

It has been suggested by more than one observer that the 
action of a ferment is similar in kind to that of NO when it 
acts as a carrier of oxygen to S0 2 in the manufacture of 
sulphuric acid. Others again have in similar fashion 
pointed to the operation of molybdic acid in quickening the 
interaction between peroxide of hydrogen and hydriodic 
acid. In the latter case 13rode has shown that 1 gramme of 
molybdic acid in 31,000,000 litres of water exercises this 
power. This has been compared to the action of a ferment. 
The analogy is, however, not quite sound. Both these 
operations are distinctly chemical in their nature and are 
due to chemical affinities acting in accordance with definite 
atomic weights. Ferments, on the contrary, are chemically 
inert and owe their molecular power to this very fact. In 
other words, in the one case the intermediary effects the 
operation by chemical affinity alone, in the other the 
ferment acts by molecular influence. Notwithstanding this, 
however, it is highly probable that in fermentation there is 
some kind of temporary union between the ferment and the 
body it acts upon, the “substrate” as it is called; but, 
seeing that the ferment is a colloid and chemically inert, it 
is most likely that the nature of the temporary union is 
physical and not chemical. In this account of the process 
it will be evident also that there is no need for a 
chemical change in the product, for the change may be 
a physical one only. The effects wrought, for instance, 
by pepsin upon fibrin, albumin, and other proteins may be a 
molecular one and they are not. without a parallel in the 
history of other colloidal substances. Thus, certain gela¬ 
tinous colloids are liquefied, without chemical change, in 
short spaces of time by very minute quantities of reagents. 
Gelatinous silicic acid is liquefied by very small portions of 
caustic potash. One part of this agent in 10,000 of water 
dissolves 200 parts of silicic acid, estimated as dry, in 60 
minutes at 100° C. The alkali, too, after liquefying the 
colloid may be separated again from it by diffusion into 
water upon a dialyser. This solution, says Dr, Graham, 
who first pointed out the differences between colloids and 
crystalloids, “is analogous to the solution of insoluble 
organic colloids in animal digestion. Liquid silicic acid 
may be represented as the peptone of gelatinous silicic acid. 
Certain other colloids, such as the pure jellies of alumina, 
peroxide of iron, and titanic acid, are even more closely 
assimilated to albumin in this respect, since they are 
peptised by minute quintities of hydrochloric acid.” 





the lancet,] DR. ARTHUR RAN SOME: ON FERMENTS AND THEIR MODE OF ACTION. [Jan. 11, 1906. 93 


Again, the rapid absorption of albuminons fluids after 
digestion points to Borne change of molecular constitution 
effected by the catalytic action of the fermentB, making the 
peptones, if not crystalloid in their character, at any rate 
diffusive and able to traverse membranous septa. There 
would be nothing contrary to experience even in the first 
supposition. Dr. Graham has shown that colloids are 
capable of taking on the crystalloid form. Thus in the 
11 blood crystals of Funke ” a soft and gelatinous body is seen 
to assume the crystalloid form. The solid condition of water 
also, as in ice and snow, is both colloid and crystalloid ; and 
Quartz declares the same power to be possessed by silica.* 
But it is probable that a mere change of molecular constitu¬ 
tion short of crystallisation may confer the power of diffusion 
upon colloids, seeing that albuminose, produced by the action 
of pepsin on proteids, is endosmotic in character—that is, 
that the digested albumin is so far altered as to make it less 
adhesive to animal membranes and more easily miscible with 
blood and lymph than undigested albumin, and thus capable 
of osmosis. 

Turning now to the first group of ferments, those that are 
formed and living, it is quite possible that even in fermenta¬ 
tions brought about by these organisms the eminently 
catalytic powers of nascent nitrogenous colloids may come 
into play. In his early researches on these fermentations M. 
Pasteur himself concluded that the mycodermic plant which 
effects the change of alcohol into vinegar or into carbonic acid 
and water “does not act by means of some agent which it 
secretes and then leaves to work by itself, but," as he goes on 
to remark, “the chemical phenomena which accompany the 
life of the plant depend upon some peculiar physical condition 
analogous to platinum black." “ It is, however,” he says, 
“ essential to remark that this physical condition of the 
plant is in some way closely bound up with its life.” What¬ 
ever be the mode of their operation, it is certain that the 
organised ferments and probably most of the bacteria are 
able to produce what are called “enzymes,” amorphous 
colloidal substances, which have perfectly specific powers of 
attracting and changing the constitution of certain other 
bodies. Enzymes are, in fact, the organic, but merely 
molecular, catalytes met with in the living cell, and one of 
the earliest of these to be made known was “invertase,” 
extracted by Berthelot from yeast. The “ clastic ” power of 
all these enzymes, probably owing to their colloidal nature, 
is destroyed by temperatures of from 50° to 70° C. (which 
cause coagulation, or, at any rate, a disappearance of the 
interspaces between their molecules), but for the most part 
their activities are not prevented by the presence of anti¬ 
septics. Thus, salicylic acid and thymol in moderate 
quantities do not hinder peptic or tryptic digestions, 
although they prevent the putrefactive changes due to 
organised ferments. 

The enzymes produced by living organisms have been 
grouped under the following heads: (I) proteolytic; 
(2) diastatic; (3) inverting ; (4) coagulation ; and (5) sugar- 
splitting. Among the first group are some, allied to trypsin, 
which act only in alkaline fluids, and others, allied to pepsin, 
which are active under acid reactions. Many bacteria belong 
to the diastatic class and secrete starch-changing enzymes. 
A smaller number of them produce inverting enzymes, con¬ 
verting saccharose into dextrose, others coagulating enzymes. 
Group (5), the sugar-splitting ferments, are, however,"often 
secreted by bacteria and they all seem to be of a similar 
nature to the zymase of yeast cells. In addition to these 
comparatively innocent products bacteria give rise, as we 
well know, to numerous toxins, as well as to ptomaines. 
Many of the former bodies are probably fermentative in 
character, but the latter are crystallisable substances, 
analogous to vegetable alkaloids and compound ammonias. 
This will suffice for the first group. 

Returning now to the subject of ferments in general we 

“ In the last odition of his work on "Human Physiology " Professor 
Starling gives several instances of the crystallisation of proteins. Thus 
he says (p. 31): "It, has long been known that proteins occur in the 
crystalline form in the seeds of certain plants, as in berap-seeds, para- 
nut, and pumpkin, and castor-oil seeds. These crystals, which are 
known as aleuron grains, consist of proteins belonging to the class of 
globulins. By mechanical means they can be separated from the 
surrounding tissues, and after washing be dissolved in a solution of 
magnesia. It is also easy to crystallise egg-albumin and serum- 
albumin. white of egg is treated with an equal bulk of saturated 
solution of ammonium sulphate to precipitate the globulins and 
filtered. The filtrate is rendered slightly acid with dilute acetic acid 
which is added until a Blight precipitate Is formed. The mixture is 
put aside for 24 hours, at t lie end of which time the greater portion of 
the albumin has been precipitated as fine needle-shaped crystals. A 
similar method is used in the case of scrum albumin." 


remark that one of their most important attributes is their 
“specificity ” ; that is, their selection of the substances upon 
which they exert their molecular power ; that, however, this 
selection is not altogether exclusive may be seen from 
the following examples. Thus starch is transformed into 
dextrine and glucose by diastases, by ptyalin, and by many 
other animal substances, but not by pepsin, but the isomeric 
substance inulin is nnaltered by diastase. Cellulose, again, 
is fermented by a peculiar ferment which does not act upon 
starch. Gum and vegetable mncilage are Dot altered by 
saliva or by gastric juice, and assamar, the bitter substance 
formed by toasting bread, sugar, kc., is not fermentable 
at all. Cane sugar is not altered by diastase or by emnlsin, 
but the sugar cane contains a colloid body which converts 
sugar into a substance intermediate between starch and 
glutin. Sorbite, another form of sugar, secreted by the 
mountain ash, is not fermentable by yeast, but when 
left in contact with cheese and chalk it suffers decomposi¬ 
tion, giving rise to lactic acid, alcohol, and butyric 
acid, without previous formation of fermentable sugar. 
Mannite and dulcite are also not fermented by contact with 
yeast, but they are decomposed by lactous ferment 
in presence of chalk, with evolution of CO, and 11 3 0 
and formation of alcohol, lactic acid, and butyric acid. 
Black mustard flour or myronic acid produces the essential 
oil of mustard and glucose under the influence of myrosine, 
but it is unaffected by yeast. Amygdaline is changed by 
emnlsin obtained from a limited number of sources into 
bitter almond oil, prussic acid, and sugar ; but the albumins 
of other plants, rennet, pancreatic juice, and saliva produce 
in it no change. Tannic acid is converted by the pectase of 
gall-nuts or of turnips into gallic acid ; but emnlsin, yeast, 
vegetable or animal albumins and legumin retard rather than 
promote this fermentation. None of the ordinary ferments, 
with the exception of emnlsin, are capable of effecting the 
decomposition of rubian, in madder, but erythro/.yme pro¬ 
duces an effect altogether sui generis. 

The enzymes, derived from living organisms, such as blood 
corpuscles and bacteria, are equally aB specific as, if not 
more specific than, the foregoing ferments. Hsemolysins 
have been found so accurate in their selective power as to 
have been used for the detection of human or other blood¬ 
stains in medico-legal inquiries. Agglutinins and precipitins 
are now widely employed in the diagnosis of microbio 
diseases. Toxins show distinct specific molecular affinities 
for definite structures of the body, as in the case of tetanus 
toxins for the nervous system, and they are daily neutralised 
by appropriate antitoxins. 

From a medical point of view, the last-mentioned subject, 
namely, the action of antitoxins, is the most important of all, 
but it would need another paper in which to discuss it. I 
may say here, however, that I regard the neutralising action 
of an antitoxin upon a toxin as a particular instance of the 
action of a ferment upon its substrate, and I may quote here 
l)r. Abbott’s remark that “for all the foreign irritants from 
which animals have been immunised, be it alien blood, tissue 
cells, milk, or bacteria, there are, circulating normally in the 
blood, ‘complements’ specifically related to each irritant on 
the one hand and to its ' receptor' on the other.” 6 

It is true that Ehrlich believes that the saturation of toxin 
by antitoxin is accomplished by chemical union, but 
Starling 1,1 shows that the amounts of “ agglutinating serum " 
taken up by a suspension of bacilli is not a definite quantity 
but is determined by the concentration of the serum. 
He also points out (p. 38) that “even in a neutralised 
mixture, both free lysin and free antilysiu, or free toxin and 
free antitoxin are present, and it needs only the alteration of 
the physical conditions of the mixture in order to display 
the action of one or other of these bodies.” He asks, “How, 
then, are we to regard this combination of toxin with anti¬ 
toxin 1 ” and he decides that ‘ ‘ though it is impossible to give 
a decisive answer to this question at the present time it 
seems probable that the specific combination of ferments 
with definite substrates is in all respects analogous to the 
combination of toxin or lysin with their corresponding anti¬ 
body.” He further points out that “ the assumption of the 
colloidal condition—a condition in which there is an enormous 
exaggeration of surface—seems to be an important condition 
in deciding the catalytic effect o! any given substance.” He 
instances platinum and other metals in the condition of what 
are called “sols”—i.e., colloidal solution—and he concludes 
that “ in every case we must regard adsorption by a surface 

s Abbott, p. 608. 

10 Physiology of Digestion, p. 37. 



94 The Lancet,] DR. WARRINGTON AND MR. MONSARRAT: A CASE OF PARAPLEGIA, ETC. [Jax.11, 1908. 


as the essential factor,” though he admits that the exact 
adsorption 11 which takes place is evidently a function of the 
chemical configuration of the substance forming the surface.” 
He goes on : “ We cannot otherwise account for the specific 
interaction between toxins and antitoxins, or for the specific 
action of the different ferments on their various substrates. 
We have here, therefore, a special class of interactions, not 
entirely chemical and not entirely physical, but depending 
for their existence on a cooperation of both chemical and 
physical factors. To definitely assign ferment actions to 
this class would be premature. There is, indeed, evidence 
that ferments act on the substrate by forming intermediate 
combinations with it, but whether these compounds are to be 
regarded as chemical or adsorptive we have not yet sufficient 
evidence to determine. The facts that all the ferments 
belong to the class of imperfect colloids and that in many 
cases—e.g., proteolytic ferments and diastase—their action 
is on complete colloids, would certainly suggest that the 
combinations must be of the physical type.” You will 
observe that this is exactly my own argument and it is no 
small satisfaction to me to find that so eminent a physiologist 
has arrived independently at conclusions which I ventured to 
formulate and to publish more than 40 years ago in a paper 
on the Physiological Relations of Colloid Substances. 11 

Bournemouth. 


A CASK OF 

PARAPLEGIA DUE TO AN INTRA¬ 
MEDULLARY LESION AND TREATED 
WITH SOME SUCCESS BY THE 
REMOVAL OF A LOCAL 
ACCUMULATION OF 
FLUID. 

By W. B. WARRINGTON, M.D. Lond., F.R.C.P. Lond., 

PHYSICIAN TO THE DAVID LEWIS NORTHERN HOSPITAL, LIVERPOOL; 
LECTURER AND EXAMINER IN CLINICAL MEDICINE IN THE 
UNIVERSITY ; 

AND 

KEITH W. MONSARRAT, M.B.Edin., F.R.C.S. Edin., 

SURGEON TO THE DAVID LEWIS NORTHERN HOSPITAL, LIVERPOOL; 
LECTURER ON CLINICAL SURGERY IN THE UNIVERSITY. 


History of the patient's illness and. remarks thereon by Dr. 
Warrington. —In view of the safety with which the spinal 
cord can now be exposed, a correct diagnosis of the cause of 
paraplegia is of much importance to the patient, for though 
the number of cases in which surgery can intervene is small 
the results obtained when operation is justifiable are 
strikingly successful. The conditions causing a slowly increas¬ 
ing paialysis of the lower limbs are not numerous, and when 
the more common diseases such as disseminated sclerosis, 
amyotrophic lateral sclerosis, syringomyelia, and the results 
of tubercle and syphilis are excluded, and this should not be 
difficult, the diagnosis must be carefully considered, for the 
cause may be one of those conditions in which surgery 
alfords the best or only chance of remedy. Tumours of the 
meninges are naturally the cases in which the most brilliant 
results have been obtained. The essential symptom is the 
combination of pain limited to definite regions of root dis¬ 
tribution with paralysis indicating an advancing transverse 
lesion of the cord. Even should pain be absent, a progressive 
palsy indicating interference with conduction at some level of 
the cord should suggest the presence of a tumour-like growth. 
For in the first place there are a number of cases on record 
in which a tumour has been successfully diagnosed and in 
which pain was not a prominent symptom, and in the second 
place pathology teaches that a simple chronic transverse mye¬ 
litis is a lesion rarely found. Lesions and growths within the 
medulla spinalis itself are considered inoperable. This case 
is recorded as an instance in which a focal intra medullary 
lesion was diagnosed and found and in which the removal of 
about 2 cubic, centimetres of fluid was followed by great 
relative improvement in the patient's condition. The 
pathology of the case is not demonstrable, but the history 
and symptoms lead me to believe that the original lesion was a 
glioma of the cord and its etiology connected with an injury 
A man, aged 22 years, a patient of Dr. E. Cleaton Roberts, 
was first seen by me at the David Lewis Northern Hospital, 

11 Brit. Med. Jour., 1866. 


Liverpool, on Feb. 14tb, 1907. He was completely para¬ 
plegic and gave the following history. In January, 1903, 
when engaged in work in a coal-pit, he slipped on a plate 
at the crossing of truck lines and fell backwards on to one of 
the metals, falling on to the lower part of his spine. He was 
able to continue his work but stated that he at once ex¬ 
perienced pains about his legs. The pain persisted for three 
months, usually of an aching character, but sometimes shoot¬ 
ing down the legs and round the waist. For a short time after 
the accident he had a little difficulty in walking, though 
apparently this did not amount to more than a * ‘ stiffness about 
both hips.” At the end of three months the pains ceased, but 
came on occasionally for the next two years ; he does not 
appear to have suffered in any other way. Loss of power in 
the lower limbs was first noticed in February, 1905 ; it was 
not, however, very marked and under the advice of a dis¬ 
tinguished surgeon he remained completely in bed for three 
months. At the end of this time the patient thinks the 
weakness had increased ; he could, however, just walk about 
with the aid of a stick. Increase in power gradually followed 
and he was able to walk fairly well. At Easter, 1906, 
progress was interrupted by an attack of pneumonia, which 
ran a favourable course, but it is from the period of con¬ 
valescence after his illness that the patient dates the 
onset of his permanent palsy. He was. however, again able 
to walk about without assistance until three months ago 
when on waking in the morning he found that the right 
lower limb was completely powerless. Gradually the power 
of the left diminished and when first seen be was practically 
absolutely paraplegic. Lately the patient had noticed slight 
hesitancy in micturition. 

To summarise this history the salient features appear to 
be ; Injury to the lower part of the Bpine followed by pain in 
the lower limbs and trunk for two years ; a slow and slight 
weakness in the legs becoming worse after a period of rest in 
bed and, after an attack of pneumonia, a gradual recovery, 
then a sudden complete paralysis of the right leg and a 
gradual paralysis of the left, leading to complete paraplegia. 
Nothing of interest was elicited from the family or ante¬ 
cedent medical history. Syphilis could apparently be ex¬ 
cluded and there was no evidence of tuberculosis in any of 
the viscera. 

The condition on examination was as follows. The general 
health of the patient was excellent and no disease other than 
that of the nervous system was detected. The urine was 
normal. Both lower limbs were absolutely powerless with 
the exception of a very feeble flexion of the thighs. The 
limbs were flaccid ; the feet and legs were blue and cold. On 
the inner side of each great toe there was a small sore. The 
muscles were flabby and the right limb in comparison with 
its fellow was wasted. Electrical irritability was normal 
both to faradic and galvanic excitation, though somewhat 
diminished in the right side. Both knee-jerks were ex¬ 
tremely feeble, so that it was doubtful at times if the left 
could be obtained. The ankle-jerks were absent; the right 
plantar response was of a feeble extensor type, the left was not 
obtained. Occasionally involuntary spasmodic flexion move¬ 
ments of the legs and thighs occurred. Abdominal, epi¬ 
gastric, and cremasteric reflexes were not obtained. The 
diaphragm and intercostal muscles acted well. The cranial 
nerves and the upper limbs were normal. The spine was 
carefully examined without detecting any deformity, but 
pressure over the ninth to twelfth dorsal spines caused pain 
round the trnnk at the level of the last rib on both sides. 
Flexion of the spine also caused some pain about the mid 
and lower dorsal region. Retention of urine was present on 
two occasions, once persisting for 86 hours. 

With regard to sensation, a fairly horizontal line starting 
posteriorly from the ninth dorsal spine or passing anteriorly 
through the lowest part of the ensiform cartilage and thus 
corresponding to the seventh dorsal spinal segment formed 
the upper limit of a fairly well-defined loss of sensibility. 
Below this, pain from a pin prick and the recognition of heat 
or cold were absent, but on the right side over the leg and 
thigh a touch by cotton wool was felt as well as the pressure 
produced by the head of a pin. On the left side both these 
forms of sensation also were absent. The patient therefore 
presented the signs of a transverse lesion of the cord at 
about the mid dorsal region, the absolute loss of power, 
great loss of sensation, and the feebleness of the reflexes 
showed that conduction was greatly interfered with, and if 
the disease progressed a complete severance of the brain from 
the lower part of the cord was to be expected. 

In diagnosis, system disease, disseminated sclerosis, and the 



The Lancet,] DR. WARRINGTON AND MR. MONSARRAT: A CASE OF PARAPLEGIA, ETC.' [Jan. 11. 19(8. 95 


results of acute myelitis or myelomalacia could be excluded. 
There remained to be considered some form of pressure 
paraplegia, syringomyelia, and late effects of trauma. It 
was felt that a study of the history could alone give any 
indication as to the nature of the lesion and it will be 
remembered that sudden paralysis of one limb (the right) 
was a striking feature. Though a sudden paraplegia not 
infrequently occurs in the course of tuberculosis of the 
spine its cause is either an increase in the pressure or a 
softening of the cord itself ; it appeared unlikely that either 
of these conditions would account for a sudden berni- 
paraplegia. On this account, together with the absence of 
local signs in the bones or of constitutional symptoms, caries 
was excluded. New growths and other forms of pressure 
had therefore to be considered. The absence of pain was 
against the diagnosis of extramedullary lesion, though, as 
already mentioned, not conclusively so. The sudden right 
hemiparaplegia indicated a vascular origin as its cause, 
and together with the subsequent slow paralysis of the 
left limb suggested an intramedullary growth and this 
was thought to be a glioma. Gliomatous formations are 
met with in two conditions in the spinal cord—viz., 
(1) the central primary glioma probably a congenital 
lesion and which may remain clinically latent or reacting 
to various conditions, notably traumatism, may evolve and 
produce the characteristic progrestire features of syringo¬ 
myelia ; sind (2) the glioma of the spinal cord, according to 
Schlesinger, the commonest intramedullary tumour. It 
varies greatly in size, it may be small or occupy the 
greater part of the transverse section of the cord. Its 
vertical extent also varies considerably. It is often 
unilateral in position so that the cord looks as if it were the 
site of an extramedullary tumour. The growth may com¬ 
pletely replace the structure of the cord. It is rarely sharply 
defined, is grey-red or grey-brown in colour, and often shows 
cavity formation, thus presenting the greatest resemblance 
to syringomyelia. The vessels of the glioma often degenerate 
and give rise to haemorrhage. 

The hypothesis of haemorrhage into a gliomatous tumour or 
into a cavity in the cord seemed the best explanation of the 
facts of the case and the findings at the operation are con¬ 
sistent with this view. The possibility of haemorrhage into 
a syringeal cavity has been urged by Sir William Gowers on 
clinical evidence. Although the relationship between glioma 
formation and syringomyelia is a very definite one I consider 
this name must be reserved for the special and well-defined 
clinical picture of a progressive disease. So also cavities in 
the cord may arise as the result of several conditions other 
than syringomyelia. 

What was the connexion, if any, between the injury and 
the patient’s illness ! Cavity formation and haemorrhage as 
the results of trauma are well known, hut such lesions as 
the primary effect are not consistent with the long period of 
freedom from palsy and its sodden accentuation nearly four 
years after the injury. On the other hand, that injury may 
be the factor which determines the growth of a glioma in 
the brain is admitted and is probably equally true in the 
case of spinal glioma. It is often maintained that injury is 
only a potent factor if there is a pre-existing excess of glia) 
tissue. This may be, but the importance of the part played 
by injury is not diminished. At the operation a tough 
pellicle was found outside the dura mater evidently of 
inflammatory origin; hence the conclusion is reached that 
the injury was the cause of the patient's symptoms, that the 
pains wore due to bruising of the meninges, and that at the 
same time a gliomatous formation started in the cord ami 
that the growth gave rise to few symptoms until a haemor¬ 
rhage occurred into its substance. 

’The iurgical treatment and findingi at the time of 
operation on May 15th, hy Mr. Monsarrat. —An incision 
was made from the fifth to the tenth dorsal spines. The 
laminte of the sixth to the ninth vertebrae were displayed 
and the four spines clipped through at their bases Bnd 
mobilised. The laminae of the seventh vertebra was sawn 
through, the separation being completed with forceps and 
subsequently the laminae of the sixth, eighth, and ninth 
vertebrae were clipped through with bone scissors. No 
abnormality of the vertebra: was discovered surd no trace of 
previous injury to the bones or to their posterior ligaments. 
The dura mater being exposed, it was seen to be overlaid 
by a tough film of reddish membrane under which a director 
could be inserted. It was raised longitudinally and stripped 
on either side from the underlying dura mater. The dura 
mater was then seen to be abnormally vascular; the 


spinal cord within stowed dark brown in colour.) The 
dura mater was opened but was intimately adherent to 
tho cord and the adhesions bad to be separated by blunt 
dissection. The dura mater was particularly adherent at 
the level of the seventh dorsal vertebra where it was 
markedly thickened by a tough yellow-white fibrous band 
running circularly. There was no escape of cerebro-spinal 
fluid ; the cord bulged through the opened dura mater. On 
inspection the posterior columns appeared transformed into 
a jelly-like substance of a greyish-black colour which pro¬ 
truded more on the right of the middle line. The abnormal 
appearance extended above to the level of the laruma of the 
sixth vertebra and below to within a few lines of the lower 
border of the ninth lamina. A fine knife was inserted in the 
middle line at its lower limit and about two cubic centi¬ 
metres of clear yellow fluid escaped and the protrusion 
collapsed. The knife was again inserted an inch higher 
but only a few drops of blood escaped. No further incisions 
weremade. The dura mater was not sutured. Haemorrhage was 
controlled throughout by pressure and the wound frequently 
irrigated by Bterile saline solution. Four catgut sutures were 
inserted through the spinal muscles on each side and the row 
of spines with their attached ligaments in the middle line. 
A small drain was inserted into the lower part of the wound. 
Throughout the operation, which lasted one and a quarter 
hours, the patient was on his face with the head low. There 
was little shock. 



Reproduction of photograph taken in October, 1907, showing 
the site of 'be scar and the ability of the patient to 
stand with slight support. 

The following abbreviated notes of tie progress of the case 
may be given :— 

May 15th: Comfortable Ihis evening: no pain in back, vomited 
several times, and passed urine involuntarilv. Cathe'cr passed at 
midnight. Patient kept In prone position. Nay i6th : A good deal of 
oozing and discharge of pale-yellow fluid. Catheter used. Patient 
B 3 










96 The Lancet,] DR. J. B. NIAS : OBSERVATIONS ON SALTS OF THE ALKALINE EARTHS, ETC. [Jan. 11, 1908. 


turned on to his back. May 17th : Urine passed voluntarily. Blisters 
on inner side of first metatarsophalangeal joint on both feet; these 
were cut and dressed with picric acid. Marked spasmodic jerkiogs of 
flexion of thighs. These are more frequent than before operation. 
May 24th : Wound quite healed. A quantity of serum came away 
from the lower end of incision and firm pads were placed along whole 
length of wound. May 26th: Some movement of toes of right foot 
noticed and can voluntarily invert foot. No movement of left limb. 
The spasmodic jerkings are less than formerly. Sensation roughly 
tested and agrees fairly well with the condition prior to operation but 
pin prick now recognised as such on the right limb. Knee-jerks 
present both sides, right and left. May 28th: Voluntary flexion of 
right thigh. Power in toes greater. Bowels acted naturally for the 
first time. June 1st: Still some collection of serum under the wound, 
horse-hair drain inserted. More power in right limb, and left thigh 
can occasionally be moved. June 6th: Power in both limbs slightly 
greater, the knee- jerks are brisker and an extensor toe response can be 
obtained on both sides. Sores on the toes healing. June 13th : Power 
still improving, spasmodic contraction of muscles marked, especially of 
peroneal muscles. Action of bowel and bladder occasionally involun¬ 
tary. June 15th: Plaster jacket applied from iliac crests to axilla:. 
June 26th : Can stand when supported; walked a few steps with help. 
July 1st: Patient went home. 

Remit of examination on Sept. 26th.— The patient 
has continually improved; he can now, with the help 
of crutches, walk 40 yards without a rest, the limbs being 
slowly advanced, and he states that improvement still 
continues. The right limb is much stronger than the left, 
the leg muscles, quadriceps, and psoas groups acting with 
fair strength. The same muscles act on the left side but 
slightly. He is able to rise from the sitting to the erect 
position. The nutrition of the muscles is good but the feet 
are still blue and cold, there are no sores, and the wound has 
perfectly healed and left a healthy scar. With regard to the 
reflexes both knee-jerks are exaggerated; there is ankle 
clonus on the right side and the ankle-jerk is brisk 
on the left. There is plantar extensor response on 
both Bides. The abdominal, epigastric, and cremasteric re¬ 
sponses are absent. There is no bladder trouble. Aperients 
are required for the bowels and spasmodic movements 
of the limbs readily occur on peripheral stimulation. 
As to sensation, this has altered to this extent, that on the 
right side over the leg and thigh there is but little deficiency. 
A light touch by cotton-wool, a pin prick as sharp, a pin 
head, hot and cold water tubes, and passive movements of 
the joints are fairly well recognised. The localisation of 
touch, “ spot naming,” is inaccurate. On the left side these 
forms of sensibility are very deficient but there is still some 
power of appreciating pressure by the head of a pin from 
that of the point but no pain arises. The upper limit of loss 
of sensation is at the original level and there is now a zone 
on the trunk and outer sides of right thigh corresponding to 
representation of the seventh dorsal to second lumbar 
segment, on which light touch is not recognised nor a prick 
appreciated as such. Thus sensation has greatly improved 
in the right leg and thigh but has diminished in degree over 
an area which corresponds to the extent of the surgical 
procedure. 

Liverpool. _ 


FURTHER OBSERVATIONS ON SALTS OF 
THE ALKALINE EARTHS WHICH 
AFFECT THE COAGULABILITY 
OF THE BLOOD. 

By J. B. NIAS, M.D. Oxon., M.R.C.P. Lond. 

(From the Laboratory of the Inoculation Department , 
St. Mary's Hospital, London.') 


In previous papers which have appeared in The Lancet 1 
it has been shown by Sir Almroth Wright and Dr. W. E. 
Paramore, Dr. G. W. Ross and myself that the carbonates 
and lactates of calcium, magnesium, and strontium are potent 
agents for increasing the coagulability of the blood when 
administered by the mouth to the human subject in doses 
ranging from 30 to 60 grains. It seemed desirable to extend 
this investigation by ascertaining to what extent the same 
property is possessed by the other salts of the alkaline earths 
which are available for pharmaceutical purposes and the 
present paper presents a further instalment of observations 
directed to this end. For liberty to continue this research in 
his laboratory my best thanks are due to Sir Almroth 
Wright. 

The method uniformly followed in this investigation has 


The Lancet, Oct. 14th (p. 1098) and 21st (p. 1164), 1905, and 
August 18th (p. 436), 1906. 


been to administer at a fixed period of the day either to 
myself or others, usually patients suffering from urticaria or 
hemophilia, a definite dose of the drug under trial, and then 
to test the resulting variation in the coagulability of the blood 
during a period of two or more hours. The apparatus used 
consisted of Sir Almroth Wright’s well-known calibrated 
capillary tubes, into which a definite quantity (6 cubic milli¬ 
metres) of blood is sucked, the tube being then immersed in 
water at blood heat, and the contents expelled after a 
measured interval of time on to blotting paper to see if 
coagulation has taken place. In spite of criticisms which 
have appeared as to the sufficiency of this method it has 
proved itself amply adequate for the purpose in hand, very 
consistent results having been obtained. In a paper on the 
subject In the Bioohemioal Journal, vol. 11., part 4, p. 184, 
C. J. Coleman rightly points out that there is a diurnal 
fluctuation in the coagulability of the blood of which note 
must be taken, and that it is particularly affected by the 
taking of food and drink. I have been careful from the 
outset to avoid this source of fallacy by limiting the period 
of observation to the hours from 3 to 7 p.m., the intervening 
time being employed in quiet sedentary work, the same rule 
being observed in the case of patients. The results obtained 
with the different salts available are given below seriatim. 

Magnesium lactate. —This salt is only mentioned to say 
that further experience with it convinces me that it is a 
valuable drug for combating the accidents of bmmophilia 
in cases when as sometimes happens the calcium salts do not 
seem to act. I detailed in a former paper the case of a 
patient of Sir Almroth Wright who being a sufferer from 
haemophilia is liable to periodical oc/.ing of blood from his 
gums. This symptom has been very effectively treated during 
the last 12 months by doses of from 40 to 60 grains once or 
twice repeated either of this lactate or that of strontium. 
The magnesium salt has the advantage for cases of this kind 
in that it can easily be prepared extemporaneously by the 
dispenser by saturating lactio acid with magnesia, which is 
always available. The large dose unfits the compound for 
delivery in a mixture; it should be dissolved in hot water 
by the patient himself. The lactate is a good standard for 
judging other Balts by, a dose of 30 grains generally pro¬ 
ducing a reduction of 30 per cent, in the time of coagulation 
either from 3 minutes to 2, or Irom 2 to 14. 

Boro-oitratc of magnesium. —This is a soluble salt said by 
Martindale and Westcott to have been introduced for the 
purpose of conveying boric acid into the bladder in cases of 
cystitis. Its efficiency in this respect I am unable to state, 
but the drug undoubtedly undergoes some dissociation in the 
body. It is not without effect as a haemostatic, but I should 
class it as inferior to the lactate for this purpose. The 
following are particulars of some trials with this drug, which 
were repeated more than once with similar results. On one 
occasion 30 grains given to the patient before mentioned 
redneed the coagulation time of the blood from 21 minutes 
to 2 minutes and 20 seconds in the course of 2 hours, a 
relatively poor result. On another occasion the same dose 
procured a reduction in the course of 1 hour from 2 1 to 
11 minutes, at which figure the time remained until the con¬ 
clusion of the experiment 1 hour later. Simultaneously the 
same dose was taken by myself after the coagulability of my 
blood had been purposely lowered by the free consumption 
of fruit; a reduction was obtained from Zi minutes to 
2 minutes and 10 seconds in the course of 60 minutes and to 
11 minutes at the end of 20 minutes more, no further reduc¬ 
tion taking place. The boro-citrate of magnesium is, there¬ 
fore, not altogether inefficacious in affecting the blood but 
seems to present no obvious advantage; in this case, also, 
the bulk of the dose requires dispensing in powder form. 

Magnesium carbonate. —Although the doses given by Sir 
Almroth Wright and Dr. Paramore amounted to 60 grains of 
the carbonate the usual medicinal dose of 10 grains contains 
magnesinm equal to 23 grains of the lactate, so that the 
latter quantity, if suitably dissolved in the acids of the ali¬ 
mentary canal, is sufficient to produce a characteristic effect 
upon the blood. Now it is interesting to note that for a long 
time past it has been the custom in the treatment of urticaria 
and other allied affections to associate the carbonate of mag¬ 
nesium with the bicarbonate of sodium and potassium together 
with bitter infusions, remedies which undoubtedly stimulate 
the secretion of gastric juice. The supposition that magnesia 
is beneficial by saturating acids suggested to be in excess in 
the alimentary canal seems untenable in view of our present 
knowledge as to the action of these associated remedies. 
There can be little doubt that urticaria, for example, depends 





The Lancet, 


DR. ALICE M SORABJI: A CASE OF EOHINOCOOCU3 DISEASE. [Jan. 11, 1908. 97 


upon an effusion of serum into the tissues connected with a 
deficient coagulating power In the blood, though why in this 
instance the effusion is determined to the skin is unexplained, 
and that successful treatment involves an increase in this 
coagulating power seems well established. Therefore in this 
Instanoe old empirical practice finds a justification in modern 
research. Though not prompt enough for treating the emer¬ 
gencies of haemophilia, the continued use of the carbonates of 
magnesium and lime when properly associated with other 
drugs which procure their solution in the alimentary canal, 
seems quite sufficient for the treatment of other disorders 
of the kind indicated. 

Magnesium sulphate, in strong contrast to other salts tried, 
seems to be quite without effect in increasing the coagula¬ 
bility of blood, even in non-purgative doses. This has been 
previously ascertained, I believe, by Dr. Paramore. 

Bromide of strontium is not a convenient drug to experi¬ 
ment with on account of its soporific effect but seems to 
share with the lactate the property of increasing coagula¬ 
bility. Two examples will suffice. A dose of 15 grains in 
my own person produced a reduction from 1 j to lj minutes 
in the course of 1£ hours, and again on another occasion the 
same dose proonred a reduction from 1| to 1{- minutes in 
the course of one hour, a trifling effect but corresponding to 
an equivalent dose of lactate. 

Laetophosphate and glycerophosphate of lime are two 
soluble modifications of the phosphate of calcium which 
have been proposed for use in medicine with a view of more 
effectually introducing this substance into the economy. 
My experience with these two drugs may therefore be read 
with interest. One would have thought that as the lime in 
milk is principally present as phosphate and is a most 
important factor in the phenomenon of coagulation by 
rennet the same substance would play an important part in 
the coagulation of blood; and again, that if introduced in 
an extra quantity into tbe blood some manifest effect of 
its presence would have been produced. I find, however, 
that the laetophosphate and tbe glycerophosphate appear 
most inert bodies. I have administered them both to myself 
and to patients in doses far exceeding those employed medi¬ 
cinally with little or no effect. Experiments with tbe 
laetophosphate were somewhat cursory as the salt is cot 
very soluble, 10 grains requiring 2 to 3 ounces of hot water 
for solution ; doses taken in the solid form, however, of 
15 to 30 grains produced no perceptible result. With the 
glycerophosphate more extensive trials were made ; as an 
example of which I may record the following exhaustive 
test. On a certain day of the present year I took 30 grains 
of the glycerophosphate of lime dissolved in water at 
4.40 P.M , my coagulation time being then 2 minutes exactly, 
and at 5.40 p.m. tbe time was unaltered. On tbe next 
day at 5 30 p.m. the time was If minutes, showing perhaps 
a trifling result from the previous day ; another 30 grains 
were then taken, and at 6.15 the time was 1 minute 
50 seconds. On the third day a third dose of 30 grains was 
taken at 5 p.m., the coagulation time being again 1 minute 
and 50 seconds, and at 7 P.M. the time was exactly the same. 
The figures here shown exhibit the uniformity in the rate of 
coagulation maintained in the blood of a healthy man, and 
also the great exactitude obtained with practice with 
Wright's capillary tubes in testing this phenomenon. A 
clear day was then allowed to elapse and on the fifth day 
of the experiment the blood was again examined, and the time 
found to bs slightly over 2 minutes. The large quantity 
of 90 grains of a reputedly aotive salt had therefore been 
taken without any manifestation of what one would expect 
to be its principal effect. An equivalent quantity of the 
lactate would, as I know by personal experience, have given 
a very different result. Four whole days were then allowed 
to elapse, during which the coagulability of the blood was 
intentionally lowered by the free consumption of oranges, 
and the test was then resumed. The day after this interval 
tbe coagulation time was taken and found to be 2 minutes 
and 40 seconds, a condition similar to what is found in 
nrticaria; 45 grains of the glycerophosphate were then taken 
at the hour of 6 p.m. and by 7.30 the time had become 
reduced to 2 minutes. On the next day at the same hour the 
remarkably short period of 1^ minutes was recorded without 
any more of the salt having been taken, but on the succeed¬ 
ing and final day of the experiment the blood had returned 
to the old figure of 2 minutes. The second trial, therefore, 
seemed to have produced an effect, though of a moderate 
amount compared to the dose taken. 

Tbe conclusions arrived at with regard to the drugs men¬ 
tioned in this paper being based on experiments carried 


out with similar thoroughness to this one, though they are 
not all here recorded for want of space, I feel entitled 
to express the opinion that these two drugs, the glycero¬ 
phosphate and laetophosphate of lime, though so much 
vaunted pharmaceutically, are drugs which in the doses in 
which they are usually prescribed can have little effect if 
they are assimilated at all. I may add that the assumption 
of this large quantity of glycerophosphate, amounting to 
135 grains in a few days, produced no sensible effect whatever 
on my internal economy, neither disturbance of digestion nor 
of any other function resulting. At the same time I have 
evidence which is not yet complete that phosphoric acid and 
some of the soluble phosphates have an influence on the 
coagulating power of the blood, at any rate in bringing it up 
to normal, which goes to show that if these phosphates of 
calcium were absorbed they would be active also in the same 
direction. In the course of the routine testings of the 
haemophilia patient so ofteD mentioned it was found that 
upon half-drachm doses of Easton's syrup which had been 
prescribed by Sir Almroth Wright as a tonic, the coagulation 
time, which was generally in the neighbourhood of three 
minutes, came up to normal and there remained for some 
weeks with prevention of the usual hsemorrbages until the 
effect wore off, when recourse had to be had to magnesia 
or some other remedy. All the samples of Easton’s syrup 
which I have been able to analyse have contained 
the large quantity of the equivalent of 18 minims of 
the dilute phosphoric acid of the Pharmacopoeia in 
each fluid drachm which is apparently necessary to keep 
the other ingredients in solution—a fact perhaps not 
known to those who are fond of prescribing this unpalatable 
preparation and which makes it decidedly injurious to the 
teeth. Discriminating tests showed that it is the phosphoric 
acid which has the effect of improving the coagulability of 
blood, though bow it acts I am not prepared to say. Certain 
phosphates have the same effect, but as my observations in 
this respect are not complete I need refer to them no further 
than to say that they lead me to the conclusion that the 
laetophosphate and glycerophosphate of lime are so com¬ 
paratively inert because they are not absorbed as a matter of 
fact, though soluble in a test-tube. In this respect the 
alimentary canal would seem to be decidedly selective, as 
witness the case of the sulphate of magnesium. 

Of the salts of the alkaline earths my conclusion is that 
none come up to the lactates and chlorides and carbonates 
if duly assimilated, and that we should rely on there for the 
treatment of hemophilia. For urticaria and conditions of 
general debility there perhaps is a larger selection. 
It may be noted that the relation of lime to magnesia 
in the serum of blood is about that which is main¬ 
tained in natural calcareo-magnesian waters—that is, 
the lime is to the magnesia as 2 to 1. Hammarsten’s 
“ Physiology,” English edition, p. 201, gives a table 
which shows that the amount present in various serums 
is very constant, ranging from 0 06 to 0 • 09 per 1000 parts 
for the calcium, and 0 02 to 0-03 for the magnesium. In 
the complete blood, for which I have not been able to find 
any analyses distinguishing these two bases, the amounts 
must be larger, though doubtless in the same proportions, as 
they are both probably ingredients in the dot. A little more 
light on this subject would be useful; as anterior to the 
researches whioh have been carried on in Sir Almroth 
Wright’s laboratory I am not aware that any one had found 
a use for the magnesium present in the blood in a quantity 
which relatively is large. Doubtless strontium is able to 
replace either of these bases when deficient, in a manner 
conformable to its chemical relations, and so is not toxic, 
though not a natural ingredient of the body. 

Gloucester-road, S.W. 


A CASE OF ECHINOCOCCUS DISEASE. 

BT ALICE M. SORABJI, M.B., B.S. LOND., 

DOCTOB-IN-CHARGE, VICTORIA ZEMA5A HOSPITAL, DELHI. 


The patient was a Mahomedan woman, aged about 29 
years, who came to the Victoria Zenana Hospital, Delhi, 
oomplainingof enlargement of the abdomen. The history of 
the case (as suoh histories generally are in India) was 
untrustworthy, but it appeared that she had had some enlarge¬ 
ment for four years. A year before admission she bad given 
birth to her fourth child. Since then the abdomen had been 
increasing in size up to the time when treatment at hospital 
was sought when it was very muoh enlarged and tense, the 




98 The Lancet,] MR. A. MAUDE: SUDDEN AND COMPLETE INVERSION OF THE UTERUS, ETC. [Jan. 11,1908. 


umbilicus being unfolded and the patient being unable even 
to sit down with comfort. Large veins were visible over the 
swelling and the skin was stretched to what looked like the 
cracking point. The patient was emaciated and she looked 
haggard and had an anxious expression. Breathing and move¬ 
ment were alike impeded and painful. She had come from a 
village 14 miles away, but.the idea of staving at the hospital 
proved so objectionable to her that she returned to her home. 
In a week she came back again begging to be admitted. 
She was in great distress, could scarcely breathe, and move¬ 
ment was all but impossible. The abdomen was apparently 
larger than before. The fulness extended to, and filled out, 
the flanks and went down to the pelvis so that it stood 
out from the lower ribs which were pressed out and hung 
over the pelvic bone. The tension was so great that no 
organs could be palpated. The heart was displaced ; the 
apex beat was heard best in the second space three and a 
half inches from the mid-sternal line. The lungs on per¬ 
cussion were found to be squeezed into a contracted 
space at the upper part of the thoracic cavity. From the 
third rib downwards it was not possible to distinguish lung 
sounds as the tumour occupied the whole space. The pulse 
was running and weak and the patient was too ill for any 
exhaustive examination to be made. She was in such 
distress that a preliminary tapping was done and four 
quarts of a greeniBh-yellow slimy fluid were withdrawn. 
Unfortunately this was thrown away before examination. 
The vaginal vault was found to be bulging downwards and 
full; and the uterus was pushed down, but was normal. No 
other organs could be distinguished. Dr. Jenny C. Muller 
of St. Stephen’s Hospital, Delhi, was called in, in consulta¬ 
tion, and a laparotomy was decided upon, the provisional 
diagnosis of ovarian cyst having been made. 

Four hours after tapping the abdomen was full and taut 
again. On the next day the patient, having been duly pre¬ 
pared and presenting a more favourable condition with a 
slightly better pulse, wasoperated upon. The ordinary incision 
was made in the abdominal wall. When the skin and fascia, 
&.O., had been divided it was found impossible to pick up 
and to divide the peritoneum. Indeed, the usual appear¬ 
ance of the peritoneum was not to be Been. Instead, a thin 
dull layer closely adherent to a thick tough wall was found. 
It was not possible to separate the two, so the thick wall was 
incised. It was at least a quarter of an inch thick and very 
tough. Its inner surface was rugose. On incision a large 
quantity of the greenish-yellow glairy fluid escaped. On 
inserting a hand into the cavity thus opened several round 
tumours were encountered. They were slimy balls filled with 
a transparent opalescent fluid. They varied in size from that 
of a pin's head to the dimensions of a football. They ocoupied 
the cyst from the level of the third rib down into the pelvis. 
The cyst contained several pockets separated from each other 
by strands of connective tissue which were broken down with 
difficulty. 200 cysts were counted and at least as many more 
were fonnd burst or escaped in the fluid used to wash out the 
cavity. The burst ones had their walls rolled up in scrolls 
and were in some cases packed away under the bigger cysts. 
The walls were slimy and transparent and varied in thickness 
with the size of the cyst. The bigger cysts showed daughter 
and grand-daughter cy6ts. On the lining membrane were 
found Bcolices on subsequent microscopic examination. The 
fluid was opalescent and bad a faint odour. It took some 
time to empty all the pockets, as they were up in the 
thorax and against the posterior wall. An attempt to 
separate the peritoneum from the thickened cyst wall was 
unsuccessful, nor was it possible to determine the seat of 
origin of the cyst, though the liver was suspected. The 
cavity was well washed out with saline solution and a drain 
left in in the lower part of the wound. In two dayB the 
heart came down and the apex beat was heard and felt in the 
fourth space; gradually the other organs resumed their 
usurped positions. The cavity was washed out daily with 
saline solution and a drain left in. At first this was a long 
tube, later a gauze drain was sufficient. Three weeks after 
the operation the patient had a rise of temperature, following 
on a couple of days of malaise. The wound bad an unpleasant 
sweetish odour. In the daily dressing another cyst was 
found and evacuated. It came from the left lobe of the liver. 
The patient improved steadily till five weeks later, when she 
had a similar rise of temperature with extreme tenderness in 
the region of the left lobe of the liver. Her breath had a 
sweet “apple’’odour and the wound smelt the same. A 
brilliant green pus exuded from the wound. On microscopic 
examination this showed the bacillus pyocyanus. As saline 


solution alone was used for her daily irrigating and an iodo¬ 
form dressing applied it was found impossible to account for 
this. She was put on alkalies and improved rapidly ; the 
wound was cleaned out. The cavity continued to diminish 
in size. Four months after the first operation a second was 
done as white cyst-wall material was seen in the discharging 
sinus. This was scraped. The patient then improved without a 
break. She was given hoematogen fora time but soon was 
in such splendid condition that she was able to do without it. 
The cavity closed entirely, the patient put on flesh rapidly, 
and went home looking 20 instead of 50 as she did on admis¬ 
sion. She came from a village and described her hut and 
surroundings as being occupied by dogs, sheep, and cattle, 
as well as her family. The open stream from which they got 
their water was common to men and beasts. 

Delhi. _ 


SUDDEN AND COMPLETE INVERSION OF 
THE UTERUS : ITS PROBABLE 
CAUSATION. 

Bt ARTHUR MAUDE, M.R.C.S. Eng., L.R.C.P. Lond. 


Complete inversion of the uterus is so rare that its occur¬ 
rence justifies notice and some remarks on the subject. I 
was hastily summoned to a young woman in labour of her 
third child. The so-called “ midwife ” in attendance realised 
that something serious bad happened but had no idea of its 
nature and thought that the patient was dead. She was 
nearly so, having no pulse at the wrist and being in a state 
of almost complete unconsciousness from Bhock. There had 
been very severe haemorrhage but it had almost ceased when 
I arrived. The uterus was completely inverted, lying quite 
outside the vulva. The cord had been separated near the 
umbilicus but was not abnormally short. The woman was in 
such a pool of blood that it was not easy to realise what bad 
happened in a few secondsthe point that gave me the clue 
at once was the feel of the round ligaments on each side, 
which were dragged right down to the most external part of 
the uterus, which was the fundus, capped by the placenta. 
Two important points I noted without at the time realising 
their importance. First, that the oord was thin and frail; 
if traction had been made on the cord sufficiently powerful 
to invert the uterus it is probable that it would have broken 
close to its placental attachment; this it had not done and I 
regard its condition as better evidence that undue traction 
had not been employed than the statement made (in answer 
to my questions) by the midwife that she had not employed 
it. Secondly, the polar position of the placenta was absolute; 
the placenta lay attached to the inverted fundus as if it had 
been placed by design in the axis. This observation is con¬ 
firmatory of the view expressed by Hennig 1 many years ago 
that the active cause of this disaster is an absolutely polar 
attachment of the placenta. 

The history of this case as given by the midwife and after¬ 
wards by the patient was that the labour had been quite 
natural and rather rapid. There was no straining effort or 
unusual position assumed by the mother daring labour. Both 
women agreed that the child, which presented head first, was 
born rapidly at the last and that the placenta and uterns came 
out together immediately after it. I found the placenta very 
large and adherent except at the edges ; so, considering the 
very grave condition of the woman and thinking that she 
would stand no prolonged manipulation, I decided not to try 
to reduce the placenta with the uterus but to risk its 
detachment. I peeled it off with the left hand, gently 
reduced the axis of the fundus first, and, fortunately, 
restored the whole organ without difficulty. Having a very 
small hand 1 followed the fundus up and kept my hand in 
the cavity till good contractions began to become constant, 
which was after about ten minutes ; during this time and 
for three hours after I kept up massage through the 
abdominal wall. Probably not more than a quarter of an 
hour had elapsed between the inversion and my arrival and 
dealing with it. Hence I found the spasm of the inverted 
ring of Bandl very slight and the ease of reduction propor¬ 
tionate. There was no serious amount of haemorrhage after 
the uterus was restored to its proper position. It is un¬ 
necessary to detail the treatment for shock and loss of blood 
employed. 

1 I’eber die Ursachen der Spontanea Invenlo Uteri, Arcbiv far 
Gyn&kologie, Band vil., p. 491. 




The lancet,] DR. R. H. FOX: ON BLOOD COAGULABILITY IN THE PUERPERAL STATE. [Jan. 11, 1908 99 


The value of this case depends on the points to which 
attention has been directed ; the inversion was complete ; the 
position of the placenta and its large size, coupled with the 
absence of evidence of artificial production, tend to support 
the theory of Hennig to which reference has been made. 
The patient made an excellent recovery and there was no 
tendency to secondary chronic inversion. 

Complete inversion of the uterus is extremely rare. Braun 
had never seen a case in 160,000 births. In Kamsbotham’s 
tables of 50,000 births the accident is not even mentioned, 
and it seems doubtful if in 1847 it had even been recognised. 
From 1745 to 1860 at the Rotunda in 191,000 deliveries it 
had only once been observed. 

Westerham. 


ON BLOOD COAGULABILITY IN THE 
PUERPERAL STATE. 

By R. KINGSTON FOX, M.D. Brux., M.R.C.P. Lond., 

PHYSICIAN TO THE FKIENl.s' PROVIDENT IMSTITUTION. 


The object of this paper is to record observations made on 
the coagulation time of the blood in the puerperal condition. 
The observations were made by Wright's method, modified 
by the author, and a correction has been introduced for 
temperature. 

Method .—Sir A. K. Wright’s apparatus is described and 
figured in The Lancet of Oct. 14,ti, 1905, p. 1096. I have 
after experience dispensed with the mercury, the segmenta¬ 
tion of the tube, and its hair-fine tapering end, and the 
method used by me is as follows 

The apparatus consists of a series of capillary tubes, eight centi 
metres in length, and each of such calibre that five cubic millimetres of 
mercury fill it to the length of five centimetres; each tube is inserted, 
the smaller end outwards, into a short larger tube aud fixed in its 
place in an air-tight manner by sealing wax. Rubber nipples 
to fit the tubes, a beaker of water standing on white paper, 
a spirit lamp, an accurate thermometer, and a piece of 
string are provided. Pour of the tubes are taken in succession and 
nearly filled with blood from a puncture near the end of the finger or 
thumb. Care should be taken that the blood flows freely, as squeezing 
the finger is apt to cause lymph from the tisanes to be mixed with the 
blood, leading to an increased coagulation time. Nor must the finger 
be ligatured, as this much lessens the coagulation period. The blood 
lying in the tube should not quite reach either end of it. Each tube 
as soon as filled is laid on the table in order by the side of the 
thermometer and the exact time of drawing the blood from the finger 
noted on paper. The finger is then wiped and the puncture closed, 
until after an interval of 30 seconds or more the next tube is applied 
and the time noted. When all four tubes have been filled the 
obeerver decides at what Interval he will examine the first tube, com¬ 
mencing well under the expected coagulation period. A rubber nipple 
is applied aud the blood in the tube expressed into the water. If the 
mass is readily diffused the next tube may be left for one or two 
minutes longer than the first. The process is repeated until either a 
defined wormlike clot is expelled, which retains its form for some 
seconds, or until the contents have become so dense that they are with 
difficulty expressed. This occurs in Borne cases apart from the forma¬ 
tion of a red wormlike clot, the mass being partially diffusible in the 
water. The reason of this variation is probably the admixture of 
coagulable lymph. At present I reckon the coagulation time to be the 
time which elapses before either a wormlike clot is formed or else the 
tube is with difficulty emptied, whichever happens first. Should the 
nipple fail to expel the contents the string should be wound tightly 
around the lower part of the nipple and then persistent efforts in com¬ 
pressing it will generally succeed in emptying the tube. If this cannot 
be done the tube must be discarded. I have not found any means of 
cleansing a tube when once choked. 

Sir A. E. Wright accounts the coagulation time to be com¬ 
pleted before the first appearance of a shred of fibrin forma¬ 
tion. This appearance is seen much earlier and I think 
may sometimes be accidental, due to the presence of a minute 
quantity of blood less freshly drawn or of skin tissue or other 
extraneous matter. It seems to me better to wait nntil the 
entire mass of blood is coagulated. As by this means we 
obtain a much longer coagulation period than Sir A. E. 
Wright’s the figures are not comparable with his. 

Correction for temperature. —Five observations in immediate succes¬ 
sion were made on a healthy man, aged 22 years, whose puUe was 72, 
regular; arterial pressure 100 degrees (Hill and Barnard). The blood was 
known to have an over-average coagulation time. The tubes when 
filled with blood were placed in small test tubes, weighted 
with mercury, and plunged into ft water bath of a capacity 
of about two litres. The water was maintained at a given tem¬ 
perature—viz., 40°, 50°, 60°, 70°, and 80 s F. respectively—in the five 
observations. It had previously been ascertained that the temperature 
of the air within the test tubes at several readings accorded closely, in 
each case, with the temperature of the water in the bath. The follow¬ 
ing results were obtained. Coagulation time at 40° K., 16 minutes ; at 
60", 10 minutes 45 seconds; at 60°, 8 minutes 30 seconds; at 7C°, 
7 minutes30 seconds; at 80°, 6 minutes 40 seconds. On plotting these 
out to scale the coagulation time is seen to form a curve, the ordinates 
of time incressing greatly as the temperature descends towards freezing 

C 'ot, to which line the curve doubtless forms an asymptote. A curve 
been found which closely approximates to this between the tem¬ 
peratures 40 9 to 80° F., but I have not yet obtained a formula for 


reducing observations to the standard temperature of 60°. This 
correction must therefore be made from the diagram graphically. 

Obsirvations on blood coagulability in the puerperal state .— 
By the kindness of Dr. W. J. Gow, physician to Queen 
Charlotte's Lying-in Hospital, I have made observations on 
the blood of eight parturient women during the first week 
after delivery in the wards of that hospital. All were primi- 
pane ; unmarried, except the patients in Cases 2 and 8 ; the 
labours were normal, bat in Cases 1, 3, 5, 7, and 8 they were 
tedious ; haemorrhage was normal; all suckled their infants, 
who appeared to be healthy. In Case 4 there was a trace of 
albuminuria and the temperature rose to 100 ■ 2° F. on the 
second day, the pulse-rate being 108 ; milk on the fifth day 
was rather deficient. Gonorrhoea was present in Case 1. The 
observations were taken between the hours of 2 30 and 6 P.M. 
The patients were, of course, recumbent in their beds. The 
results, corrected for temperature, are as follows, the period 
required for complete coagulation being represented in 


minutes : 

Years of age. 

Minutes. 

Minutes. 

Case 1 

... 26 ... First day 

... 4 ... Fourth day 

... 64 

.. 2 

... 25. 

... 5. 

... ■84 

3 

... 22. 

... 5i ... Fifth 

... 64 

4 

... 21. 

... 64. 

... 74 

.. 5 

... 28 ... Third „ 

... 64 ... - 

— 

6 

... 20. 

... 64 ... Seventh „ 

... 64 

7 

... 23. 

... 54. 

... 74 

.. 8 

... 23 ... Seventh,, 

... 7 ... — 

— 


The observations may also be summarised as under :— 


First day 
Third day 
Fourth day 
Fifth day 
Seventh day. 


Four observations 
.. Three „ 

.. Two „ 

.. Two ,, 

.. Three 


4, 5, 58, 6i minutes. 

64, 64. 54 
64.81 
64, 74 
7. 64, 74 


Comparing these figures with many other observations 
taken by the same method I find that the coagulation time 
immediately after delivery is below the normal but not to 
the same extent as is commonly supposed. For I have often 
found a much lower coagulation time in adults, as low as 
three minutes or less. Five and a quarter minntes, the 
average time on the first day after confinement, is not 
therefore very low. Perhaps under the careful management 
of labour in the hospital the haemorrhage is less, and so the 
blood coagulability is less altered on this account. It will 
be noticed that in every case in which two successive obser¬ 
vations were taken the coagulation time had increased 
during the interval. The excretion of calcium salts In the 
milk tending to reduce the coagulability of the blood was 
probably one cause of this increase. 

An observation of the coagulation time of the blood after 
delivery might give useful warning : of the risk of thrombosis 
or embolism if the coagulation time were low, or of post¬ 
partum haemorrhage if it were high. Appropriate treatment 
—for example, with citric aoid on the one hand or with 
calcium lactate and salines on the other—would rectify the 
condition. 

I made a few observations on some of these women during 
the latter part of pregnancy and subjoin them for what 
they are worth. So far as they go, they indicate a tendency 
to a low coagulation time, in several cases lower than after 
delivery. 1 The blood during pregnancy is probably rich in 
nutrient matter required for the growth of the foetus. 
According to Winckel, it has a somewhat diminished 
alkalescence and exhibits a more ready (mdtrige) leucocy- 
tosis. Bar and Daunay state that the density of the blood 
is diminished at the end of pregnancy but rises again after 
partns. My observations of the coagulation point were made 
under varions conditions as to time of day and relation to 
exercise and to meals, contrasting with the even conditions 
attaching to those made in the wards of the hospital. 


Obeervatiom on the Same Cruet during Pregnancy. 


C«18« 1 ... . 

11 days before partus ... . 

4i minutes. 

„ 2 ... . 

.. 18 „ ... . 

■ n „ 

„ 3 ... . 

.. 31 „ 

2S ,. 

„ 6 ... . 

.. 54 „ 

. 74 

„ 7 . 

.. 47.. ... 

• 14 .. 


I have not found any reference to the coagulability of the 
blood in pregnant or puerperal states In recent workB on 
obstetrics, BritUh, French, or German. 

Weyinouth-street, W. 


1 Compare Dr. Blair Bell's reference to the presence of large 
quantities of calcium salts in the systems of pregnant women, Brit. 
Med. Jour., April 20th, 1967, p. 921. 














100 The Lancet,] CLINICAL NOTES.—ROYAL SOCIETY OF MEDICINE : OBSTETRICAL SECTION. [Jan. 11,1908. 


Clinkal Jtoks: 

MEDICAL, SURGICAL, OBSTETRICAL, AND 
THERAPEUTICAL. 


A NOTE ON TWO CASES OF ACRANIAL FCETUS. 

By James Pihie, M.A., M.D. Aberd. 

On Oct. 12th, 1907, a woman, aged 43 years, was delivered 
of an acranial foetus. The entire vault of the cranium was 
absent and the floor of the gap thus caused was formed by the 
basilar process of the occipital bone. The scalp was intact 
and formed a coil on the top of the vacuity. The brain was 
almost entirely absent but the medulla oblongata was 
present. Along with a rudimentary pons Yarolii several of 
the cranial nerves could be recognised at the base of the gap. 
On Nov. 7th a woman, aged 38 years, in the same village, 
was delivered of a similar fcetus which also showed a spina 
bifida. Both fuctuses were otherwise well nourished and not 
malformed in any other way. The former one was extremely 
large and weighed 10J pounds. 

An interesting feature, and adding to the extraordinary 
nature of the coincidence of time and place, was that both 
mothers had very large goitres, and one at any rate had taken 
a great number of a certain advertised pill warranted to 
remove “ female irregularities.” 

Hmrbury, Leamington Spa. 


HERMAPHKODISM 

By E. S. Crispin, M.R.C.S. Eng., L.R C.P. Lond., 

SENIOR M EPICAL OFFICER, RED SEA PROVINCE. 


The accompanying illustration is a reproduction of a 
photograph of a case of hermaphrodism and may be of some 
interest to readers of The Lancet. I am unable to say if it 
is a case of true hermaphrodism or false, most probably the 
latter, of the masculine type. The patient's features are 
masculine; he has enormous breast development, as is well 
seen, but without any known secretion of milk ; his pelvis is 



of a masculine type. His genitals consist of a very small 
penis with complete hypospadias. The scrotum is cleft with 
a very small testicle (?J in each half. He informs me that he 
has been married some time and is able to perform the act 


of coitus but has no children. His voice is distinctly 
falsetto. He was engaged in work as a male messenger. 

Port Soudan, Red Sea. 


A CASE OF GANGRENE CAUSED BY THE APPLICA¬ 
TION OF CARBOLIC ACID. 

By A. 0. D. Firth, M.A. Cantab., M.R.C.S. Eng., 

L R C.P. Lond., 

HOUSE SURGEON TO THE WEST LONDON HOSPITAL. 


As cases of gangrene caused by carbolic acid are now 
somewhat uncommon the following case is of some interest. 

The patient was a thin, anaemic girl, aged 16 years, who 
while at work on Nov. 20th, 1907, ran a wooden splinter a 
short way under the nail of the right ring finger. The 
splinter was extracted and a carbolic acid compress of un¬ 
certain strength was applied to the finger at the factory in 
which the girl was working. The compress was applied at 
8 30 p.m. and remained on until 11.30 a.m. on the next day, 
and after removal the finger was found to be cold, white, and 
acaistbetic. There was no sensation of tingling or numbness 
while the compress was applied to the fiDger. On the 23rd 
discolouration began and the girl attended the West London 
Hospital for the first time on the 25th. On that occasion the 
skin as far as the proximal interpbalangeal joint was black 
and insensitive, the last two phalanges being in a state of 
dry gangrene, of which the line of demarcation was appa¬ 
rently well established. No carboluria had been noticed. 
The finger was disinfected as far as possible and wrapped in 
dry dressings, but these precautions failed, the gangrene 
became moist, and it was eventually found necessary to 
amputate the finger at the metacarpo phalangeal joint. 

This condition, although described in all the text books, is 
comparatively rare, as the public have learnt, in many cases, 
the dangers of applying carbolic acid in this manner as an 
antiseptic "precaution.” No doubt the unfortunate person 
who applied it in this case will spread the warning as widely 
as possible. 




ROYAL SOCIETY OF MEDICINE. 


OBSTETRICAL AND GYNECOLOGICAL SECTION. 
The Supports of the Pelvic Viscera.—Exhibition of Specimens. 

A meeting of this section was held on Dec. 12th, 1907, 
Dr. Herbert R. Spencer, the President, being in the chair. 

« Dr. W. E. Fothergill read a paper on the Supports 
of the Pelvic Viscera. He considered that the current 
teaching of gynaecological anatomy, while correct in a 
general sense, lacked that accnracy which was essential if 
the student was to have a real grip of his clinical work. It 
was generally assumed that the urino genital organs were 
partly suspended by the so-called ligaments of the uterus 
and partly supported from below by the pelvic floor. But the 
perineum and the pelvio diaphragm were often seriously im¬ 
paired by injury or loss of tone without any consequent change 
in the position of the pelvic viscera, which showed that 
support from below was not essential. Again, during abdo¬ 
minal operations the ligaments of the uterus were seen to lie 
loose and slack upon the subjacent structures and to have no 
supporting aotion whatever. The operation of vaginal 
hysterectomy afforded confirmation of these observations 
and revealed to the clinician the fact that the uterus was 
really supported by the sheaths of its blood-vessels which 
attached it firmly to the sides of the pelvic diaphragm. In 
the same way the vagina and the bladder were held in posi¬ 
tion by the sheaths of their blood-vessels, the rectum 
having an independent attachment to the back of the 
pelvis. Thus lengthening and laxity of the sheaths of the 
blood-vessels was the one constant and essential factor in 
the causation of prolapse of the pelvio vicera. Dr. Fothergill 
considered that while gynecologists were well aware of these 
facts they refrained from teaching them, because they 
borrowed their anatomical statements from the writings of 
professed anatomists. He therefore went on to show by 
quotation from recent papers by anatomists of the first rank 
that descriptive anatomy had changed in a way exactly parallel 





The Lancet 


ROYAL SOCIETY OF MEDICINE: DERMATOLOGICAL SECTION. [Jan. 11, 1908. 101 


to that in which clinical gynaecology had moved. The utero- 
sacral ligament was a mere peritoneal fold ; the broad 
ligament was simply a mesosalpinx and mesovarium. The 
ronnd ligament was a vestigial structure, the homologue of 
the gubernacnlum teBtis, which pulled down the ovary and 
uterus in early foetal life, and by no means supported them 
during post-natal life. The superficial perineal muscles 
derived from the primitive sphincter cloacae had a sphincteric 
and not a supporting action. The muscles of the pelvic 
diaphragm were vestigial structures, being the degenerated 
representatives of the powerful tail-moving muscles of lower 
vertebrates. Their muscular action was largely lost ; but, 
by virtue of their position, they, with their fascial coverings, 
formed the funnel-shaped musculo-membranous structure 
known as the pelvic diaphragm. This could not support the 
plastic pelvic viscera, either by its shape or its muscularity, 
if the pelvic viscera were not firmly attached to its sides. 
The conception of the pelvic fasciae as independent and 
definite structures must be given up, and the fascim must be 
regarded simply as the connective-tissue coverings of the 
muscles, the viscera, and the blood-vessels. The vessels and 
their sheaths, together with the ureters, nerves, and 
lymphatics, formed masses of tissue which extended between 
the sides of the pelvis and the lateral aspects of the uterus, 
bladder, and vagina, and which held these structures in 
position. The rectum was independently attached to the 
back of the pelvis, and lay loose in a channel between the 
vessels of the right and left sides. It was free from the 
urino-genital organs and did not descend with them in 
prolapse unless the anterior rectal wall was pathologically 
adherent to the posterior vaginal wall. 

The President thanked Dr. Fothergill for the interesting 
and lucid communication which he had brought before the 
section. Although the question of the support of the pelvic 
viscera was one to be settled by anatomical research, anyone 
who had performed total abdominal hysterectomy and had 
noticed the ‘ 1 ligamentum transversals colli ” which lay at 
a lower level than the uterine artery and was very dense in 
structure, would find it difficult to accept the statement 
that it was the sheath of the vessels which kept the uterus 
in place. Also, how could the bladder be kept up by the 
sheath of the vessels which were small in number and size 1 

Dr. Amand J. M. Routh congratulated Dr. Fothergill 
on his lucid and excellent discourse and felt that it 
would be greatly to the advantage of both students 
and gynaecologists if the antiquated views so long held 
on the subject of the uterine supports were replaced by 
those now elaborated. He thought that Dr. Fothergill 
had succeeded in proving his contention that the uterus 
was mainly supported by the perivascular connective- 
tissue bundles above the pelvic floor. He bad put into 
words much of the scepticism which gynaecologists had held 
as to the acceptance of the orthodox views. No one who was 
in the habit of opening the abdomen and of seeing the 
flaccid broad ligaments and the redundant circuitous round 
ligaments could hold the view that these structures supported 
the uterus, whatever might be thought of the functions of the 
utero-sacral ligaments. He had long held the view that the 
connective tissue in the bases of the broad ligament and 
utero-sacral folds (which really unite and form one common 
connective-tissue bundle at their junction with the supra¬ 
vaginal cervix) were very important agents in holding down 
the uterus to the floor of the pelvis. If in amputating the 
cervix per vaginam these bundles were cut through, the 
freed uterine body could not only be easily drawn down¬ 
wards by traction but would be spontaneously elevated 
behind the pubes if not held down by vulsella forceps. 
He thought, therefore, that the bundles of connective tissue 
grouped round the vessels and the ureters served rather as 
anchors to fix the uterus down to the pelvic diaphragm, pre¬ 
venting undue mobility both upwards and downwards. The 
normal anteversion of the uterus was doubtless maintained, 
according to Dr. Fothergill’s view, by the perivascular 
sheaths suspending the supravaginal cervix from a direc¬ 
tion upwards and backwards (in the erect position), much in 
v;he same way as the utero-sacral folds had been hitherto 
supposed to act. He hoped that Dr. Fothergill’s views would 
receive general attention and acceptance. 

Dr. R. H. Paramore disagreed with what had been said 
by Dr. Fothergill. In determining the position of the 
uterus and the maintenance of this position in the pelvis 
they had to consider not only the structures which united the 
uterus to the pelvic wall and the pelvic floor itself but also 
the intra-abdominal pressure which had a definite influence 


upon the position of the pelvic viscera. The intra-abdominal 
pressure depended upon the capacity of the abdomen, the 
volume of the abdominal contents, and upon the condition 
of the contraction of the muscles which enclosed and formed 
its boundaries. Dr. J. Matthews Duncan had laid stress on 
the retentive power of the abdomen and had drawn attention 
to the fact that the uterus did not alter its position as a result 
of complete rupture of the perineum alone, but if prolapse 
occurred other factors had come into play. In women with 
an undamaged pelvic floor and in whom the intra-abdominal 
pressure was much increased by a deposit of fat in the 
omentum or mesentery, the uterus was often found high up 
owing to the activity of the levator ani muscle. If in such 
cases the pelvic floor was damaged by childbirth, an 
inevitable prolapse resulted. 

Dr. Briggs believed that too much was attributed to 
ligaments. The muscular and tendinous and other fibrous 
tissues around a joint controlled its security and mobility 
and produced its stiffness. The ligaments of the pelvic 
viscera were insignificant compared with the mass of the 
muscles and their fascia, the fibrous packing between, and 
the fibrous envelopes of, the viscera and canals. 

Sir Arthur V. M acan said that the importance of the pelvic 
connective tissue was pointed out years ago by W. A. Freund 
and more recently a firm band in the lower part of the broad 
ligament at each side of the cervix had been differentiated 
by Kooks under the name “pars cardinalis ligamenti lati.” 
The effect of taking away the support from below could often 
be observed clinically in cases where prolapse of the anterior 
vaginal wall followed rupture of the perineum. As the 
vaginal wall prolapsed it drew the cervix downwards and 
forwards which produced backward displacement of the 
fundus and, finally, prolapse. Prolapse of the uterus 
was also met with in old women due to senile atrophy 
of the pelvic connective tissue removing the natural 
support of the pelvic organs. The strength of the support 
from below was, he thought, well shown by the resistance 
which the pelvic floor offered to the expulsion of the child’s 
head during labour. 

The following specimens were shown :— 

Dr. C. Hubert Roberts : A Cancerous Uterus and Glands 
removed by Wertheim’s Method. 

Dr. Peter Horrocks : Tuberculous Disease of the Cervix. 

Dr. James Oliver : A Somewhat Unique Tubal Gestation. 

Dr. Lewers : Sarcoma of the Ovary complicated by Car¬ 
cinoma of the Body of the Uterus ; Operation. 


DERMATOLOGICAL SECTION. 

Exhibition of Catet. 

A meeting of this section was held on Dec. 19th, 1907, 
Dr. T. Colcott Fox being in the chair. 

Mr. G. W. Dawson showed a case for diagnosis. The 
patient was a woman, aged 33 years, who had had for the 
past six years an affection of the skin which had slowly 
spread from the palms and soles to occupy the forearms and 
legs. These parts were reddened, slightly thickened, and 
scaly, presenting a finely rugose surface. The diagnosis was 
not clear. 

Dr. Colcott Fox showed a woman with Verrucose Granu¬ 
lomatous Swellings on the Upper Lip, the Nose, the Chin, 
and Nasolabial Furrow. These had persisted for three 
months. There was no history of syphilis or tubercle and 
she had not been taking any drugs that could be held respon¬ 
sible for the appearances. A yeast-like fungus had been 
found in scrapings, and the possibility of its being a case oi 
blastomycosis was suggested.—Others contended that it was 
a verrucose sypbilide. 

Dr. E. G. Graham Little showed: 1. A case of Favus of tho 
Scalp and Nail in a woman, aged 40 years, who had never left 
England and was a native of Essex. Very numerous and 
typical scutula were seen on the scalp and the fungus was 
readily found in the hair. A nephew, aged eight years, living 
in the house had apparently contracted the disease from the 
previous patient and when shown had very numerous 
pityriasic and alopecic patches, the result of the disease on 
his scalp. 2. A case of Bazin’s Disease of unusually rapid 
development in a young woman, the legs having numerous 
deep-seated ulcers and nodose swellings which dated from 
only two months previously. There was no history of pul¬ 
monary tuberculosis and the tuberculo-opsonic index was 0 96 
on the single occasion on which it had been examined. 

Dr. J. M. H. MacLeod and Mr. E. Treacher Collins 
(introduced) showed : 1. Three caiea of Keratosis Follicularis 






Th* Lancet,] 


SOCIETY OF TROPICAL MEDICINE AND HYGIENE. 


[Jan. 11, 1908. 103 


notice that some of the species which hitherto had escaped 
notice were widely distributed, extremely frequent, and highly 
pathogenic. One of the worst scourges of the tropics was 
without doubt the endemic anaemia, now generally known as 
ankylostomiasis. In 1838 Dubini discovered the ankylosto- 
mum duodenale in the duodenum of a peasant woman who died 
at the Ospedale Maggiore in Milan. In 1851 Griesinger showed 
that Dubini's worm was the cause of Egyptian chlorosis. 
Later, Wucherer showed that the Brazilian disease called 
*' oppilatio ” was likewise an ankylostomiasis. The world¬ 
wide distribution of endemic anaemia indicated the possi¬ 
bility of more than one type of disease in the various regions. 
In 1888 Lutz noticed that the Brazilian worm was not 
provided with the hooked teeth described by European 
authors, and Stiles in 1902 showed that the endemic ansemia 
of America was not, as a rule, due to ankylostomum duo¬ 
denale but to a new species of the closely allied genus 
necator, for which he proposed the specific designation of 
11 Americanus,” believing it to be special to the American 
continent and the adjacent islands. Later, however, it was 
found by Loose in pygmies from Central Africa and by 
others in Assam, Burma, West Africa, and Italy, suggesting 
probably Africa or Asia as the original habitat. In 1905 
Baillet and Henry described another new strongyloid of man 
which, like necator Americanus, might also be an impor¬ 
tant agent in the causation of tropical ansemia. They 
discovered the new parasite in the collection of the Paris 
Natural History Museum. It was represented by two spe¬ 
cimens presented by Dr. Monestier in 1865 and collected 
at the post mortem examination of an African negro who died 
from endemic anaemia in Mayotte. Another new parasite, 
likewise belonging to the sub-family Sclerostominse, was the 
ociophagostomum Brumpti discovered by Brumpt in 1902 in 
Africa. Another group of parasites mentioned was that of 
the schistosomidse For a long time only one species was 
known to occur in man; it was the schistosomum haema¬ 
tobium, better known as bilharzia after the name of the 
investigator who discovered it in Egypt in 1851, and showed 
that it was the cause of endemic bsematuria. In 1904 
Professor Katsurada discovered a new species in Japan and 
called it schistosomum Japonicum. It was not recognised 
before probably because its ova lacked the characteristic 
spine of the eggs of schistosomum hasmatobium and 
greatly resembled those of ankylostomum duodenale with 
which they must have been frequently confounded. The 
adult parasites closely resembled those of schistosomum 
hmmatobium; the striking difference was the absence 
-of cuticular prominences on the outer surface of the body 
of the male. Schistosomum Japonicum did not affect the 
bladder; its ova were eliminated by way of the intestine 
and frequently accumulated in the liver, giving rise to a 
peculiar form of cirrhosis. A third species of schistosomum 
was described by himself (Dr. Sambou) last summer. He 
called it schistosomum Mansoni, because Sir Patrick Manson 
had already suggested the possibility of its specificity. 
The material at his disposal being scarce and badly pre¬ 
served, he had not been able to study their anatomical 
structure. He had noticed that the body surface of the 
male presented cuticular prominences somewhat similar to 
those of schistosomum haematobium, and he had pointed out 
-that the differences in the structure of the female genital 
tract described by Fritsch as abnormal were characteristic of 
the new species His determination was based chiefly, but 
not solely, on the characteristics of the ovum which in 
schistosomum Mansoni differed greatly from that of schisto¬ 
somum haematobium not only in the position of the spine but 
also in the size and shape both of the spine and of the body 
of the egg. His determination was based also on the peculiar 
geographical distribution and on the peculiar anatomical 
habitat of the new parasite. In Egypt both schistosomum 
haematobium and schistosomum Mansoni were found side by 
side, but the former appeared to be more prevalent and was 
certainly more conspicuous owing to the hmmaturia to which 
it gave rise. That was probably the reason why the two 
forms had been confounded, the spined ova of schistosomum 
Mansoni being looked upon as abnormal. They must go 
elsewhere to become aware that the differently shaped eggs 
represented two different species. Thus in the West Indies 
schistosomum Mansoni was the only species present, 
endemic hsematuria was unknown, and the parasite 
escaped observation until quite recently, when a sys¬ 
tematic examination of stools for the detection of ankylo¬ 
stomum ova made them suddenly aware of its extreme 
prevalence. Schistosomum Mansoni, like schistosomum 


Japonicum, never affected the bladder. Its ova were deposited 
within the submucous layer of the rectum. They had been 
found not infrequently in the liver, giving rise to a cirrhosis 
similar to that produced by schistosomum Japonicum. A new 
porocephalus and some new parasitic larvae of diptera were 
also mentioned. Then Dr. Sambon discussed the patho¬ 
genic action of metazoan parasites and spoke of the toxins 
which they produced. He drew special attention to the 
migrations of certain parasites in their larval or immature 
stages before reaching the anatomical habitat in which they 
were usually found, and he said he believed that such 
wanderings would explain much that was cow obscure in the 
pathogeny of certain species. Until quite recently the 
route followed by intestinal parasites was supposed to be 
a direct and simple one. The eggs of the parasite were 
swallowed by the host. They reached the intestine with water 
or food and hatched in the part most convenient. Likewise 
maggots found beneath the skin were supposed to have been 
laid in the very spot by the parent fly. The true mode of en¬ 
trance might be very different and complicated. At one time 
it was believed that hypoderma bovis, the ox warble fly, laid its 
eggs upon the back of cattle and that the larva imme¬ 
diately penetrated the skin and lived there without wander¬ 
ing. Now it was known that the fly laid its eggs upon the 
legs of cattle, especially just above the hoof. The animal 
licked its legs and the larva at once hatched and was carried 
down into the (esophagus, the walls of which it penetrated. 
It then wandered through the connective tissues of the host 
and found its way into the spinal canal. (In young cattle as 
many as 57 larvae had been found distributed throughout 
the whole length of the spinal canal.) Ultimately it reached 
a point beneath the skin on the back of the animal. Another 
example was that of ankylostomum duodenale. Until quite 
recently it was believed that the so-called encysted larva 
was swallowed with water, food, or possibly even earth. Thus 
it passed straight into the duodenum. Loose had suggested 
another mode of entrance through the skin. According to 
this investigator the nematodes pass with the blood through 
the heart to the lungs, from the lungs to the air passages, 
up to the larynx, down the (esophagus to the stomach, and 
then to the small intestine. Loose’s theory of skin infection 
had been thoroughly demonstrated by experiment but Dr. 
Sambon doubted whether the trachea-oesophagus part of the 
journey was mure than a mere conjecture. In cesophago- 
stomnm and in other sclerostomies; which inhabited the 
intestine when fully mature for the purpose of fertilisation 
and oviposition, the immature forms before entering the 
lumen of the intestine were found in small cysts beneath the 
intestinal mucosa. Recently he (Dr. Sambon) had bad the 
opportunity of investigating the life-history of a heterakis 
of the pheasant. Here again the parasite appeared in small 
cysts beneath the mucous membrane before entering the ca;cal 
cavities. Many other examples were given by Dr. Sambon, 
some of them observed by himself, as, for instance, in the case 
of porocephalus armillatus. Lastly, he spoke of the agency 
of metazoan parasites in the conveyance and development of 
secondary infections. Already in 1903 and 1905 at meetings 
of the British Medical Association he had pointed out that 
probably entozoa within the alimentary canal or within the 
tissues performed a role similar to that of blood sucking 
artbropoda from without conveying more minute pathogenic 
organisms from one anatomical habitat to another. Already 
Metchnikoff in 1901 had suggested that intestinal parasites 
might inoculate pathogenic organisms through the Intestinal 
mucosa and thus give rise to infectious diseases. Guiart, 
Blanchard, and others had recently maintained that 
appendicitis might be brought about by the agency of 
intestinal worms, and more especially the whipworm. Guiart 
had even suggested that typhoid fever and cholera might 
be favoured by the agency of whipworms, tapeworms, 
and other intestinal parasites. Finally, Weinberg had just 
published a most suggestive article on the subject in the 
Annales de Vlnstitut Patteur. So far they had little positive 
information in favour of the agency of entozoa with regard 
to the transmission of secondary infections, but on considera¬ 
tion the Bubject was pregnant with possibilities, and he 
believed the day was not far off when they would have 
experimental proof of the truth of this theory. In any 
case, whether harmful in themselves or on account of 
possible complications, the prophylaxis of the entozoan 
parasites of man imposed itself most urgently. In order 
to be able to prevent infection they needed to encourage 
and to further in every possible way the study of helmin¬ 
thology. 




104 The Lancet,] 


LIVERPOOL MEDICAL INSTITUTION. 


[Jan. 11, 190a 


LIVERPOOL MEDICAL INSTITUTION. 


lagliocotian Skin-grafting of the Arm .— Ununited Fracturet 
Treated by Bone-grafting .— Tabetic or Trophic Foot .— 
Physiijue and Health in the Liverpool Sohoolt. 

A meeting of this society was held on Dec. 19th, 1907, 
Mr. Frank T. Paul, the President, being in the chair. 

Mr. G. P. Newholt showed lantern slides of a case 
operated upon by the Tagliocotian Method. The patient’s 
forearm had been severely injured in a railway accident, both 
bones being broken, the skin much lacerated, and the muscles 
and tendons partially torn away. A long flap of skin was 
raised from the abdomen below the left breast and the arm 
was passed under it so that it lay as if in a sling. As a result 
of this operation, which was completed in two further stages, 
the arm had been saved ; sensation was good and there was 
some movement in the Angers. The patient is still under 
treatment. 

Mr. RCSHTON Parker related two cases of Ununited 
Fracture treated by clearing out unossified tissue from between 
the fragments and planting in the interval small pieces of 
bone clipped from the seat of fracture. One case was that 
of a man, aged 35 years, whose left humerus had been 
broken six months previously and imperfectly united by 
incomplete callus, permitting movement and unfitting the 
limb for use. Union resulted in six weeks. The other case 
was that of a woman, aged 48 years, with total non-union of 
the left ulna of eight months' standing. There was pain as 
well as weakness and flexibility at the Beat of fracture. 
Union was still absent in six weeks but after hammering 
the seat of fracture it resulted firmly a week later. 
The practice was based upon the principle laid down 
bj Sir W. Macewen in his celebrated case. 1 —The Presi¬ 
dent said that he quite accepted the truth of Sir W. 
Macewen’s observations on which Mr. Parker had based his 
treatment of these interesting cases, but he did not consider 
that these observations contained the whole truth in refer¬ 
ence to the development of bone. If so, how were they to 
explain the formation of bone in various tissues, such as 
arteries, where no bone cells had ever existed 1 The constant 
precursor in such cases was a calcareous degeneration. If 
this excited any inflammatory change the young connective 
tissue formed bone. Calcified arteries, cysts, tumours, 4cc., 
in this way frequently originated bone in the neighbourhood 
of the calcareous deposit, and he would suggest that Mr. 
Parker should try the effect of the presence of phosphate of 
lime alone, as this could be introduced without a regular 
operation. 

Mr. T. 0. Litler Jones showed a patient both of whose 
feet he had amputated on account of the condition known 
as Tabetic or Trophic Foot. Lantern slides were shown of 
x ray photographs of the feet at various Btages of the disease, 
exhibiting very clearly the progressive melting away of the 
phalanges without primary inflammatory changes. The 
patient had none of the ordinary symptoms of tabes dorsalis, 
appeared to be in excellent health, and could walk remark¬ 
ably well on his artificial feet. 

Mr. A. S. Arkle read a paper on Physique and Health in 
the Liverpool Schools based on his examination of children 
from schools of three classes under the control of the 
county borough education committee and the boys of a 
public school. The statistics showed clearly that there was a 
close relation between status in life and feeding and the growth 
and development of the children. The influence of feed¬ 
ing was shown by comparing the children of industrial schools 
with those of the lower class of council schools. In regard to 
health, attention was drawn particularly to heart lesions and 
abnormality of the eye, ear, nose, throat, and teeth.—Professor 
T. R. Glynn said that some of the facts demonstrated by 
Mr. Arkle's figures might have been anticipated, but others, 
as the small number of congenitally syphilitic children, were 
contrary to what might have been looked for ; the explanation 
was in some degree the early death of the infected children. 
He hoped that Mr. Arkle would have an opportunity of extend¬ 
ing his observations in other directions, such as the relative 
prevalence of hereditary degeneration.—Dr. E. W. Hope 
mentioned that the excellent work which had been done by 
Mr. Arkle during the last few years gave some indication of 


1 Reported to the Royal Society in 1881, repealed and amplified in 
his lecture at the University of Liverpool in December, 1906, again 
related to the Royal Society in January, 190'/, nuid published in the 
Proceedings of June and in the British Medical Journal of June 22nd, 
1907. 


the magnitude of the task of the medical inspection of school 
children. It was absolutely necessary, as the excellent 
Memorandum of the Board of Education pointed out, to follow 
np the examination by an extension of the amelioration of 
the sanitary condition which had already proved so powerful 
a factor in improving the health of children. The methods 
of carrying out the Act had not been decided upon and Dr. 
Hope expressed the belief that the views of the medical pro¬ 
fession, if focussed and brought to the notice of the education 
authority, would receive every consideration at the hands of 
that body. He regarded the medical inspection of school 
children as an extremely important accessory in public 
health administration.—Mr. J. Bark agreed with Dr. Hope 
that the object of the Education Department was to prevent 
the occurrence in children of certain diseases which were 
detrimental to their physical and intellectual future. In the 
case of adenoids the earlier the removal was undertaken the 
better. The best results were obtained in children operated 
on between the ages of two and seven years. 90 per cent, 
of young children with enlarged faucial tonsils had adenoids. 
If the new Act was carried out efficiently the future genera¬ 
tions would be freer from deafness and chest troubles than 
the present. Dental examination and treatment were most 
important; oral sepsis was responsible for much of the 
physical deterioration of the race.—Dr. A. C. Wilson, 
medical officer to the truant schools at Hightown, said that 
he agreed with Mr. Arkle that under-feeding was the great 
cause of bad physique in the poorer classes of children. He 
rarely met with congenital syphilis, and this he attributed 
to the infected children dying out or getting into special 
institutions for the deaf and dumb, blind, or imbecile, Soc. 
The most pressing reform needed was the better care of the 
teeth. He was glad to say that the Liverpool education 
committee had recently appointed a dentist for all Liverpool 
schools. He believed that defective vision in children was 
to some extent due to the eye not being trained to distances. 
—Several other members having spoken. Professor Gi.yNN 
proposed, and Dr. G. G. Stopford Tayi.or seconded, the 
appointment of a subcommittee of the institution to consider 
and report on the Memorandum of the Board of Education. 
This proposal was adopted and a subcommittee was elected. 


LEEDS AND WEST RIDING MEDICO- 
CHIRURGICAL SOCIETY. 


Exhibition of Cases. 

A meeting of this society was held on Dec. 20th, 1907, 
Dr. J. Allan being in the chair. 

Mr. B. G. A. Moynihan showed a case of Complete 
Gastrectomy. The patient was a man, aged 43 years, with a 
two and a half years’ history. At the operation, on May 31st, 
1907, a condition of “leather-bottle” stomach was disclosed. 
The whole stomach was removed, the jejunum being joined 
to the oesophagus. The patient now ate well, worked as 
before, and had gained 3 stones in weight. 1 

Mr. Moynihan, with Dr. T. W t ari>rop Griffith, exhibited 
a case of Gastro-enterostomy for Pyloric Stenosis following 
corrosive poisoning. The patient swallowed half a pint of 
“spirits of 6altB.” At the operation the pyloric antrum was 
found to be almost solid. Gastro-enterostomy combined with 
jejunostomy was performed. 

Dr. A. G. Barrs, with Mr. J. F. Dobson, showed a case of 
Sub-diaphragmatic Abscess and Empyema rupturing through 
the Lung, apparently following a duodenal perforated ulcer. 
Drainage of the abscess and empyema by separate operations 
was followed by recovery. . 

Dr. T. Ciiurton showed: 1. A ca9e of Acute Spinal 
Myelitis in a boy, aged nine years. There were absolute 
paralysis and anfesthesia of the legs and incoordination of 
the detrusor and sphincter muscles in micturition. On 
July 13th he fell on his back ; in August the first symptom 
was difficulty in micturition. On the 17th signs of total 
transverse myelitis showed themselves. 2. A man, aged 57 
years, with Heart Disease and Anuria. Theocine sodium 
acetate, one grain every six hours, with strophanthin, ,Jothot 
a grain, had caused a great increase in the quantity of urine. 
In two former cases five-grain doses had been used ; the 
patients both got worse. 3. A girl, aged seven years, wit 
Partial Anuria and old Mitral Disease. Half a grain or 


1 Bee The Lancet, Dec. 21st, 1907, p. 1748. 






The Lancet,] 


EDINBURGH MEDICO-CHIRURGICAL SOCIETY. 


[Jan. 11,1908. 105 


theocine every eight hoars with digitalis were administered 
and the urine became doubled in quantity. 

;Mr. La WORD Knaggs showed; 1. A case of Actino¬ 
mycosis of the Jaw after two scraping operations. The 
patient had been accustomed to drive a cart laden with 
grain and whilst doing so to chew some of the grain. At 
Christmas he pulled out one of his teeth and afterwards 
grams would lodge in the wound and the latter did not heal. 
Soon after the disease made its appearance. 2. A case of 
Stone in the Left Ureter of 11 years’ history, with removal. 
A median laparotomy was performed in October, 1907. The 
ureter was dilated and the kidney was hydronephrotic. The 
stone was pushed up from the pelvis to the loin. The ureter 
was then exposed through an incision in the posterior 
peritoneum and the stone was steadied by two strips of gauze 
slung round the ureter above and below it. In this way the 
ureter was temporarily occluded above and below and when the 
stone was expressed through a longitudinal incision no urine 
escaped. The wound in the ureter was closed with fine silk 
sutures a la Lembert and a drainage tube was passed through 
the left loin. The peritoneum was then closed over the 
ureter and the abdominal incision was sutured in the ordinary 
way. Recovery was without incident. 3. A case of Extro¬ 
version of the Bladder; Hysterectomy ; Peter’s Operation. 
The patient was a woman, aged 31 years. At four years of age 
she had had Wood's (!) operation performed by Mr. W. H. H. 
Jessop. The result had been satisfactory, the bladder wall 
being covered over. Her condition, however, as she grew up 
became one of great misery, the vulva being kept in a 
constant state of irritation and inflammation as a result of 
the dribbling of urine and the deposit of phosphates on the 
hair and within the cul-de-sac which had been formed by 
operation. Her sufferings were aggravated at the periods 
and on inspection the condition of the parts was very foul. 
On June 26th, 1907, an operation was proceeded with 
and six weeks later a second one was performed. The parts 
were now clean, there was no offensive odour, and the urine 
was retained for four, and sometimes for five, hours. There 
was a small leak from a deep pocket in the original wound 
area, but she kept herself quite comfortable by a small pad 
which she changed two or three times a day. 

Dr. J. Gordon Sharp exhibited a case of Vaso motor 
Neurosis with Dermographism in an undersized boy, 14 
years of age. The patient had always a diffused blush over 
his face, which became accentuated by excitement and by 
stimulation of the skin. When any part of the skin of the 
body was written upon by a blunt instrument there followed 
in a few seconds a deep blush, and in a few seconds later 
the writing appeared as a white wheal, and remained 
for some time. The pulse-rate was now about 100. A 
thrill was ielt in the mitral area, and in the same region 
presystolic and systolic murmurs were heard but conducted 
to other areas. 

Dr. Barrs and Mr. H. Littlewood showed a case of 
Paraplegia with Sarcoma of the Spinal Meninges, in which 
laminectomy and removal of the growth were performed, 
recovery ensuing. The patient had for six months suffered 
from pain in the back at the level of the tenth dorsal spine, 
with stiffness and numbness of the right leg. There bad 
been a rapid increase of symptoms. On admission to hos¬ 
pital there were found to be complete paraplegia with 
anaesthesia up to two inches above the umbilicus and a 
narrow zone of hyperesthesia above this. Laminectomy 
was carried out and the tumour was removed. The patient 
had been shown to the society before but at that time he 
could only move his legs, whereas now he could walk. 

Mr. Littlewood showed : 1. A case of Carcinoma of the 
Rectum and Splenic Flexure in a patient, aged 52 years. 
Colotomy was performed on Nov. 8th, 1906, but with no 
relief. On Nov. 14th the abdomen was opened in the middle 
line and a mass was found in the splenic flexure. A Paul’s 
tube was put into the csecum. On Dec. 6th an enterectomy 
was carried out and on Jan. 10th, 1907, proctectomy was per¬ 
formed. 2. A case of Carcinoma of the Rectum and Ascend¬ 
ing Colon in a patient, aged 69 years, in which a polypoid 
malignant mass was found. On August 22nd, 1907, proct¬ 
ectomy was performed. The patient had symptoms of 
obstruction three months later and a mass was found in the 
ascending colon with nodules in the liver. On Nor. 14th a 
lateral anastomosis of the small intestine with the transverse 
colon was carried out and great relief followed, 3. A case 
of Pigmented Lymphangioma of the Foot in a patient aged 
14 years. 

Mr. W. Thompson showed a case of Actinomycosis of 


the Cheek and the Glands of the Neok. 18 weeks previously 
a swelling bad appeared in the mouth which had burst 
externally. The patient bad been in the habit of eating a 
little corn when feeding his pigeons. 

Dr. A. Wear showed: 1. Erythema Induratum Scrofulo- 
sorum in a patient, aged 36 years. The first appearance of 
the disease had occurred ten years previously, both legs 
being affected simultaneously, and repeated attacks had since 
been experienced. 2. Adenoma Sebaceum. The tumours 
were situated on either side of the nose. 

Mr. L. A. Rowdex and Dr. W. H. Maxwell Telling 
exhibited a case of Chronic Favus of Six Years’ Duration in 
a Child Treated by X Rays. Only a siDgle exposure was given 
on each affected area. 

Dr. Telling showed : 1. A case of Congenital Hypotonia 
(or amyopla-ia) in an infant, aged one year and nine months. 
Since birth the hands and feet had been noticed to be very 
soft ; these especially, and the limbs and skeletal muscles 
generally, were markedly flaccid and toneless, allowing 
considerable bending at the joints. The patient had been 
under continuous observation for 15 months with no notable 
change in the muscular condition. 2. Subacute Tylosis of 
the Nail-matrix. The condition bad commenced about three 
and a half months previously in one finger and rapidly 
spread to all the other fingers. There was a dry warty over¬ 
growth at the distal margin of the nail-bed which was 
lifting up the nail and spreading to the root in a V-shaped 
manner. 

Dr. E. F. Trevelyan showed : 1. Five cases of Peripheral 
Birth-palsy, illustrating lesions of the brachial plexus. 
2. Brown-Sfiquard Paralysis in a woman, aged 47 years, who 
had been stabbed in the back in August, 1907. On Oct. 4th 
a scar was seen in the neck to the right of the third cervical 
spine. There were motor paresis of the right arm and 
paralysis of the right leg and a considerable sensory loss on 
the left side. The patient was improving. 

Dr. Alexander Sharp showed a case of Fibroma of the 
Larynx. 

Mr. A. L. Whitehead exhibited a case of Congenital 
Left-sided Ptosis treated by Plastic Operation. 

Mr. Michael A. Teale showed : 1. A case of Staining of 
the Cornea of the Right Eye following an extensive haimor- 
rhage into the anterior chamber. 2. A boy showing a Con¬ 
genital Coloboma of the Right Iris directed upwards and 
inwards. 

Cases were also shown by Dr. A. Bisonner, Mr. H. Secker 
Walker, and Mr. Alexander Smith. 


EDINBURGH MEDICO-CHIRURGICAL 
SOCIETY. 


Exhibition of Cages. 

A meeting of this society was held on Dec. 18th, 1907, 
Dr. James Ritchie, the President, being in the chair. 

Dr. Alexander Bruce showed the following patients. 
1. A woman suffering from Myasthenia Gravis. She became 
fatigued on the slightest exertion and after climbing a stair 
she was completely collapsed. No muscular atrophy was 
present and there was no reaction of degeneration in the 
muscles, but the myasthenic reaction to electricity was 
present—i.e., the muscle soon ceased to respond to elec¬ 
trical stimulation. 2. A woman suffering from Amyo¬ 
trophic Lateral Sclerosis. This was essentially progres¬ 
sive muscular atrophy along with lateral sclerosis. The 
patient also showed bulbar phenomena. The condition 
had lasted barely two years. Atrophy of the left hand 
and arm was marked, the right extremity not being so 
advanced. The facies was peculiar, the lips were tightly 
compressed, and there was difficulty in protrnding the tongue. 
3. A woman exhibiting Neuritis of the Left Median Nerve. 
She had pricked her hand with a needle last July and 
subsequently a diffuse cellulitis of the front and back of the 
hand developed with pain along the course of the median 
nerve which was followed by desquamation of the skin in 
this area. At present there was tenderness over the whole 
of the left arm with tactile anesthesia over the whole 
area of distribution of the nerve, while marked hyper¬ 
algesia was present over this area. There was involve¬ 
ment of the roots of nerves of the cervical plexus 
and this extended as far down as the fourth dorsal 
nerve. The muscles of the left shoulder were atrophied. 




106 The Lancet,] 


ROYAL ACADEMY OF MEDICINE IN IRELAND. 


[Jan. 11, 1908. 


4. A woman who easily became very emotional and this was 
associated with a Clonic Spasm of the Right Hand. The 
right eyeball was prominent and the right side of the face 
was also enlarged. When she cried tears flowed most 
abundantly from the right eye and she also perspired more 
freely on this side of the face. The right side of the thyroid 
gland was somewhat enlarged. The condition was con¬ 
sequent on removal of both ovaries on account of double 
ovaritis. 5. A man who suffered from the rare spasmodic 
form of Syringomyelia. In February, 1907, he had an attack 
of numbness of the left arm and suddenly the Eecond and 
third fingers became flexed firmly on the palm and since then 
they could not be extended. The wrist, the elbow, and the 
shoulder-joint were also fixed. Over the left shoulder there 
was a large swelling and the whole tissues on the left side of 
the thorax were tough and firm as compared with those 
on the right side. There was loss of sensibility to heat and 
cold along the inner side of the left forearm. 

Professor John Chiene said that he was not satisfied 
with any of the methods of treating Congenital Wryneck. 
In a recent case he had operated by tumiDg down a flap of 
skin and tissue on the side of the contracted muscle over the 
mastoid ; he had then stripped off the periosteum from the 
mastoid process and so freed the upper end of the 
sterno-mastoid muscle. He had attached the upper extremity 
of the detached periosteum to the apex of the mastoid process 
and had thus elongated the muscle on the shortened side. 
The result had been excellent. He demonstrated the case 
of a young man who had been incapacitated for work by 
reason of a loose body in his left elbow joint which caused 
the joint to lock. The operation consisted in turning down 
a flap of skin from the back of the elbow above the joint and 
splitting the triceps after which an excellent view of the 
interior of the joint was obtained and a large loose body was 
removed. 

Mr. F. M. Caird exhibited eight cases in which Pylor- 
ectomy had been performed for malignant disease and in 
which the patients survived in perfect health. Healso showed 
a woman, aged 27 years, who had made a good recovery after 
an operation for Acnte Pancreatitis. She bad been seized 
with acnte epigastric pain, vomiting, and catchy respiration. 
The pupils were remarkably contracted and a diagnosis of 
acute pancreatitis was made. On opening the abdomen 
bloody serum exuded and on the surface of the omentum 
white spots of fat necrosis were observed. On the pancreas 
two large necrotic areas were observed ; these were scraped 
and drained. The gall-bladder was greatly enlarged and was 
stitched to the abdominal wound. When it was opened much 
dark bile and numerous gall-stones escaped. 

Dr. R. W. Philip showed several patients illustrative of 
the Cutaneous and Ophthalmic Tuberculin Reaction. He 
said that iu suspicious and not easily recognised cases of 
tuberculosis this reaction might be useful. For some years 
past he had employed the subcutaneous injection of tuber¬ 
culin as a diagnostic aid and stated that it was accompanied 
by no serious risk. It had been condemned, however, as 
likely to induce an acnte exacerbation in latent tuberculous 
conditions. He showed cases in illustration of the cutaneous 
method. The skin c f the arm was scarified in the ordinary 
manner and a solu ion of tuberculin was rubbed in. This 
solution contained 25 per cent, solution of old tuberculin. 
25 per cent, solution of carbolic acid in glycerine, and 50 
per cent, of normal saline solution. In the course of from 
24 to 48 hours a definite local reaction in the form of a rosy 
red patch was seen, the skin became infiltrated, and papules 
or vesicles formed. A scaly condition of the skin followed 
and the redness faded, but for some weeks subsequently a 
certain degree of pigmentation remained. The ophthalmic 
reaction was obtained by dropping one minim of the 
following solution between the eyelids. In from 
three to six hours later a perfect reaction was ob¬ 
tained and left no permanent change. The solution 
consisted of five milligrammes of dry tuberculin (preci¬ 
pitated by alcohol) in ten minims of sterile normal saline 
solution. A congestion appeared on the palpebral and ocular 
conjunctiva, especially towards the inner canthus. The 
caruncle became inflamed and a certain amount of exudate 
might form. The reaction seldom persisted for more than a 
week. It had to be borne in mind that the reaction might 
not occur even in cases in which tubercle bacilli might be 
abundantly observed. 

Mr. H. Alexis Thomson showed a patient, aged 29 years, 
who had sustained a Gunshot Injury of the Upper Arm six 
months before he came under observation, with smashing of 


the humerus and tearing of the mnsculo-spiral nerve. An 
operation was performed for ununited fracture of the 
humerus, when it was found that the extent of destruction 
of the nerve rendered suture impossible. The distal end was 
therefore inserted into the median nerve above the elbow. 

Mr. J. W. B. Hodsdon showed a case of Dupuytren’s Con¬ 
traction which had persisted for 20 years and was cured by 
hypodermic injections of “ fibrolysin.” Two cubic centi¬ 
metres of the solution bad been injected on 19 occasions, 
either intravenously or subcutaneously, and not necessarily 
near the affected part. Fituolysin caused a softening of 
pathological fibrous tissue, but as it did not cause its absorp¬ 
tion this had to be facilitated by massage, Ac. This treat¬ 
ment was useful in all cases of fibrous adhesions, scars, 
adhesions of the pelvic organs, corneal opacities, Ac. 

Mr. E. W. Scott Carmichael showed a boy, aged ten 
years, after Acute Suppurative Cholangitis and Cholecystitis 
following generalised streptococcal peritonitis. 


ROYAL ACADEMY OF MEDICINE IN 
IRELAND. 


Section of Obstetrics. 

Exhibition of Speciment .— The Teaching of Obstetrioe. 

A meeting of this section was held on Dec. 13th, 1907, 
Mr. E. H. Tweedy, the President, being in the chair. 

Dr. Henry Jellett exhibited a Uterus showing unusual 
tliinniDg of the muscle of the fundus after pregnancy 
obtained from a patient who was 30 years old and was 
suffering from carcinoma of the vagina. She had had a baby 
four weeks before going into hospital. He decided to 
perform an operation but during the night before it was to 
take place her temperature rose to 104° F. and she had 
severe rigors. On the morning of the day of the operation 
her temperature was still 104° and her pulse-rate anything 
up to 140. The operation was therefore contra-indicated 
and so he thought it best to wash out the uterus. Before 
doing so he inserted a sound and this passed into the abdo¬ 
minal cavity straight through the fnndns the resistance of 
which was quite inappreciable. He did not like to leave a 
probably septic uterus with an opening into the peritoneum 
and so he removed the uterus by the vagina and as much of 
the cancerous vaginal wall as he could. After the operation 
be split the uterus to see why the sound had gone through it 
and he found that there was a cone-shaped excavation 
extending through the fundus almost up to the peritoneum. 
The rest of the wall preserved its normal thickness. Micro¬ 
scopical examination of the fundus showed no evidence of 
malignant growth. The only explanation that he could offer as 
to the cause of the perforation was that the placenta had 
exercised an eroding influence on the uteruB at one spot. 
The patient got better for a time but died about two months 
afterwards from general metastases and weakness. 

The President exhibited a Double Pyosalpinx removed 
intact. He said that the patient complained only of sterility. 
She had no pain and she did not look ill. She was young, 
two or three years married, and had been sent to him to be 
curetted. He palpated the tumours and diagnosed double 
ovarian cyst; the uterus was felt lying between them. He 
was very much surprised to find that they were really very 
large tubes. They were taken out and joined together 
without difficulty. The point of interest was that he hoped 
he had thus cured the patient's sterility. There was one 
ovarian cyst which was removed. The other ovary was 
resected and a good sound piece left behind together with 
healthy tube stumps. 

Sir William J. Smyly opened a discussion on the Changes 
which had been suggested by the General Medical Connell 
in the method of Teaching Practiced Obstetrics. He said 
that the circumstances which had led up to the action of the 
General Medical Council originated in the discovery of the 
true nature of puerperal fever by Semmelweis and its pre¬ 
vention by Lord Lister, in consequence of which this scourge 
bad been practically banished from our lying-in hospitals- 
The hope that a similar result would follow in general 
practice had not been realised, and Dr. R. Boxall had shown 
that from the returns of the Registrar-General it appeared 
that the maternal mortality from septic infections in child¬ 
bed was even worse than it had been. The pnblio'tion of 
these facts produced a profound impression in England, the 
outcome of which had been the Midwives Act and the eno » 




Thi Lancet, ] 


WINDSOR AND DISTRICT MEDICAL SOCIETY. 


[Jan. 11,1908. 107 


on the part of the General Medical Conncil to improve the 
education of students in midwifery. In England the oppor¬ 
tunities for the teaching of practical midwifery were meagre 
so that it was necessary to make very moderate demands 
upon students with regard to the practical study of mid¬ 
wifery, but in Ireland, with its great lying-in hospitals, 
it would be a retrogression to adopt any of the recommenda¬ 
tions of the General Medical Council. Dr. Boxall had shown 
that the statistics of obstetrics in general practice were 
worse in Ireland than in England. In order to remedy this 
students must either be compelled to attend a certain number 
of confinements or demonstrations, or, what would be much 
better, a desire to study practical obstetrics must be aroused 
in them by adopting the recommendation of the General 
Medical Council with regard to practical clinical examination. 
They should be made to feel that a practical knowledge of 
obstetrics and gynaecology was useful in passing examinations. 
—Mr. A. J. Horne said that the subject was of particular 
interest to Dublin, which was practically the home of 
obstetrics. The Dublin school for a great number of years 
had rightly insisted that the course of study should be a 
comparatively long one, and the General Medical Council, in 
order to raise the standard of both England and Scotland, 
had offered to compromise with Dublin by suggesting that 
the period of study should be three months. Annually in 
Dublin something like 200 students had to take out their 
course of midwifery. If they simply attended for three 
months it would be utterly impossible to supply them 
with material for each man to take out his 20 “con¬ 
ductions.” The period was too short. How it would 
be accomplished in England he did not know, but 
he did not believe that the keeping up of the existing Dublin 
standard would cause a single pupil to leave the country.— 
Dr. Frederic W. Kidd said that midwifery was a subject 
in which it was very necessary to have a thorough knowledge 
of the theory before practical work was attempted. It was 
an established fact that the mortality in the lying-in hospitals 
was lower than that of general practice in the country, not¬ 
withstanding that the dangers to a woman in a hospital were 
greater than those in private practice and the cases were 
more morbid and serious. The unavoidable inference was 
that the medical practitioners and nurses did not carry out 
in general practice the same strict rules of asepsis as in the 
institutions where they were taught to do so. He felt that 
a man who lived in the precincts of a hospital for one 
month would in all probability lay up a greater store 
of knowledge than one who attended a lying-in hospital 
two days in the week for three months.—Dr. Richard D. 
Purbfoy suggested that some arrangement might be made 
with the masters of the hospitals by which the obstetrical 
examiners of the colleges might make a monthly visit snd 
have opportunity given to examine certain students. This 
would obviate the difficulty of carrying out the practical 
examination for a large number of students at one time. 
He thought that students should be encouraged to reside 
even for one month, in some of the maternity hospitals.— 
Dr. Jei.lbtt said that they were all probably agreed 
that the recommendations of the General Medical Council 
were extremely good, with the exception of the altera- 
tion in the course of attendance at maternity hospitals 
from six to three months. In Ireland such an altera¬ 
tion would shorten the present course, whereas in England 
and Scotland it would raise it to a much higher standard 
than before. He was quite aware that the present state 
of affairs was open to the objection that all students did 
not attend the full course. A three months’ course pre¬ 
sented the great practical difficulty that students could not 
1 m given their 20 cases in so short a time. He thought that 
if the Dublin Colleges adhered to their six months’ course 
and made some attempt to define regular attendance they 
would not only maintain but enhance the reputation of the 
Dublin School and would make the obstetrical train¬ 
ing of the greatest value to the student,—Dr. Robert J. 
Rowlbtte said that there were certain faults in the 
final examinations in midwifery and gynaecology and that 
if these were taken away the subjects would be more 
attractive to students : one was the excessive amount of 
surgery required by the gynecological examiner ; it vas ro 
part of the duty of an ordinary medical practitioner to be 
able to perform highly technical operations. If the student 
was going to be a specialist he must make up his work afler 
his qualifying examination, not before it. He was only 
referring to highly technical operations; operations of 
emergency must, of course, be within the knowledge of every 


medical man. As to the high mortality in private practice he 
thought it might be explained by the fact that more cases of 
childbirth were left unattended by medical men in Ireland 
than in England. It was also quite impossible for a medical 
man to practise the same aseptic precautions in a country 
cottage as in a hospital.—The President said that it was 
pleasant to see with what unanimity the members of the 
Obstetrical Section opposed the suggested curtailment of the 
period at present deemed necessary in Dublin for attendance 
at maternity hospitals —It was then proposed by Sir William 
Smyly, seconded by Dr. Jelleit, and carried unani¬ 
mously :— 

That the Obstetrical Section of the Academy of Medicine regRrdB the 
recommendations of the General Medical Council regarding obstetrical 
teaching as in many rases a very great advance on the present con¬ 
ditions. The section, however, considers that the suggested alteration 
of the period of attendance on a maternity hospital from six months 
would not be advisable or practicable. The section considers that 
instead of reducing tlie attendance the licensing bodies should adopt 
such regulations as will insure regular attendance of students at the 
clinical teaching of the hospitals. With regard to the adoption of a 
practical examination in midwifery and gynaecology, the section con¬ 
siders that such a step is most desirable and urges ita members to aid it 
by all means in their power. 

Dr. Purefoy then proposed, Dr. Kidd seconded, and it 
was carried unanimously :— 

That a committee consisting of the masters and assistants fpast and 
present) of the Dublin maternity hospitals be appointed for the purpose 
of urging upon the licensing bodies the inadvisability of changing the 
course of practical obstetrics from six months to three months. 


Windsor and District Medical Society.—A 
meeting of this society was held at the Guildhall, Windsor, on 
Dec. 18th, 1907, Dr. E. S. Norris (Eton), Vice-President, 
being in the chair.—Dr. W. H. W. Attlee read a paper 
entitled, “ The Treatment of Puerperal Eclampsia.” He com¬ 
menced by recounting the theories advanced to explain the 
phenomena of eclampsia, the microblc, the placental, that 
of thyroid inadequacy, and the auto-intoxication theory, 
pointing out that the last was the one which found most 
favour at the present day, the toxin being supposed to be 
formed in some way in the intestinal tract and absorbed 
from there into the general circulation. This was 
borne out by post-mortem appearances, for the cell 
necrosis so evident in the abdominal viscera was 
most noticeable in the liver, which was what would 
be expected if the portal vein were collecting the poison 
from its tributaries. Dr. Attlee proceeed to divide 
the treatment into two stages : (1) that before the con¬ 
vulsions bad occurred ; and (2) the actual attack of 
eclampsia— i.e., when the convulsions had begun. In the 
first stage he advised the postponement of active measures 
as long as possible, treating the patient with rest in bed, 
absolute quiet, free purgation with calomel or diuretic salts, 
and a milk diet, if in spite of this matters grew worse 
labour would have to be induced. In this connexion Dr. 
Attlee emphasised the importance of examining the urine of 
every pregnant woman and related a case illustrating the 
benefit derived from such routine examination. When the 
fits had already begun the first duty was to attend to the 
convulsions. The patient should be prevented from injuring 
herself and the tongue should be protected. One minim of 
croton oil or five grains of calomel or even salts if possible 
should be administered at once. Chloroform should be 
used to control the paroxysms, and when the patient was 
well under its influence an examination should be made 
and a decision arrived at as to whether labour should be 
terminated or not. With regard to this important point 
Dr. Attlee said that probably the indications for induction of 
labour were similar to those which would point to a grave 
prognosis—viz., fast and feeble pulse, scanty urine, rising 
temperature, and a prolonged duration of coma between the 
fits. The scantiness of the urine was more important than 
the amount of albumin. After describing the best means of 
inducing labour Dr. Attlee detailed the treatment to be 
adopted if it should be decided not to terminate the labour. 
In this event he said that morphine should be given, best 
hypodermically in doses of one-third of a grain every 
two hours until a grain had been given. Saline 
solntion should also be infused both into the subcutaneous 
tissues and into the rectum. The administration of thyroid 
extract was discussed. Should the eclampsia occur 
actually during labour Dr. Attlee advised that the labour 
should be terminated as quickly as possible, great care being 
taken to avoid sepsis, the danger of this complication in 
such cases being duly insisted on. Allusion was made to the 



108 The Lancet,] 


REVIEWS AND NOTICES OF BOOKS. 


[Jan. 11,1908. 


post-partum variety of eclampsia, and here again it was 
said that the drag indicated was morphine. Finally, 
Dr. Attlee read notes of a most unusual case, fortu¬ 
nately with a favourable termination, in which the 
puerperium was complicated by symptoms of the gravest 
augury—viz., jaundice, suppression of urine, twitching 
of the limbs, drowsiness, and coma. There were diminution 
of the area of liver dulness and tenderness over the right 
hypochondrium, the temperature and pulse being only very 
slightly raised. The rapidity with which these symptoms 
disappeared suggested some form of toxaemia as the cause, 
but whether this was of the nature of eclampsia, Icterus 
gravis, or saprtemia he was unable to determine.—A brief 
discussion ensued in which Dr. Norris, Dr. W. F. Lloyd, Mr. 
J. W. Gooch, Dr. A. M. Amsler, Mr. A. D. Crofts, and Dr. 
C. R. Elgood took part. 


Jekietos aito State of Jacks. 

Surgery, its Principles and Practice, By Various Authors. 
Edited by William Williams Keen, M.D., LL.D., 
Professor of the Principles of Surgery and of Clinical 
Surgery, Jefferson Medical College, Philadelphia. Vol. I., 
pp. 983. With 261 text illustrations and 17 coloured 
plates. London and Philadelphia : W. B. Saunders Com¬ 
pany. 1906. Price 30». 

Professor Keen has secured the assistance of 66 able 
colleagues in the arduous work of compiling a system of 
surgery. It is to extend to five volumes and will contain 
more than 4000 pages, and the names of the writers are in 
themselves a guarantee that this treatise will contain a full 
exposition of modern surgery. No one could be better fitted 
for the task of editing such a work as this than Professor 
Keen and a careful perusal of this volume serves but to 
confirm our anticipations. Dr. Mumford of Boston has con¬ 
tributed a sketch of the History of Surgery and though by 
no means exhaustive it is sufficiently full for a text-book. 
Unfortunately, few surgeons seem to care about the history 
of their craft. It has often been suggested that the history 
of medicine should be a subject for examination ; this is not 
desirable, as the curriculum is quite extensive enough at 
present; but at most medical schools a few lectures each 
year on the history of the medical sciences would, we are 
sure, be well attended and very popular. The University of 
London might well consider the question of instituting some 
such lectures. Dr. G. W. Crile of Cleveland has contributed 
a chapter on Surgical Physiology. It deals chiefly with the 
changes of blood pressure in injuries and operations. It is of 
very definite interest and importance. The article on the 
Examination of Blood by Dr. J. C. Da Costa, jun., is mode¬ 
rate in tone and does not claim for examinations of blood that 
finality in doubtful cases which some of the advocates of 
bsematology demand for it. In many difficult cases the 
surgeon needs all the aid that can be obtained and exa¬ 
mination of the blood may assist in deciding on a diagnosis, 
but like most other signs and symptoms it must not be given 
pathognomonic value. Dr. Ludvig Hektoen of Chicago has 
written a useful chapter on Infection and Immunity and he 
has explained fully the various current theories of the latter 
condition. 

The chapter on Inflammation has been contributed by Dr. 
J. G. Adami of Montreal and it is hardly necessary to say 
that the account is thoroughly good. The part of the article 
dealing with the treatment of inflammation has to do only 
with the broad questions of treatment, the details of the 
treatment of special inflammations being dealt with else¬ 
where. Dr. G. K. Armstrong has assisted Dr. Adami in 
some of the practical details and the result is excellent ; it 
is a happy combination of theory and practical knowledge. 
The treatment advised must depend, to a large extent, on 
our present knowledge of inflammation, but recognising, as 
we all mast, that that knowledge is not final the authors 


have wisely not carried the theories to extremes. They 
explain the arrest of erysipelas from painting the healthy 
skin beyond with nitrate of silver as due to a localised 
leucocytosis, and the frequent failures of this method of 
treatment are attributed to the painting having been done 
too near the advancing erysipelatous edge, for strepto¬ 
cocci may be as much as half an inch in front of the 
visible edge of the erysipelas. In similar ways the authors 
explain both the successes and the failures of many of our 
procedures which we have employed for empirical reasons 
for many years. 

Dr. L. Freeman of Denver is responsible for the section 
on Suppuration, Abscess, Ulceration, and Gangrene, and we 
need only say that it is very readable and up to date. Dr. 
F. C. Wood’s account of the process of repair is provided 
with a good bibliography, though, as the writer remarks, it 
contains only the more important references. Here we may 
mention that all the articles conclude with a list of the more 
valuable writings on the subject treated. Dr. C. H. Frazier 
of Philadelphia has written on Thrombosis and Embolism 
and the succeeding articles deal mainly with specific diseases, 
Dr. Frazier writing on Erysipelas, Tetanus, Anthrax, Actino¬ 
mycosis, and similar infections ; Dr. Frazier speaks in favour 
of intraneural injections of antitoxin in the treatment of 
tetanus—a method but little used in this country. 

Dr. E. A. Smith of Buffalo has contributed an excellent 
article on the Traumatic Fevers. He objects to the use of 
the term “ sapnemia," chiefly apparently because it is not 
always possible to distinguish between cases where the pro¬ 
ducts only of the micro-organism in the wound have been 
absorbed and those cases where the pathogenic organisms 
themselves have entered the blood stream. We cannot agree 
with him ; the distinction in typical cases is clear and im¬ 
portant and the term well deserves to be retained. The 
article is illustrated by some very good temperature charts. 
In Dr. E. H. Nichol’s paper on Rickets he discusses the 
etiology and he mentions the deficiency of lime theory, 
the lactic acid theory, and the toxic theory, but he does not 
(so far as we have been able to seel say anything about the 
theory that absence of assimilable fat in the food is the 
cause of rickets. The chapter on Surgical Tuberculosis by 
Dr. J. C. Da Costa occupies over 80 pages and gives a good 
account of this important branch of surgery. The tuberculin 
treatment is mentioned and condemned but nothing is 
said of the use of tuberculin when controlled by opsonic 
estimations. m 

Dr. E. Martin of Philadelphia has written on Chancroid 
and on Syphilis. We agree with him that the chancroid is 
probably caused by a special micro-organism and is not 
merely the result of ordinary pyogenic cocci. The 
spirochaita pallida is described and figured. The section 
on parasyphilis is poor. This grouping suggested by 
Fournier of a large number of indefinite conditions, many 
of which have absolutely nothing to do with syphilis, is 
decidedly a retrograde step. To include in one class leuco- 
derma, keloid, diabetes, and neurasthenia is absurd. Tabes 
and general paralysis of the insane stand upon quite a 
different footing. It is useless to finish this section by such 
a sentence as this: “Infantilism, hydrocephalus, hare-lip 
and cleft palate, olub-foot, idiocy, any of the dystrophies 
may be parasyphilitic in nature.” Mr. J. Bland-Suttons 
paper on Tumours is characterised by that originality of idea 
and method for which he is well known. It is very complete, 
occupying nearly 150 pages. Dr. Crile has written on Wounds 
and Contusions and also on Shock. He describes the "pneu- 
matiosuit” which he invented ; it consists of a double layer of 
rubber which is inflated with a bicycle pump. By means of 
this suit he can raise the blood pressure by from 15 to 40 
millimetres of mercury. It is certainly ingenious and 
deserves to be known more widely. 

The whole volume is very fully illustrated and we must 





Th* JjANCKT,] 


REVIEWS AND NOTICES OF BOOKS. 


[Jan. 11, 1908. 109 


not omit to mention the extensive index which has been pro¬ 
vided. The work is a credit to the editor, to the contributors, 
and to the publishers. 


The Labyrinth of Animals. By Albert A. Gray, M.D. 

Glasg., F.R.S.Edin. Vol.I. London : J. and A. Churchill. 

1907. Pp. 198. Price 21s. 

This volume is the first instalment of a series of stereo¬ 
scopic plates illustrating the internal ear of animalB, by 
which we presume vertebrates are meant. The author decides 
—and we think wisely—to work downward through the verte¬ 
brate phylum, beginning with man ; consequently this first 
volume with its 31 plates deals with only a part of the 
mammalian class and includes the orders of Primates, 
Cheiroptera, Carnivora, Ungulata, Edentata, and the 
majority of the Rodentia. An examination of the plates 
shows that technical skill of the highest class must have 
been expended on the preparation of the specimens 
as well as in photographing them, and we are not 
surprised to read that the author has spent seven 
years in completing his series and that a large part 
of this time was devoted to perfecting his methods. Each 
plate shows the labyrinth decalcified and removed from 
the sknll, suspended by the superior semicircular canal and 
looked at generally from the outer side. A small stereo¬ 
scope is inclosed in a case in the cover of the book and with 
a very little practice a perfectly beautiful representation of 
the original specimens is seen magnified some five times. 
The method of preparation is fully detailed; roughly 
speaking, it consists in decalcifying and clearing but the 
minutiae are complicated and each specimen takes three 
months before it is ready for photographing. 

There is no donbt that this will prove a valuable work 
of reference for the comparative anatomist, the physiologist, 
and the aural surgeon. To the first certainly it is 
most valuable because up to the present so little has 
been known about the internal ear of mammals, although 
Retains has done much for that of the lower verte¬ 
brates. Dr. Gray regards the cochlea as a useful structure to 
take into account in the classification of animals, because, as 
he says, it is not subject to marked variation as a result of 
particular environment. Whether an animal lives in the air, 
the water, in the tree tops, or underground, it must always 
hear and so, if its cochlea varies, it is a sign of relationship 
rather than excessive use or disuse. We are a little doubtful 
whether the material at Dr. Gray’s disposal is sufficiently 
large to allow him, cot to dogmatise—he does not attempt 
that—but to make even plausible suggestions. It must be 
remembered that, immensely valuable though his contribu¬ 
tion to science is, it is only a contribution, and that 
generalisations on the bats have to be made on his two 
specimens, one of the fruit bat and the other of the pipis¬ 
trelle, while that extremely heterogeneous order, the Edentata, 
is also only represented by two specimens, the three-toed 
sloth and the Tamanduan ant-eater. Until more material is 
available it would be premature to say whether the cochlea 
is or it not a point of classificatory value. ' 

The author notices that cochleae fall into two categories 
which he calls flat and sharp pointed and that these are not 
necessarily dependent on the number of turns there is in 
the spiral. He further points out that the different orders 
of mammals fall moderately satisfactorily into one or other 
of these categories; but here again we should like more 
material before expressing an opinion since both types of 
cochlea have been found in the marsupials, although only 
the kangaroo, the wallaby, and the phalacger have been 
examined. A very interesting point in the semicircular 
canals is the variable size of the perilymph space which is in 
most mammals small or even absent, though sometimes, as in 
man, larger than the endolymph space. Dr. Gray thinks 


that the latter is probably the more primitive or generalised 
condition since it also exists in reptiles and birds. 

In discussing the subject of otoliths the author says that 
it is important not to mistake them for pathological deposits 
of calcareous salts which may occur in any animal and in 
any position in the vestibule. It is not quite clear whether 
these deposits are the otoconia which are well known to 
comparative anatomists and are so constantly found that it 
is doubtful whether pathological is quite the right adjective 
to use; indeed, there is one shark which accumnlates 
granules of sand through an open aqueductos vestibuli and 
these apparently serve the same purpose as the otoconia in 
other forms. 

At the end of the book is a table of measurements which 
will be undoubtedly valuable in the future when the morpho¬ 
logists, physiologists, and field naturalists come to tackle 
seriously the meaning of the variations found in the internal 
ear. Meanwhile, we cordially thank Dr. Gray for a valuable 
addition to our knowledge and look forward to the appear¬ 
ance of his second volume. 


Atlas and Epitome of Diseases of Children. By Dr. R. Hecker 
and Dr. J. Trumpp. Authorised translation from the 
German, edited by Isaac A. Abt, M.D. With 48 coloured 
plates and 147 black-and-white illustrations. London and 
Philadelphia : W. B. Sannders Company. 1907. Pp. 453. 
Price 21s. net. 

The original German work, of which the present volume is 
the authorised English translation, was published in the year 
1905. In Germany the book has proved an undoubted 
success owing probably to the fact that a work of this kind, 
attractive in appearance and profusely illustrated, presents 
a striking contrast to the usual ponderous and dull class of 
book which is published for the instruction of German 
students. The authors admit that no text-book can take the 
place of clinical observation but they believe that this 
failing can to a great extent be supplied by pictorial illustra¬ 
tion of the kind to be found in their atlas and epitome. With 
this object in view they have arranged an enormous number 
of coloured and uccoloured illustrations in a series and in a 
manner which they believe will be useful to students who 
have not had the advantage of complete clinical instruction. 

In the translation considerable changes have been made in 
the sections on therapeutics and these have been revised in 
accordance With accepted practice in America; additions 
made by the editor will be found inclosed in brackets. So 
far as the text is concerned there is little need for comment; 
it represents a highly condensed and commendably accurate 
summary of the common diseases and ailments to which 
children are subject. Therapeutics and treatment, in spite 
of the alterations and amendments made by the editor, are 
scanty and of such a superficial character that we doubt 
whether they will be of much use to the student or 
indeed to the practitioner. On the other hand, the illustra¬ 
tions, especially of the rashes of the specific fevers, should 
be extremely valuable ; there seems to us, however, to be 
far too many illustrations of microscopic and macroscopic 
pathological specimens. The illustration of Hecker’s urine 
vessel for infants which appears on p. 386 shows an infant 
placidly sucking an indiarubber teat. We hope that the 
students who read this book will not regard ‘ ‘ the comforter ’* 
as an essential in nursery equipment. 

An Index of Treatment by Various Writers. Edited by 
Robert Hutchison, M.D, Edin., F.R.C.P. Lond., 
Physician to the London Hospital, &c., ana H. 
Stansfield Collier, F.R.C.S. Eng., Surgeon to St. 
Mary’s Hospital, &c. Bristol: John Wright and Co. 
1907. Pp. 877. Price 21*. net. 

WnETHER it is that we are pygmies compared with our 
forefathers, or that collectivism is in the air, or simply that a 
multitude of authors provide so many separate centres of 





HO The lancet,] 


REVIEWS AND NOTICES OF BOOKS. 


[Jan. 11,1908. 


infection, if we may bo term them, for the Bale of a book, 
certain it is that the tpivos or contribution feast is now 
popular in medical literature rather than the banquet pro¬ 
vided by the mature experience of a single author. The 
Index before us is the work of 72 contributors and, amid 
such a multitude, we cannot but admire the modesty 
of the surgical editor who has apparently made no con¬ 
tributions to the text but has contented himself with super¬ 
visory work. The book deals with medicine, surgery, and 
speoial subjects and so far as it is possible to comprise the 
treatment of all ailments to which flesh is heir in 
a single volume the result is satisfactory. The articles 
are clear and to the point and “ care has been taken to avoid 
embarrassing the reader with a large choice of procedures.” 
The book should prove useful to the practitioner in the course 
■of his everyday work. The impossibility of separating treat¬ 
ment from questions of diagnosis and pathology is illustrated 
In this Index, and here and there the editors have been 
nnable to refrain from sections dealing summarily with these 
subjects. It has also apparently been thought necessary 
to add an index, which is rather a confession of failure 
In the original arrangement. The supplementary index 
■contains a good many examples of how not to do it. 
Such entries as “Incision, its use in empyema,” “Danger, 
■Condition of, in Anaesthesia,” serve as examples. We 
may add that “Achoria” can only mean inability to 
dance, the treatment for which would presumably be 
different from that for “ acoria ” (dxopfa), failure of the sense 
of satiety. The printing of the book is good, the type 
employed being clear though necessarily close, while mis¬ 
prints are rare. The illustrations are also useful and are 
adequate in number. 


LIBRARY TABLE. 

Light and A' Ray Treatment of Skin Diseases. By Malcolm 
A. Morris, F.R.C.S. Edin., Dermatologist to King Edward 
VII.’s Hospital for Officers, Surgeon to the Skin Department 
of the Seamen’s Hospital, Consulting Surgeon to the Skin 
Department of St. Mary's Hospital; and S. Ernest Dore, 
M.D. Cantab., Assistant in the Skin Department of the 
Middlesex Hospital. With 12 plates. London, Paris, New 
York, Toronto, and Melbourne : Cassell and Company, 
Limited. 1907. Pp. 172. Price 5i.—This is one of a 
series called “Modern Methods of Treatment” which is 
being issued by Messrs. Cassell and Company. In recent 
years many new methods of treatment have been introduced 
and there is a demand for more detailed accounts of them 
than those to be found in the ordinary text-books. Espe¬ 
cially is there a need for a fall description of radiant 
methods of treatment of diseases of the skin. Most medical 
men have very vague ideas of FinBen light and x rays and 
they would like to know more even if they have no intention 
of practising these methods. Sir Malcolm Morris and Dr. 
Dore are well qualified to speak with authority in these 
matters, as they have both had much experience in 
the radiant methods, and the former was one of the 
earliest to employ Finsen light in this country. The book 
is not, and is not intended to be, exhaustive but it contains 
all the essentials. The authors are very satisfied with the 
x ray treatment of ring-worm, and though they use and 
appreciate Sabouraud’s “ pastilles ” to measure the intensity 
of the rays, yet they do not think it advisable to depend on 
them alone. The amperage of the primary current, the volume 
of the induced current, the spark-gap, the appearance of the 
tube and of the anode, and the time of exposure should all 
receive attention. 

Le Micro-organisme de la Syphilis, Ireponema Pallidum 
(,Sehaudinn ). Par le Dr. LKVY-BlNG, Chef de Laboratoire 
de Saint-Lazare, Lamest de la Faculty de Helecine. (The 
Micro organiemof Syphilis. By Dr. Levy-Bing.) With figures 


in the text and one chromo-lithographic plate. Paris : Octave 
Doin. 1907. Pp. 329. Price 5 francs.—The microbe first 
described by Sehaudinn is now accepted almoBt universally 
as the cause of syphilis. Many previous “discoveries” of 
the bacillus of syphilis have been made but time has always 
disproved the claims. The spirochsota pallida, as it was first 
called, or treponema pallidum as it is now known, is stained 
with a good deal of difficulty and it was not till the special 
stain was employed that it waB possible to see it. It is now of 
diagnostic value, at least so far as its presence is concerned ; 
if it is not found its absence may only be apparent and may 
be due to want of skill on the part of the examiner. This 
volume contains all that was known up to the moment of 
publication of the treponema pallidum. The microscopic 
technique is fully detailed and the natural history of the 
organism is discussed. Unfortunately, we cannot grow it on 
any of the media tried and so its life-history is as yet 
undetermined. An interesting chapter is that dealing with 
the action on the treponema of mercurial treatment. Some 
observers have found the organism present after some treat¬ 
ment but Dr. L6vy-Bing has shown that under careful 
mercurial treatment the treponema steadily diminishes in 
abundance as the treatment is continued. The book is very 
thorough and well deserves perusal by all interested in this 
subject. 

Wit and Humour of the Physician. By F. R. London: 
Alexander Moring. 1907. Fp. 218. Price Is. 6 d .—This little 
book contains an abundance of medical anecdotes, quips and 
cranks, and if they are not all likely to be greeted by 
“wreathed smiles” yet there is a sufficiency of amuse¬ 
ment in them to justify their title. The way to enjoy a book 
of this kind is to take it in small doses ; if many pages be 
ingested at one gulp they are liable to cloy. We are a little 
tired of the many variants of the old theme which jocularly 
accuses the doctor of being the immediate cause of a sick 
man’s demise or a fee-lover above other men. The book may 
be useful to after-dinner speakers at professional gatherings 
who have not the natural means of leavening their wisdom. 

The Poems of Samuel Taylor Coleridge. With an intro¬ 
duction by A. T. Quiller-Couch. The Three Clerks. By 
Anthony Trollope. With an introduction by W. 
Teignmouth Shore. The Life of John Sterling. By 
Thomas Carlyle. With an introduction by W. Hale 
White. Margaret Catohpole. By Richard Cobbold, with 
an introduction by Clement Shorter. The World's 
Classics Series. London: Henry Frowde. 1907. Price 
Is. each .—Sesame and Lilies and Ethios of the Dust. 
By John Ruskin. London: George Allen. 1907. Price 
Is. net.—The World’s Classics continue to stream from 
Mr. Frowde’s press with a regularity that seems to 
bespeak a solid appreciation on the part of the reading 
public. Every batch which we receive serves to remind us 
of the richness of true English literature. It is not the 
function of a medical paper to review critically the substance 
of such reprints as these, and indeed in the case of many 
there is hardly any new thing to be said. Coleridge has cer¬ 
tainly found his level as one on whom the fire from Heaven 
descended in his youth but whose flame was wofully 
quenched by profitless metaphysical self-torture in his 
riper years. But whilst poetry lives, “The Ancient Mariner” 
and “ Kubla Khan ” will retain to the full their mystic force. 
Two of the lesser known works of Carlyle and Trollope come 
next before us, the one an earnest apologia, the other a novel 
written only to amuse, and both with the stamp of a bygone 
day upon them. We take it that the introduction to “John 
Sterling ” by W. Hale White is not written by the physician 
of that name but by the able author of ‘ 1 Mark Rutherford’s 
Deliverance ” who now employs the name of his hero as a 
literary pseudonym. Mr. Teignmouth Shore’s introduction 
to “The Three Clerks” is delightful. The remaining novel 





Thu lanokt,] 


REVIEWS AND NOTICES OF BOOKS. 


[Jan. 11, 1908. Ill 


of Mr. Frowde’s batch is a well-known Suffolk story of the 
barbarous penal code which prevailed in the eighteenth 
century. The last book of which we write, though of almost 
similar format, is from Mr. Allen’s press at the house which 
bears the name of the author of “Sesame and Lilies” and 
“Ethics of the Dust.” In spite of Raskins well-known 
desire that his books should be sold at “an entirely jest 
.price,” which meant more than the members of the work¬ 
ing classes were usually prepared to give to obtain them, 
yet we welcome the wider dissemination of his teaching 
by the lowering of its market value. No author could surely 
wish to put a bound to the knowledge of such a notable 
saying as this, that a book is written because “the author 
has something to say which he perceives to be true and 
useful or helpfully beautiful. So far as he knows no one has 
yet said it; so far as he knows no one else can say it. He is 
bound to say it, clearly and melodiously if he may, clearly at 
all events,” and so on to the rest of that noble passage. 
Think what we may of Raskin's ideals and illusions, his 
almost painful sense of justice or his lack of balance, we 
must ever be grateful for such beautiful thoughts as abound 
in “ Sesame and Lilies,” “The Crown of Wild Olive,” and 
many other of his writings. It is also a real pleasure to 
renew acquaintance in this volume with his charming idyll of 
the crystals which certainly did not receive the recognition 
that it deserved when first it was published. We hope to see 
before long all of Raskin’s works issued in series with this 
volume, on the production of which we congratulate his 
publisher. 

The Maternity Nurse's Daily Guide or Pocket Book of 
Reference. By Gkrtruije C. Marks, Certificated, Obstetrical 
Society of London. London :Bailli&re, Tindall, and Cox. 1907. 
Pp. 112. Price lr. 6 d. net.—Miss Marks describes her book as 
containing clear and concise directions as to the duties and 
responsibilities of a maternity nurse from the time of her 
engagement to nurse a patient until the completion of the 
case, and we are able fully to endorse her claim. Not only do 
the material duties of the maternity nurse receive clear con. 
sideration but a few sentences upon the tactful manage, 
ment of cases prove that Miss Marks is fully appreciative 
of one of the most important elements that make 
for success in her calling. Another praiseworthy feature 
of the book is that, with one exception, it draws 
a clear and authoritative distinction between the spheres 
of duty of nurse and medical man ; the exception 
occurs on p. 32, Section 86, where the nurse is directed to 
remove the placenta from the uterus manually if it be not 
expelled within an hour. In the case of urgent post-partum 
haemorrhage, such as is considered on p. 89, this might well 
be the right course for her to adopt but in the absence of 
urgency we consider that a medical man should be 
summoned to effect the removal, for the nurse’s protection no 
less than the patient’s. The list of “ necessary articles for 
the mother ” is a little long but certainly they are all 
desirable. We venture to think that this book will prove 
especially useful to midwives who were practising before 
the recent Act was passed ; it is conveniently small and 
cheap. 

Eossjeld's Polyglot Correspondent. London : Hirschfeld 
Brothers, Limited. 1907. Pp. 461. Price 3*. 6 d. net.— 
The intention of this little book, which will fit into the 
pocket, is that “any mercantile letter may be composed in 
either English, French, German, or Spanish by the simple 
method of combining sentences selected from the pages of 
the work.” It also contains a vocabulary of technical 
expressions and business words in everyday use. A book 
constructed on these lines is likely to be very useful to the 
Englishman who has to compose a letter in a hurry in any of 
the foreign languages mentioned and this little book should 
be of some assistance, but we think it needs careful 
revision as we have detected several errors in turning 


over its pages. For instance, on p. 63 we see “plustdt 
for “plus tot”; on p. 71, “ Wicderholte ” instead of 
“ wiederholte ” ; on p. 86, “ erhaltei ch ” instead of “ erhalte 
ich”; on p. 83, “SeinSie” instead of “ Seien Sie”; on 
p. 123, "ton” for “ tous ” ; on p. 182, “ hdehsten ” for 
“hoohsten”; on p. 232, "ordrez”for "ordres”; on p. 347, 
“ ing ” or “ inq ” for “cinq”; on p. 359, “camphore” for 
“camphor”; and on the same page "capres” instead of 
“capers. On p. 361, "Chartreuse liquor ” is not usual. On 
p. 436, for "bill of lading” we miss the familiar “con- 
naissement.” On p. 441, “roue dentde” is hardly “dented 
wheel,” but should be toothed-wheel or cog-wheel; and on 
the same page “ marchand de comestibles ” is hardly “dealer 
in eatables,” but ought to be “provision merchant" in 
English. On p. 442, “Down the river” is translated into 
French by “Amont,” but “amont” means “up the river.” 
“ En aval ” is the French for “ down the river.” On p. 446 
the expression “ mark of a coin ” is hardly what is meant, 
we think. Should it not be “ mint-mark ” ? 

Hindustani Grammar Self-Taught. In four parts : 1. A. 
Simplified Grammar ; 2. Exercises and Examination Papers ; 
3. The Vernacular; 4. Key and English-Hindustani Dic¬ 
tionary. By Captain C. A. Thimm. Second edition. Revised 
by Shams’ul ’Ulama Sayyid ’Ali Bilgrami, M.A. Cantab., 
LL.B., Assoc. R.S.M. London, M.R.A.S. London : Marl¬ 
borough and Co. 1907. Pp. 120. Price, wrapper, 2s. ; 
cloth, 2s. 6d.— This is an attempt to teach Hindustani by 
means of the Roman character and the attempt has been 
successful. It is not, of course, possible to transliterate 
exactly the Hindustani words but much has been done to 
facilitate the acquirement of the colloquial language. Many 
Europeans find great difficulty in reading the Arabic 
character in which Hindustani is uaually written and there¬ 
fore the Romanisation is useful. The Arabic character is, 
however, taught to some extent and reading exercises are 
given and there is one page in Hindustani script. A few 
examination papers are answered. This little book is really 
wonderfully complete for its size. 


• JOURNALS AND MAGAZINES. 

Clinical Studies: A Quarterly Journal of Clinical Medicine. 
By Byrom Bramwell, M.D. Edin., F.R.O.P. Edin., F.R.S. 
Edin., Physician to the Edinburgh Royal Infirmary. VoL V. 
With 90 illustrations. Edinburgh: R. and R. Clark, Limited. 
1907. Pp. 413.—Some very interesting lectures and reports of 
cases are published in this volume of “ Clinical Studies. A 
lecture on the Process of Compensation and Some of its 
Bearings on Prognosis and Treatment is well worth 
careful perusal. Dr. Bramwell points oat that the com¬ 
pleteness of compensation depends upon several factors, 
the most important of which are: (1) the amount 

of the reserve ; (2) the suddenness and extent of the 
call: whether sufficient time is allowed for the realisa¬ 
tion or development of the reserve is obviously a most im¬ 
portant point; and (3) whether the demand for compensa¬ 
tion is temporary or continuous, in other words, whether the 
lesion is stationary or progressive. He then proceeds to 
apply these statements to compensation in lesions of the 
brain. His remarks on compensation in valvular affections 
of the heart will be found most interesting and sug¬ 
gestive. He directs attention to the conditions that are 
necessary for the production and maintenance of a sufficient 
and satisfactory muscular hypertrophy—the muscular tissue 
must be sufficiently healthy to become hypertrophied. It is 
evident that when myocardial degeneration is present to 
any extent hypertrophy can never be quite satisfactory. 
The cardiac muscle must receive a sufficient supply of 
healthy blood and the waste products of its combustion 
must be sufficiently quickly removed. Finally, the trophic 
nerve apparatus must be in a healthy condition. These 



112 Thb Lancet,] NEW INVENTIONS.—BRITISH MEDICAL BENEVOLENT FUND. 


[Jan. 11,1908. 


various points have an important bearing when prognosis 
has to be considered. A clinical lecture on the preven¬ 
tion o! Pulmonary Tuberculosis will also be found 
interesting. In speaking of the infectivity of the 
disease Dr. Bramwell is careful to emphasise the fact 
that all cases of ‘‘phthisis” are not infective. In order that 
danger of infection may arise tubercle bacilli must be found 
in the sputum. Dr. Bramwell supports the imposition of 
compulsory notification of tuberculosis and details the 
measures which he considers necessary for the prevention of 
the spread of infection. We cannot altogether agree with 
the elaborate machinery which he wishes to set in motion to 
complete the logical sequence of compulsory notification 
but we do thoroughly endorse his wishes that each medical 
practitioner “ should become a missionary for the diffusion of 
knowledge regarding the nature of phthisis and the means 
by which it should be prevented.” 

Caledonian Medical Journal .—The first article in the 
January number of the Caledonian Medical Journal is by 
Dr. W. A. Mackintosh of Stirling, being a continuation of his 
account of an ancient Gaelic medical manuscript. Colonel 
Kenneth Macleod, I.M.S., writes on Medical Education in 
India. A description of a journey from London to Gibraltar 
on the P. and O. steamer Rome suggests the reflection that it 
deserves to be read by those who are familar with Henry Field¬ 
ing's “ Voyage to Lisbon.” Fieldiugwent to Lisbon in 1754 ; 
the route of the two vessels was, or at least might have been, 
exactly the same, for part of Lisbon was faintly discernible 
from the Rome, and yet how different were the conditions of 
travel in the two cases. A reference to the recent Pan- 
Celtic Congress held in Edinburgh contains the surprising 
information that in Morocco there are Celtic tribes who live 
a clan life, play on bagpipes, speak a language intelligible 
to Scotch Highlanders, and use the names of M‘Tir and 
M‘Tuga, which are said to be practically the same as those 
of MacTier and MacDougall. 


ftefo 


THE “KENT” CHAIR. 

The Equipoise Company, of Ashford, Kent, have recently 
brought to my notice an ingenious form of chair which they 
have termed the “ Kent ” chair. This chair is manufactured 
under their patents and is arranged so that the patient can 
instantly be placed in any position for examination. This 
chair would be particularly suitable for the examination of 
school children under the new Act, or could be used as a 



consulting-room couch. In its ordinary position it is a 
comfortable easy-chair. With practically no effort the back 
can be depressed to any angle desired and when horizontal, 
with the foot-rest raised, it becomes a couch, and when not 
in use it folds into a small compass. The chair is con¬ 
structed of polished wood and upholstered in railway 
carriage velvet and sold at li guineas. 

Ashford, Kent. D. L. HAMILTON, F.JLC.S. Edin. 


BRITISH MEDICAL BENEVOLENT FUND. 


At the December meeting of the committee 22applications 
for assistance were received and grants amounting to £177 
were voted in relief, four cases being passed over and one 
postponed for further inquiries. Appended is an abstract of 
the cases which were helped :— 

Widow, aged 56 years, of P.R.C.S. Eng. Has been a confirmed invalid 
for the last two years. Only income a small pension which is unite 
insufficient for the bare necessities of life Voted £5. 

Daughter, aged Si years, of late M.D, Earnings very small and 
decreasing, lias recently been defrauded of a few pounds which she 
had saved. Voted £5. 

M li.C.S # L S.A., aged 62 years, who used to practise in London but 
whose receipts greatly decreased owing to changes in the neighbour¬ 
hood and competition. For some years past has endeavoured to support 
himself as a locum tenent but finds increasing difficulty in obtaining 
work. Wife receives boarders ; children unable to help. Voted £10. 

Widow, aged 60 years, of M.R.C.S., L.S.A., who practised in Lincoln¬ 
shire and whose estate yielded barely 5s. in the £. Onlv certain 
income £12 10s a year ; children at present unable to help. Voted £6. 

M.R.C.S., L.S.A., aged 64 years, who has been quite incapacitated 
for the last three months. Wife’s income £23 a year; children only 
able to give occasional and very slight help. Relieved twice, £20. 
Voted £10. 

Daughter, aged 60 years, of lnte M.D. Edin. No income, and unable 
to earn for herself because an invalid sister requires constant attention. 
Relieved twice, £24. Voted £12. 

M.R.C.S, aged 53 years, who for more than a year has been totally 
incapacitated. No income. No children ; wife takes paying guests but 
at present has none. Relieved once, £15. Voted £15. 

Widow, aged 59 years, of L.R.C.P., L.R.C.S. Edin. No income. 
Earns about 2*. 6 d. a week by needlework. Only child barely self- 
supporting. Relieved nine times, £93. Voted £12. 

Daughter, aged 57 years, of late M.R.C.S., L.S.A. Income £16 a 
year. Health will not permit of continuous work. Relieved once, £8. 
Voted £6. 

Daughter, aged 61 years, of late M.D. Edin. Il&s just lost a situa¬ 
tion through the death of her employer. Is allowed £6 a year by a 
charitable society. Eyesight very defective. Relieved three times, 
£35. Voted £12. 

Daughter, aged 63 years, of late L.S.A. No income. Used to be a 
governess, but has had bad health for years. A small weekly allowance 
from a sister-in-law but insufficient for board and lodging. Relieved 
six times, £62. Voted £6. 

Widow, aged 69 years, of M.R C.S., L.R.C.P. Endeavours to support 
herself by taking boarders or resident patients. Slight, irregular help 
from children. Relieved 15 times, £156. Voted £12. 

Widow, aged 58 years, of M.K.C S. Quite unprovided for at husband's 
death. Receives 2*. a week from relations. Relieved four times, £46. 
Voted £12. 

Widow, aged 41 years, of L.S. A. Acts as lady-help, but salary in¬ 
sufficient for maintenance of her boy and her own unavoidable 
expenses. Relieved twice, £24. Voted £12. 

M.R.C.S., L S.A., aged 68 years, who is quite incapacitated by 
hemiplegia. Only income a pension from the Kent Medical Benevolent 
Fund. No children* Relieved twice. £24. Voted £6. 

Widow, aged 62 years, of L.R.C.P. Edin. Is the owner of a small 
house but rent barely covers the necessary repairs and the lease expires 
in a few years. No children Relieved eight times, £90. Voted £12. 

Widow, aged 65 years, of M.D. Edin. Unprovided for at husband's 
death, and for several years acted as matron to a large institution. I* 
now dependent on a married daughter who can ill afford to assist. 
Relieved six times, £62. Voted £12. 


Rugby School.— The governing body of Rugby 

School has transferred Dr. Clement Dnkes to a new post 
created for him of consulting physician to the school, with a 
salary, in consideration of the long series of years during 
which he has acted as medical officer. The change will 
take effect after July next. 

Pulmonary Tuberculosis in Leicester.— 
During the year 19D6 213 cases of pulmonary tuberculosis 
were voluntarily notified by medical men to the medical 
officer of health of the borough of Leicester. According to 
a report issued by the sanitary committee of the Leicester 
town council an increasing proportion of persons suffering 
from consumption apply to be admitted for treatment at the 
isolation hospital and many of these cases have not been 
previously notified. During 1906 the total number of appli¬ 
cations for admission was 197 but unfortunately most of the 
sufferers had allowed the disease to progress too far before 
making their application, consequently their chances of 
recovery had become very remote. The total number received 
into the hospital for treatment was 82 and even of these only 
a small proportion conld be described as being in the early 
stages. The committee point out that it cannot be too- 
widely known that it is of the utmost importance that the 
sanatorium treatment should be begun at the earliest 
possible stage of the disease. At the present time too many 
of the cases admitted, although greatly benefited for the 
time being, leave the hospital only to relapse sooner or 
later. 




The Lancet,] 


THE TREATMENT OF TRYPANOSOMIASIS. 


[Jan. 11, 1908. 113 


THE LANCET. 


LONDON: SATURDAY, JANUARY 11, 1908. 


The Treatment of Trypanosomiasis. 

Tub researches which have been carried out in recent 
years with the object of discovering an effective treatment for 
sleeping sickness and other forms of trypanosomiasis are of 
great importance to both human and veterinary medicine, 
since this group of diseases is responsible for an enormons 
loss of life, both human and animal, in Africa and other 
tropical regions. Until 1904, when Ehrlich and Shiga 
recorded their results with trypan-red, a new dye discovered 
by the former, the only drug which was known to be of any 
valne in these diseases was arsenic, the beneficial effect of 
which was first observed in the tsetse fly disease by the ex¬ 
plorer Livingstone. The value of this drug was confirmed by 
H. W. Thomas and by Laveran in 1902, and before that 
time Linbard and Bruce had employed it, but its toxicity 
when given in effective doses and the liability to produce 
sloughing at the site of injection were found by Laveran 
and Mesnil to militate against its use in the form of sodium 
arseniate or any of the ordinary preparations. Various 
attempts have been made to obtain effective non-toxic pre¬ 
parations of arsenic and the most successful so far has 
been that of W. Landsberger of Charlottenburg who, in 
1901, obtained atoxyl. This substance was at first regarded 
as the anilid of meta-areenious acid but was shown by 
Ehri.ich and Bertheim to be the sodium salt of para- 
amido-pbenyl-arsenic acid. At the outset it must be stated 
that atoxyl is not non-toxic but that it is less liable to produce 
sloughing when injected or to give rise to toxic symptoms 
than the ordinary preparations of arsenic and can therefore 
be given in larger doses. It is stated that its toxicity is 
only one-thirtieth of that of other preparations. It was 
first employed therapeutically by Blumenthal in 1902, who 
reported favourably upon its use, but it achieved but little 
notice until Thomas and subsequently Thomas and Bbeinl 
administered it in cases of trypanosomiasis in 1905. Since 
that time it has been extensively given in various forms of 
disease due to trypanosomes in man and animals, such as 
sleeping sickness, nagana and surra, with, at any rate, tem¬ 
porary benefit. Its actual value as a curative agent cannot 
be said as yet to be determined definitely and there is some 
diversity of opinion in this respect in regard to the 
cases already published, but there is a general agree¬ 
ment that it causes at any rate at first a disappear¬ 
ance of trypanosomes from the blood of infected animals 
with remarkable rapidity, a single dose often clearing the 
blood within from eight to ten hours. Unfortunately, they 
usually reappear after a longer or shorter interval but can 
be again removed by atoxyl again to reappear. As many as 
seven reappearances have been observed in rats with trypano¬ 
somiasis treated with atoxyl by Mr. H. G. Plimmer and Dr. 
J. D. Thomson. In most cases the trypanosomes sooner or 


later acquire a resistance to the action of atoxyl and they 
are then able to develop unchecked, eventually causing the 
death of the infected animal. This condition of resistance 
to the action of atoxyl is called by Ehrlich “ atoxyl-fest.” 
Unfortunately, it appears that such a resistant or atoxyl-fest 
trypanosome can infect another animal, producing the disease 
in a form which also resists the action of atoxyl; in other 
words, the condition of resistance once acquired is trans¬ 
mitted. In view of these facts, which have been elicited from 
a study of various forms of trypanosomiasis in animals, many 
of which are of rapid course, it is not surprising to find that 
in the human disease of sleeping sickness with its much 
more protracted course no very conclusive results have yet 
been obtained. The use of atoxyl in such cases with due 
caution and care in its administration is now recommended 
by most authors, and it has been employed by Todd, 
Ayres Kopke, Broden and Rodhain, van Campenhout, 
Thiroux and d’Anfrevili-e, Burnet and Koch. It has, 
however, been pointed out that not only is its action not 
permanent but that in the production of an “atoxyl-fest” 
strain of trypanosome as a result of treatment there is a 
possible danger of producing an even more resistant form 
of the disease Bhould infection occur in other subjects 
with such an organism. Other substances used for treat¬ 
ment have proved less satisfactory than atoxyl. Of 
these the most important is Ehrlich’s trypan-red 
which has marked trypanocidal properties. It is not, 
however, a very safe drug, its injection even intramuscularly 
is likely to lead to sloughing and it has a tendency to cause 
nephritis. The partial failure of atoxyl led to the trial with 
it, or alternately with it, of other trypanocidal substances, 
notably trypan-red, but although some observers have 
recorded improved results the combination has been generally 
found to be of no greater value than atoxyl alone. 

One of the most important contributions to the subject 
recently is the paper by Moore, Nierenstein, and Todd. 1 
These observers offered the ingenious suggestion that the use 
of atoxyl might lead to the development of a stage in the 
life-history of the trypanosome which, though resistant 
to atoxyl, might be vulnerable to other substances not 
noxious to the ordinary form. They therefore investigated 
the use of various substances, especially salts of the 
heavy metals, in conjunction with, or alternately with, atoxyl. 
With perchloride of mercury they obtained some strikingly 
encouraging results. In an experimental injection with 
trypanosoma Brucei, the infective agent in nagana, the tsetse 
fly disease, they found that 68 per cent, of the animals 
treated with atoxyl and perchloride of mercury survived, 
while of those treated with atoxyl only none survived, all 
dying eventually from trypanosomiasis although surviving 
longer than untreated animals. They insist that atoxyl 
should be given as soon after infection as possible and 
that fresh solutions only must be used. It should be fol¬ 
lowed by the administration of perchloride of mercury, full 
therapeutic doses of both drugs being given. An interesting 
research on similar lines was carried out under the 
direction of the Tropical Diseases Committee of the Royal 
Society by Mr. Plimmer and Dr. Thomson. Their results 
were read before the Royal Society on July 20th, 1907, 

1 Biochemical Journal, vol. II., Pt. 5 and 6, p. 300, 1907. 




114 Thb Lancet,] 


INFANTILE MORTALITY AND SCHOOLS FOR MOTHERS. 


[Jav. 11, 1908. 


The trypanosomes investigated by them were trypano¬ 
soma Brncei, the parasite of nagana, which was 
fatal to rats in an average time of 5 5 days, and 
trypanosoma Evansi, the parasite of sarra, which proved 
fatal to rats in 6 9 days. They found that trypan-red 
lengthened the duration of both diseases in the rat to 14 
days but in all cases living trypanosomes were found post 
mortem. Arsenious acid likewise lengthened the course of the 
disease without curing it and bad the disadvantage of pro¬ 
ducing sores or sloughing at the sites of injection, even when 
over neutralised with carbonate of sodium. After various 
trials with other bodies, including monophenylarsenic acid, 
nitrophenyl-arsenic acid, and paratolyl-arsenic acid, they 
concluded that there is no substance known which will by 
itself cause a permanent disappearance of trypanosomes 
from an infected animal and they proceeded to employ 
treatment with two or more drugs. Among the substances 
they used in conjunction with atoxyl were the lactate, snccini 
mide, and sozoiodol of mercury. Of these, the combination 
which gave the best results was atoxyl and succinimide of 
mercury, by means of which a number of rats infected with 
nagana and surra were apparently cured, being alive and 
without trypanosomes months after infection. They advise 
that two or three doses of atoxyl should be given and that 
a dose of succinimide of mercury should be given at the same 
time as the second and third, with perhaps a third dose 
alone afterwards. The results with atoxyl and sozoiodol of 
mercury were less satisfactory and the latter drug has the 
disadvantage of giving a dense precipitate with a solution of 
atoxyl, so that the two drugs cannot be given together. 
Lactate of mercury has a similar property and is, moreover, 
very irritating to the tissues. A trial was also made with 
atoxyl and iodipin, a combination which gave encouraging 
results. 

A valuable critloal investigation of the action of atoxyl 
in the treatment of dourine or mat de c-oit due to the 
trypanosoma equiperdum by Professor Uhlenhuth, Dr. 
HUBBNKR, and Dr. Woithe has been published in Germany s 
under the auspices of the Imperial Board of Health. They 
arrive at results in the main similar to those of the 
English observers to which we have already referred. They 
sum up their opinion in regard to atoxyl by recommending 
that it should be given as early as possible and in as large 
doses as possible. They investigated the effect of that drug 
among many others upon experimental infections of dourine 
in horses, dogs, rabbits, rats, and mice, and obtained dis¬ 
tinctly good results. They also mention with approval the 
method of Moore, Nierenstein, and Todd of following the 
atoxyl with perchloride of mercury. Their paper is well 
illustrated and contains a useful bibliography. The out¬ 
come of these various experiments by different investigators 
seems to hold out distinct hopes that an effective treat¬ 
ment for trypanosomiasis is within reach ; but it should be 
remembered that the work is of very recent date and 
sleeping sickness and some other forms of this type of 
infection are of such slow and protracted course that the 
matter must still be left sub judice until more extended 
trials have been made and longer periods have elapsed 
after treatment than is the case at present. 

- Arbeiten aus deni Kalserlichen Geauudheitsamto, Rand xxvil.. 
Heft 2, 1907. 


Infantile Mortality and Schools for 
Mothers. 

However much or however little statistics in general 
may appeal to the minds of thinking people, there can be no 
doubt that the statistics of infantile mortality and of our 
declining birth rate have brought home to the public con¬ 
science the urgency in these respects of our national 
position. Moreover, the pressing necessity for setting our 
house in order which is involved in these two considerations 
has stimulated our inventive powers and produced a number 
of suggestions for mitigating the evils. In evidence of this 
national awakening to the grim realities of the situation a 
number of schemes for grappling with this appalling waste 
of human life has sprung up in all directions. Municipal 
authorities, public health departments, public charities, and 
private individuals are now vying with one another to find 
some simple and practical solution of this grave problem. 
Parliament has certainly contributed to the success of these 
schemes by passing an Act for the early notification of 
births, though the claims of medical men in respect of 
the new legislation have received no recognition ; prospects 
of still greater benefits are held out in the Bill which 
is contemplated for controlling milk-supplies. Experience 
has abundantly proved that municipal or private effort to 
ameliorate the conditions under which infants are reared 
in the poorer class of homes is seriously handicapped 
for want of a pure milk-supply and for want of information 
of the birth of infants until it is almost too late to render 
them material assistance. In these two respects the ground 
is becoming oleared, but no one can fail to regret that 
medical cooperation should not have been secured on fair 
terms. Once again our professional altruism is to be 
relied on. 

Although it is still too early to judge of the respective 
merits of the many schemes, municipal or otherwise, which 
are on foot for dealing with the problems of infant mortality, 
it may nevertheless be interesting to compare and to contrast 
some of the methods by which different organisations are 
striving to arrive at similar goals. We have from time to 
time published in The Lancet reports of the working of 
municipal milk depute, of the operations of public health 
departments, and of combined enterprises, such as 
those which have been successfully carried on in 
Huddersfield, St. Marylebone, and Finsbury, and we 
have now before us a little work, entitled “ Schools 
for Mothers,”' which supplies an interesting account of 
one of the most recent experiments of this kind which 
for the last few months has been on trial in the metropolitan 
borough of St. Pancras. This new scheme combines certain 
of the features which have contributed to the success of 
some of the older ventures, such as those in Huddersfield 
and St. Marylebone in this country and that in Ghent in 
Belgium. That is to say, it aims at instructing the mother 
in the home by personal visitation and by demonstration in 
the school, while the infant is supervised medically in a 
special department for “infant consultations.” In pursuance 
of the policy of the medical officer of health a great effort is 
made to encourage breast feeding among those attending at 

i Schools for Mothers. Loudon: Horace Marshall and Sons. Price Is, 






116 Thk Lancet,] 


THE HAMPSTEAD GENERAL HOSPITAL. 


[Jan. 11,1908. 


of Surgeons, which has, we believe, been hitherto univer¬ 
sally accepted as a qualification for the surgical posts of 
general hospitals. 

It will be seen that there is one body of men who 
are vitally interested in the settlement whose views 
on the matter might have received more attention, 
and that is the staff of the North-West London Hospital. 
It is true that these gentlemen are not absolutely entitled 
to be heard by the Council of the Hampstead Hospital on 
the matter, although, considering what an integral factor 
they form of the hospital with which the amalgamation has 
been arranged, we hold that it would have been a graceful 
act to take their opinion. We consider it fair to make 
public their view of the matter so far as we have learned it 
from various circumstances. In the first place the staff of 
the North-West London Hospital agree that the amalgama¬ 
tion of the two hospitals is in the best interests of the 
necessitous poor in the neighbourhood of both, and they 
accordingly welcome the proposal of this principle by 
King Edward's Hospital Fund and its adoption by the 
subscribers of both hospitals. Here we may say at once that 
we are in complete concord. Whatever the Hampstead 
subscribers may say about a “Hampstead hospital for 
Hampstead people ” the fact remains that, largely owing to 
the generosity of a few of their number, an important 
suburban general hospital has been erected, that a large 
number of its beds are empty, and that the free beds at 
present in use are found sufficient for the needs of “ Hamp¬ 
stead, Highgate, Hendon, and the neighbourhood,” the 
district which it was intended to serve. This may be largely 
accounted for by the fact that the out-patient depart¬ 
ment is looked on with much disfavour by local prac¬ 
titioners who, indeed, have never been enthusiastic about the 
new hospital. On the other hand, the Kentish Town district, 
which is much nearer to the doors of the hospital than are 
Highgate and Hendon, has a teeming population of very poor 
people who supply some 23,000 fresh attendances a year to 
the out-patient department of the North-West London Hos¬ 
pital and who badly need bed accommodation to replace that 
of which they have been recently deprived by the closing of 
the latter hospital’s wards for lack of funds. Hampstead 
must realise that its hospital is no longer a nursling for 
local petting; it has outgrown its swaddling clothes 
and is ready to take its place in a sphere of large 
utility which lies before it. So far, then, we are in 
accordance with the King's Fund, inasmuch as its 
proposals affect the public service ; but this is not the 
whole of the matter. The King's Fund has laid it down 
as an inalienable condition to its support of the scheme 
that the new staff shall be composed of consultants, subject 
to the reservations in favour of the present staff at Hamp¬ 
stead which we have mentioned above. It further sug¬ 
gested the condition that three of the North-West London 
staff should ex-offioio become members of the combined staff ; 
but this proposal has been rejected on the report of the 
committee of Hampstead subscribers appointed to consider 
the matter on the ground that the council must have a free 
hand to elect consultants to staff their hospital. The attitude 
of the staff of the North-West London Hospital on the 
matter is that they have not received equal treatment with 
the Hampstead staff, for the latter are to have the chance 


of remaining for a certain number of years and they them¬ 
selves are given no guarantee of continued office. The 
inequality they consider to be accentuated by the fact that 
they are ‘ ‘ a body of pure physicians, surgeons, and specialists, 
who have for many years administered a general hospital with 
23,000 new out-patients annually, while the Hampstead insti¬ 
tution has been a cottage hospital staffed by local general 
practitioners.” This is true enough but it must be remembered 
that the North-West London staff are somewhat in the 
position of shipwrecked sailors, undoubtedly able mariners 
and wrecked through no fault of their own, but certainly 
with no such strong claim to man the vessel that rescues 
them as have the crew already in possession of it. This is 
scarcely an over-statement of the case, for although the 
North-West London Hospital might drift on as an out¬ 
patient department, yet the only hope of continued beds for 
members of its staff hails from the new building in Hamp¬ 
stead, and we do not think that they have an authoritative 
claim to these beds, though they may have a moral one. 

But is it not possible that there should be room at the 
Hampstead General Hospital for both crews 1 The exact 
conclusions to which the North-West London staff has come 
are as follows : It considers that in the amalgamation of 
the two hospitals one of two alternative courses should be 
pursued : (1) that all members of the present staffs should 
become members of the staff of the new institution ; or 
(2) that all members of the present staffs should retire from 
office and the vacancies so created be advertised in the 
medical journals. Seeing that the work of the combined 
hospitals will require the services of a staff nearly equal to 
the sum of the existing staffs, Including the various 
specialists whom the North-West London Hospital can pro¬ 
vide, we are inclined to think that this course would have 
formed a reasonable solution of the difficulty, or if it 
be found that fewer men are required a joint 
committee representing the committees and staffs of 
the two hospitals might recommend a new staff fairly 
representing both hospitals and relying on the public spirit 
of those not chosen to accept their retirement unhesitatingly. 
Unhappily, the chance of the adoption of such a via media 
has almost entirely gone, for since the final decision of the 
governors the members of the staff of the Hampstead Hos¬ 
pital have sent in their resignations to the council in a 
body, with the exception of the dental surgeon, and have 
asked to be relieved of their duties as soon as the council 
can make other arrangements for the staffing of the hos¬ 
pital, in which action they have the support of the Hamp¬ 
stead division of the British Medical Association. We print 
in another column a letter from the honorary secretary of 
that division in which he states the position of the local 
practitioners of Hampstead as indicated in the replies sent 
by a substantial portion of them to a circular inviting their 
opinion. Neither King Edward's Hospital Fund nor the 
Hampstead staff, we are assured, will now go back on its 
position, the latter body having definitely decided to oppose 
both the amalgamation and the introduction of consultants. 
The whole position is most unfortunate. We greatly regret 
the impairment of the utility of the hospital which is bound 
to follow from this state of civil warfare, while the issues 
have been so confused as to make the task of those interested 
in the hospital’s welfare an extremely difficult one. 





The Lancet,] 


HEALTH OF LONDON IN 1907. 


[Jan. 11, 1908. 117 




" No quid nimla." 


HEALTH OF LONDON IN 1907. 

The quarterly and weekly returns of the Registrar-General 
for 1907 enable us to supplement the recent valuable report 
on the health of London in 1906 by the medical officer of 
health of the county of London with an analysis of the vital 
statistics of the metropolis during the year just ended. Sir 
Shirley F. Murphy called attention to the constantly declining 
rate of mortality in the London population daring recent 
years as conclusive evidence of improved health conditions. 
The death-rate in London per 1000 of the resident population, 
which was equal to 24'4 in the ten years 1861-70, has 
successively declined to 22 • 5, 20 • 5, and 19 • 6 per 1000 
in the three more recent decades 1871-80, 1881-90, 
and 1891-1900. This continuous rate of decrease, satis¬ 
factory and remarkable as it was, has been considerably 
exceeded during the current decennium. The mean annual 
rate of mortality in London during the seven years 1901-07 
has not exceeded 16'2 per 1000, showing a decrease of 3'4 
from the much reduced rate in the preceding ten years 
1891-1900, and being no less than 8 • 2 per 1000 below the 
mean rate in the ten years 1861-70. The decrease in the 
rate has, moreover, been practically continuous during the 
last seven years and was in 1907 unprecedentedly low. The 
London death-rate, which had been equal to 16 6, 15'6, 
and 15‘7 per 1000 in the three preceding years, fell so 
low as 14'7 in the year just ended. The London rate of 
infant mortality, too, which was equal to 160 per 1000 births 
registered in the ten years 1891-1900, has not exceeded 135 
per 1000 during the seven years (1901-07) of the current 
decade and was unprecedentedly low, 116, during last year. 
The London death-rate from the principal epidemic or infec¬ 
tious diseases, which was 2 • 2 per 1000 in the 52 weeks of 
1906, also fell to 1 ■ 4 in 1907, mainly owing to the unprece¬ 
dentedly low mortality from diarrhcna, principally infantile. 
The fatal cases of diarrhoea registered in London, which had 
been 4507 in 1906, fell to 1523 in 1907, a decrease which 
is only partly explained by the meteorological conditions 
during the past summer. No death from small-pox was 
registered in London last year, but the fatal cases of 
measles, scarlet fever, diphtheria, and whooping-cough 
were, of each disease, somewhat more numerous than in 
1906. On the other hand, the deaths referred to “ fever ” 
(principally enteric) did not exceed 200, showing a decline 
of 75 from the number in 1906, and being the lowest number 
recorded in any year of which record exists. With regard to 
the increase in the fatal cases of scarlet fever from 533 in 
1906 to 645 in 1907, it should be noted that while the annual 
number of deaths from this disease in London averaged 
3439 in the ten years 1861-70 it successively declined to 
2125, 1327, and 819 in the three succeeding decades, and has 
further fallen to 513 in the last seven years 1901-07. An 
inquiry, with a view to ascertain how much of this decline 
in the mortality from scarlet fever can be attributed to the 
hospital isolation of cases of this disease, would be full of 
interest and would be of real value to sanitary autho¬ 
rities. During the 52 weeks of last year 2667 deaths in 
the county of London resulted from different forms of 
violence, against 2794 in 1906 ; and 6868 inquests were held, 
the number in the previous year having been 6910. It is 
eminently satisfactory to note that with the exception of 
only 81, the causes of all the 69,953 deaths registered in 
London last year were duly certified by a registered medical 
practitioner or by inquest; the number of uncertified causes 
of death in London in 1906 was 146. The proportion of 
London deaths recorded in public institutions continues to 


increase and was equal to 38 • 4 per cent, during last year, 
exclusive of the deaths of London residents occurring in 
metropolitan institutions situated outside the county of 
London ; in 1906 the proportion was 38 • 3 per cent, after the 
inclusion of the institution deaths occurring beyond the 
county boundaries. While awaiting with interest the 
Registrar-General’s annual summary for 1907 relating to 
London and other large towns the foregoing figures afford 
conclusive evidence of the encouraging results of the con¬ 
stant growth of sanitary interest, activity, and organisation 
in London during recent years. This remarkable decline of 
mortality, which necessarily implies a corresponding increase 
in the duration of life, affords also a refutation of the 
constantly asserted increase of the physical deterioration 
of the nation, at any rate as regards the nearly five millions 
of population residing within the metropolis. 


THE WINTER EXHIBITION AT THE ROYAL 
ACADEMY. 

The thirty-ninth annual winter exhibition of the Royal 
Academy was opened to the public on Monday and is a 
collection of great interest. Of the portraits which more 
immediately concern the medical profession there are two, 
the one (95) a portrait of Dr. T. Hanson of Canterbury 
painted by Zoffany. and the other (157) one of Abraham 
Cowley by Lely. As regards the former we have been unable 
to find any information concerning him, for he is not 
mentioned in either the “ Dictionary of National Biography ” 
or in Munk’s Roll of the College of Physicians. Possibly 
he may not have been a Doctor of Medicine. As for 
Cowley the picture represents him after the fashion of the 
artificial pastoral heroes of the seventeenth and eighteenth 
centuries ; he is sitting under a tree dressed in 
brown with long hair falling over his shoulders with 
a flageolet in his right hand and a long staff, possibly 
a crook, in his left. Cowley began to study medicine 
about 1656 and on Dec. 2nd, 1657, he was created M.D. at 
Oxford “by order of the Government,” a piece of servility 
impossible in these days. With regard to the remaining 
pictures, the first room is devoted to early Flemish and 
Italian masters. Of these perhaps the most striking is No. 19, 
“The Adoration of the Kings,” by Herri Met de Bles, a 
highly decorative and overcrowded composition shewing 
marked rococo characteristics. The fascination which metal¬ 
work exercised over the early Renaissance painters, many of 
whom were also goldsmiths, is well exemplified, for the 
central column which supports the architectural canopy 
under which the figures are grouped is apparently composed 
of a gigantic metal candlestick, nearly half of the base of 
which projects over the edge of the wall on which it rests. 
With regard to the other pictures in the exhibition we have 
only space to mention a number of Hogarths and magnificent 
examples of Romney, Raeburn, and Reynolds. 


THE HOLDERS OF MIDWIFERY LICENCES. 

Our attention has been directed to a correspondence on 
the somewhat curious question whether a Licentiate in 
Midwifery possessing no other or registrable qualification 
could with propriety or safety engage in medical practice, 
either as principal or assistant, or could describe himself on 
a doorplate as “L.M., Obstetric Surgeon.” It was asked 
whether the medical protection societies would think it 
necessary to intervene in such a case, and whether the 
General Medical Council would be likely to exercise its 
powers in relation to it. A midwifery licence was at one 
time given by the Royal College of Surgeons of Ireland, 
and was instituted by the Royal College of Surgeons of 
England about 1850, at a time when the diploma of 
Membership conferred a right to practise ; and the inten¬ 
tion was to enable Members to obtain from their own 





118 Thb Lancet,] 


A FROLIC OF VARIABLE WEATHER. 


[Jan. 11, 1908. 


College an official recognition of their knowledge of 
obstetrics. The only persons admitted to examination for 
the licence were either those who were already Members 
of the College or who possessed some other surgical 
qualification, or those who had completed the curriculum for 
Membership and had obtained all the necessary certificates 
for admission to examination. A student in this position 
might, as a matter of chance, present himself first to the 
Midwifery Board and pass and might thereafter either fail 
to present himself to the surgical examiners or present him¬ 
self and fail to satisfy them. A Member of the College 
who was deprived of his diploma could not be deprived of bis 
midwifery licence. It is only in one of these two ways that the 
holder of such a licence from the English College could now 
be destitute of a registrable qualification ; and it cannot be 
said that either of them would justify an attempt to practise. 
The “unqualified assistant,” who has been abolished by the 
General Medical Council, was, in nine cases out of ten, a 
student who had been unable either to finish the curriculum 
or to satisfy the examiners ; and no individual coming under 
this head would be likely to receive an indulgence which was 
steadily denied to the class. For the licentiate now in 
question to call himself “Obstetric Surgeon” would plainly 
be to use a title implying that he was registered, and would 
be an offence under the Medical Acts. Fortunately, the 
question cannot now be of more than individual interest. 
The Coombe Hospital diploma was destroyed as a “ qualifica¬ 
tion "by the Medical Act of 1858. The English and Irish 
Colleges have ceased to issue a midwifery licence, the last 
examination for which in England was held in 1875; it is 
probable that the gentleman referred to in the correspond¬ 
ence is now the only unqualified holder of a document which 
would be deprived of its only justification by the medical 
legislation of 1886, under which a qualification in midwifery 
is required from all practitioners. The “L.M.” cannot 
even find shelter under the Midwives Act, the provisions 
of which are strictly limited to women. 


A FROLIC OF VARIABLE WEATHER. 

Not a little alarm has been experienced in domestic 
circles by the appearance of considerable moisture on the 
walls and furniture of the house during the severe changes 
of temperature which we have recently experienced. Fears 
of the house being in an unhealthy damp condition have 
been entertained, and of some irreparable damage being 
done to the papers on the wall, the decorations, the piano, 
and other articles of furnitnre. The occurrence has given 
rise to a deal of apprehension as to the soundness of the 
building from the health point of view ; and the conclusion 
has been reached by a good many, we dare say, that 
rheumatism, sore-throats, and other diseases engendered 
by damp are likely to follow in the wake of such 
a phenomenon. As a matter of fact, the appearance of 
moisture on the interior surface of a house under the 
conditions which obtained is no evidence at all that the 
house is damp. The truth is that the house and its contents 
are extremely dry previously to the onset of warm moist air 
which commonly happens when the wind changes from the 
easterly to the westerly direction. The moisture is derived 
exclusively from the warm air and not from the building at 
all. The house is still cold, and warm moist air coming 
into contact with the cold surfaces deposits some of the 
moisture with which it is saturated. Everyone is familiar with 
the deposition of moisture which takes place on a cold 
tumbler or glass when it is brought into a warm room. In 
the phenomenon referred to the house is, so to speak, the 
tumbler and the moist westerly breeze is the warm room. As 
a rule no harm is done, the separated moisture disappearing 
as the house recovers from its cold condition. Fabrics 
appear to be uninjured by the visitation and even blistered 


paper settles down again, leaving little or no evidence that 
anything of the kind had taken place. Neither is the 
healthiness of the house affected in the least degree. The 
action is simply that of a cold mass condensing moisture out 
of a water-saturated air, the damp itself not residing in the 
house at all but in the air. The preventive and remedial 
measures are the same—the house should be kept thoroughly 
warm. _ 


THE ASSOCIATION OF PUBLIC SCHOOL SCIENCE 
MASTERS. 

The annual meeting of the above association will be held 
by the kind permission of the head-master at Westminster 
School on Tuesday, Jan. 14th. The meeting will last from 
10 A.M. until 7 P.M. The President, Dr. Henry Miers, F.R.S., 
Waynflete professor of mineralogy in the University of Oxford, 
will take the chair at 11 A.M. and will deliver an address 
upon the Order in which Science Subjects should be Taught 
(a) in Public Schools, and (b) in the Universities. The address 
will be followed by a discussion upon the Teaching of 
Mechanics opened by papers read by Mr. C. F. Mott of 
Giggleswick and Mr. H. Wilkinson of Durham. In the 
afternoon there is to be a discussion upon the Teaching of 
Physics opened by papers read by Mr. C. Cumming of Rugby, 
Mr. W. E. Cross of Waitgift, and Mr. J. M. Wadmore of 
Oldham. The programme of the conference certainly gives 
promise of useful performance and we wish the association 
success. _ 


THE RETIREMENT OF THE MEDICAL OFFICER 
OF HEALTH OF THE TRANSVAAL. 

Thf. immediate retirement is announced of Dr. George 
Turner, D.P.H. Cantab., J.P., Cape, Transvaal, and Orange 
River Colonies, who since 1901 has served with great and 
successful energy as medical officer of health of the 
Transvaal. He retires on completing his sixtieth year, an 
event which will bring to a close a distinguished public 
career in the ranks of preventive medicine. He was edu¬ 
cated at Cambridge and Guy’s Hospital and at the age of 
25 years was appointed medical officer of health and public 
analyst of the Borough and Port of Portsmouth and also 
physician of the Portsmouth Fever Hospital. He held these 
posts for seven years and in 1880 relinquished them to become 
medical officer of health of the Hertfordshire and Essex 
combined sanitary district which was under his able control 
until 1895 ; during the last 13 of these 15 years he was 
lecturer on hygiene at Guy’s Hospital and was also an 
examiner in public health to the Conjoint Board in London. 
In 1895 he proceeded to South Africa, having gained the 
appointment of medical officer of health of the Cape 
Colony, where the value of his services soon became 
apparent both in connexion with the public health 
of its inhabitants and also with the suppression of rinder¬ 
pest which was then raging furiously amongst the cattle. 
Dr. Turner took charge of the Kimberley rinderpest station in 
1897 and during the five years of his service in Cape Colony 
he is said to have saved the Colony “something like a sum 
of six millions sterling ” by his treatment of this disease. 
His connexion with Cape Colony ceased with the war, as in 
1900 he was seconded as sanitary adviser for service with 
Lord Roberts in the Transvaal, and in the following year 
Lord Milner appointed him medical officer of health of that 
colony. Here he again attacked rinderpest vigorously and 
established a serum factory at Dasspoort which enabled him to 
cope with the epidemic in somewhat disadvantageous cir¬ 
cumstances. He still further enlarged the scope of his public 
activities and in 1904 successfully undertook the compilation of 
the first census of the Transvaal and Swaziland ; at the same 
time he was a member of the Legislative Council of the 
Transvaal, to which he was elected in 1903 and on which he 



The Lancet,] COMPLETE INVERSION OF THE UTERUS —PUBLIC VACCINATION IN OLDHAM. [Jan. 11,1908. J 


served until its dissolution in 1906. The great feature of his 
work in the Transvaal, however, has been his superintendent- 
ship of the Pretoria Leper Asylum for the past seven years. 
He found it with 90 patients and leaves it with 400, and 
has devoted a large amount of careful clinical study 
to each case under his charge with the result that he 
has become an authority on the disease. It was hoped 
that an arrangement would be made by the Transvaal 
Government which would enable him to continue to hold 
this post in the Leper Asylum but the remuneration which 
has been offered to him is not such as be could reasonably 
accept. Dr. Turner’s distinguished public services are 
admitted at every hand and we consider it very desirable 
that his Government should see its way to retain them in 
a connexion in which they are of special value, an opinion 
that has been fully expressed in a resolution passed and 
brought before the Transvaal Government by its Medical 
Council. Should his retirement ensue we wish him many 
years of honourable ease and we are assured that he will bring 
home with him from South Africa the gratitude of many 
friends, if not of the Government which he has served so well. 


COMPLETE INVERSION OF THE UTERUS. 

Ax interesting case of this kind is recorded in the present 
number of The Lancet by Mr. Arthur Maude. The inver¬ 
sion was a complete one and associated with total prolapse 
of the uterus which lay outside the vulva. No undue trac¬ 
tion had been made upon the cord and the labour had 
apparently been spontaneous and rapid. The placenta was 
attached exactly to the fundus of the uterus and in this fact 
Mr. Maude is inclined to see a partial explanation of the 
occurrence in accordance with the hypothesis put forward by 
Hennig that such an attachment of the placenta is likely to 
produce this accident. Some support is given to this view 
by the inversion of the placenta which undoubtedly often 
occurs during its normal expulsion when it is attached in this 
position. In these cases there is usnallya large retroplacental 
hmmatoma and there is no improbability in supposing that in 
cases of rapid or almost precipitate labour, as in the 
present case, some inversion of the uterus may accompany 
that of the placenta when the organ has not time 
to accommodate itself to the new conditions and remains 
flaccid and partly empty. The tendency would natur¬ 
ally be for a flaccid uterus to follow down the escap¬ 
ing child and placenta and for inversion to occur. A 
similar mechanism is probably at work when the uterus, 
after it has been successfully reinverted, tends to follow 
down the hand as it is withdrawn from its cavity. No 
doubt this accident must be accompanied by complete atony 
of the whole of the uterine musculature, and the old view 
put forward by Matthews Duncan and others that a partial 
atony of the placental site alone may account for it 
is no longer held by the majority of obstetricians. 
Numerous theories have been put forward to explain this 
dangerous complication of labour, but whatever the con¬ 
tributory causes may be the actual exciting cause is usually 
to be found in a sndden pressure applied to the upper part of 
the uterus, the result either of some sudden straining effort 
on the part of the patient or of undue force applied to the 
fundus of the uterus in an injudicious and improper attempt 
to express the placenta. A further contributory cause is to 
be found in the size and weight of the placenta and in his 
case Mr. Maude remarks that it was of considerable size. 
The extreme collapse which accompanies this accident is 
always interesting; it is commonly due to the severe 
haemorrhage but it may occur when very little blood has 
been lost and its explanation then is not so simple. Possibly 
in some cases it is caused by sudden lowering of the intra- 
abdominal pressure, in others by stretching or tearing of 
some of the sympathetic nerve fibres in the uterine wall, or by 


the excessive dragging on the uterine appendages, especially 
the ovaries, which must occur. The extreme rarity of this 
accident is proverbial, at any rate if we consider the figures 
obtained from lying-in hospitals alone, such as those which 
Mr. Maude quotes. At the same time, it must be remembered 
that the publication of cases occurring in the private prac¬ 
tice of midwives or medical men is by no means uncommon, 
and it would appear almost as if this accident was one 
especially likely to occur in such conditions—a supposition 
which leDds some support to the view that as a rule it is 
related to Borne error in the management of the labour, 
especially of its third stage Mr. Maude is to be congratu¬ 
lated on the successful issue of his case, as the immediate 
mortality even at the present day is very high, amounting to 
as much as from 14 to 22 per cent. 


PUBLIC VACCINATION IN OLDHAM. 

In our issue of Dec. 2lst, 1907, we referred to the situa¬ 
tion in Oldham as regards the appointment of a public 
vaccinator. Shortly, the position was as follows. The 
guardians originally proposed to appoint a public vaccinator 
who was to give his whole time to the work and to 
receive a salary of £500 per annum. Owing, however, to 
recent legislation this scheme was dropped and it was pro¬ 
posed to pay the public vaccinator in the usual way by fees 
on the minimum scale—i.e., 2s. on. per case, with an 
additional £15 per annum for a dressing station, he having 
to give his whole time. Eventually Dr. J. P. Walker 
of Earlestown was appointed but he declined to accept 
the appointment on the ground that the terms did not 
afford a Hying wage. What the income may be can be 
seen from the following figures for the quarter ended 
Dec. 31st. Notices are paid for at Is. each and successful 
vaccinations at 2s. 6<f. each. For the three months in ques¬ 
tion there were 270 notices amounting to £13 10s. and 208 
successful vaccinations amounting to £26, a total of £39 10s. 
for the quarter. For the year therefore the total sum may 
be £158 which with the addition of the £15 for the dressing 
station makes £173 per annum, and this is certainly not 
a sufficient salary for a whole-time appointment. The 
guardians, we learn, are willing that the minimum salary 
should constitute a living wage but they decline to state 
what amount constitutes a living wage. As we mentioned 
before, the local medical men have expressed their willingness 
to accept a yearly salary of £350, a sum which we call 
modest, and as the guardians were originally willing to give 
£500 we hope that they will see their way to grant at least 
the £350. The post, we learn from the Oldham Evening 
Chronicle of Dec. 31st, has now been offered to Dr. Leigh of 
Bolton. _ 


THE TOMB OF AN ANCIENT EGYPTIAN 
PHYSICIAN. 

The excellent work upon “The Burial Customs of Ancient 
Egypt ” by Professor John Garstang, just published by 
Messrs. Archibald Constable and Co., for the first time gives 
a scientifically complete record of the contents of the 
sepulchre of an F.gyptian physician, and in this case of a 
personage who flourished under the twelfth dynasty, circa 
b.c. 2000. The deceased, whose tomb is described, was 
named Nefery and in all the numerous repetitions of hiB 
name upon the two coffins provided for him is termed “a 
physician.” That he either came of a wealthy family or 
amassed wealth by the practice of his profession is proved 
by the expense that was lavished upon his burial, his 
funerary furniture being one of the most complete sets 
of such appointments found in other than princely 
tombs at Benl-Hassan where he was interred. Various 
and many as were the objects deposited beside his 
body only two of these can in any way be considered 




120 The Lancet,] THE NATIONAL HOSPITAL FOB PARALYSED & EPILEPTIC, QUEEN SQUARE. [Jan. 11,1908. 


as connected with his vocation. These are a set of 
writing implements, consisting of a writing tablet and a 
pen box, the latter furnished with a number of reed pens 
ready for use. The writing tablet, which together with the 
pen box was placed upon the lid of the outer of Nefery’s 
two coffins, was coated with stucco and then painted, and 
the surface so carefully smoothed by some polishing process 
that it was probably possible to remove any temporary 
memoranda made thereupon as soon as their purpose was 
fulfilled. At one end of the pen box were two ink-wells in 
which the remains of a red and of a blue-black ink can be 
detected. Unfortunately no written notes Burvive upon the 
palette. Among the objects found in the tomb are some 
beautiful models of Nile boats, one having 20 rowers ; also 
an imitation of a granary and many figures of domestics 
and labourers. The inner coffin, or sarcophagus, bore some 
quite new texts to scholars of the most archaic Egyptian 
religious books and explained that Nefery was a devotee of 
Osiris. The body had been laid upon its side wrapped in 
folds of linen cloth and was not mummified. The head was 
encased in a painted cartonage. This physician's tomb has 
been rearranged, as it was when first reopened, in the Cairo 
Museum where it is the subject of much interest. 


THE NATIONAL HOSPITAL FOR THE PARALYSED 
AND EPILEPTIC, QUEEN SQUARE. 

In connexion with the approaching jubilee of this hospital, 
H.R.H, the Duchess of Albany has written a letter accom¬ 
panying a circular issued by the hospital authorities. In this 
letter Her Royal Highness expresses the deep interest which 
she has in the welfare of the institution—an interest which 
has been shown on many occasions and in an exceedingly 
practical manner. The secret of this interest is in some 
degree, at least, to be ascribed to the fact that the hospital 
is a memorial to the late Duke of Albany, whose help in its 
successful development, especially in connexion with the 
rebuilding in 1885, was both sustained and practical. Yet 
Her Royal Highness has herself developed an interest in the 
hospital which has extended now over a good many years and 
certainly does not become less with the lapse of time. In 
no hospital in London was the element of what may be 
called scientific romance more interwoven with the develop¬ 
ment of a hospital than in this. Commenced at first at the 
instance of two ladieB, one of whom, at least, was a sufferer 
from one of the formB of illness which it was instituted to 
relieve, and depending in its early days on the actual work 
which these ladies did with their own hands, it received its 
official recognition at a Mansion House meeting in 1859. In 
its early days it was fortunate in attracting to its practice 
men of mark like Brown-Sequard, Russell Reynolds, 
Hughlings Jackson, Buzzard, Bastian, and Gowers, and 
latterly Ferrier, Beevor, Ormerod, Victor Horsley, and 
others have become incorporated in its fame and its 
progress. Between 1880 and 1890, Queen Square was cer¬ 
tainly the centre of neurological interest in this country, 
and it is probably not incorrect to say that it was the centre 
of neurological progress in Europe. This fact is attested by 
the numbers of medical men who began to attend its practice 
then and who have continued to do so in ever-increasing 
numbers up to the present time. And it may be asserted 
that its students are drawn from every European country, 
from Canada, the United States, Australia, and South 
Africa, so that it may be said to have established a claim to 
be more than a national hospital, more even than an imperial 
institution. In the circular which accompanies the letter 
above referred to particulars are given of the rise and pro¬ 
gress of the hospital. An interesting map is appended, on 
which are indicated the number of .the patients from the dif¬ 
ferent counties of England and Wales and also the numbers 
from Scotland, Ireland, European and Asiatic countries, the 


United States, and English colonies. From this map it is 
obvious that from the point of view of the relief 
of sufferers the hospital makes at least as wide an 
appeal as it does in the matter of instruction in neuro¬ 
logy. The requirements of such an institution are many. 
They are constantly increasing and varying and they cost 
money. In the appeal, which Her Royal Highness supports 
with cordiality and cogency, the necessity for various 
extensions and improvements in the present accommodation 
is very clearly detailed. It is to be hoped that this great 
hospital will not be hampered in its good and beneficent 
work and that its opportunities for the relief of suffering, 
the investigation of the problems of nervous disease and the 
dissemination of the knowledge so acquired, may not be in 
any way curtailed by want of money. We anticipate that 
great success will attend the efforts of the jubilee committee 
over which the Duchess of Albany has consented to preside, 
and we are sure that the whole medical profession will join 
in hoping that the hospital authorities will be enabled to 
carry out all their projected improvements. 


THE DEATH OF DR. W. BAYARD. 

The death is reported, at the age of 94 years, of Dr. William 
Bayard who for 70 years had practised medicine in St. John, 
New Brunswick, and who continued in active work prac¬ 
tically to the last. Dr. Bayard was born in Kentville, Nova 
Scotia, the son of Dr. Robert Bayard who had removed from 
New York to the provinces on the outbreak of the American 
Revolution and settled later in St. John. He graduated from 
the University of Edinburgh in 1837 and soon after began 
practice in the town adopted by his father. He was the 
founder of the St. John General Public Hospital, was chair¬ 
man to the hospital commission for many years, and at 
various times had been chairman of the New Brunswick 
Medical Society and president of the Council of Physicians 
and Surgeons. He was coroner for 28 years, chairman of the 
provincial board of health, and in 1895 president of the 
Canadian Medical Society. In August last, on the seventieth 
anniversary of Dr. Bayard’s graduation, the Faculty of the 
University of Edinburgh conferred upon him the honorary 
degree of LL.D. in absentid, the letter accompanying it 
stating that Dr. Bayard was believed to be the oldest living 
graduate of the University. Dr. Bayard’s wife died in 
1876 ; there were no children. 


DECEMBER AT HOME AND ABROAD. 

Visitors from these islands to the south of Europe may in 
some cases have been surprised at the occasional chilliness of 
the atmosphere and cold winds, as well as disappointed at 
the frequency and quantity of the rain, but generally the 
weather was more sunny than in this country, even in the 
most favoured localities, and the afternoons were always 
warmer. With the temperature of the nights, however, it 
was not everywhere the same. After sunset the Scilly Isles 
were milder than many of the resorts of the Riviera and in 
northern Italy, and Sandown, Plymouth, and Torquay were 
no cooler than Nice and warmer than Florence. The 
foreign resorts had the great advantage of escaping the 
cold, cutting easterly wind that set in over this country 
after Christmas Day. It was this sudden change from 
autumn to winter that brought down the mean tempera¬ 
ture of the month in these islands ; previously it had 
been very high for the time of year, the thermometer 
rising frequently to well above 50° by midday and not sink¬ 
ing much below that point at night except in the midlands 
and north. Over the southern portion of the Mediterranean, 
as represented by Malta and Algiers, the month was both 
fine and warm and the day temperature at Palermo was also 
high. The favourite resort of Biarritz suffered much from 
heavy rains and boisterous winds during the earlier half of 





Thb Lancet,] 


A8PIRATION.—SIXTY-ONE EYE OPERATIONS IN ONE DAY. [JAN. 11, 1908. 121 


the month bnt the temperature was never low, and the 
second moiety brought ample compensation. Among the 
inland districts Berlin was by far the coldest; as many as 
18 of its nights were frosty and towards the end of the month 

the cold became very severe, the sheltered thermometer 
showing 14° of frost. Brussels was also cold and often 
frosty, while at Paris the days were slightly colder and the 
nights appreciably colder than in London. Harrogate was 
colder than the Midlands and slight frost was very common, 
while its mean temperature was exactly 5° lower than that 
at Bath. 


- 

Highest tempera¬ 
ture. 

!« 
s 

a 

§e 
' Ij 3 

1 ? 

* 

Mean maximum 
temperature. 

S 

= © 
IJ 

.2 g 

s| 

si 

a 

Mean temperature 1 
for month. 

_ t. 

0 3 

1 

« a 

© 

1 

i a 

‘H 

' £» 

«e 

Q 

Total fall in 
month. 



o 

° 

o 

o 

o 

o 


t 

ins. 

Scilly . 


65 

41 

51 

46 

48-4 

5 

22 

4 51 

Jersey . 


58 

33 

50 

42 

46-3 

8 

16 

3-23 

Plymouth ... 


56 

32 

49 

42 

45 3 

7 

23 

4 83 

Torquay 


57 

34 

50 

42 

456 

8 

20 

4 37 

Weymouth ... 


57 

32 

48 

41 

44-7 

7 

16 

3 67 

Bournemouth 


57 

32 

47 

40 

43-7 

7 

16 

4 29 

Brighton 


55 

32 I 

46 

40 

42-9 

6 

11 

1-98 

Sanriown, Isle 

of 









Wight 


57 

33 

51 

42 

461 

9 

14 

3-47 

Bath . 


67 

29 

47 

38 

42-1 

9 

13 

4 94 

Harrogate ... 


52 

29 

42 

32 

37 1 

10 

16 

3-66 

Manchester... 


54 

29 

45 

37 

410 

8 

14 

2 83 

Nottingham 


55 

27 

44 

35 

39-6 

9 

11 

2-56 

London. 


57 

33 

47 

39 

42 6 

8 

14 

3-06 

Paris . 


58 

24 

46 

36 

40 9 

10 

11 

1-90 

Berlin . 


4B 

18 

38 

31 

34-5 

7 

14 

1 91 

Brussels 


55 

23 

43 

33 

380 

10 

15 

1-68 

Nice . 


64 

32 

54 

42 

48-0 

12 

7 

4-41 

Genoa . 


•68 

39 

55 

48 

51-4 

7 

16 

9 67 

Florence 


62 

29 

55 

40 

47 4 

15 

14 

3 32 

Rome . 


64 

30 

56 

45 

50-5 

U 

13 

5-64 

Naples . 


62 

39 

57 

48 

523 

9 

19 

9 71 

Palermo. 


69 

34 

63 

48 

551 

15 

8 

2-50 

Malta . 


70 

42 

63 

54 

58-7 

9 

6 

0*44 

Algiers . 


73 

41 

67 

54 

60-1 

13 1 

10 

1*54 

Biarritz. 


68 

40 

61 

47 

54 2 

14 

15 

7-44 

Lisbon . 


63 

46 

58 

1 

52 1 

549 | 

i 

6 ! 

12 1 

3-83 


* A day with at least 0'04 in. 


ASPIRATION. 

Under the above heading Dr. Lachlan Grant delivered an 
illuminating address to the Mutual Improvement Society of 
Ballacbulish on Dec. 6th, 1907. Man, he said, must aspire, 
and many great thinkers, notably Carlyle, have said the 
same thing. Dr. Grant divided his address into four 
headings—namely, personal, local, national, and inter¬ 
national aspiration. As regards the second of these heads 
he pointed ont that individnals may desire something 
for themselves which may or may not benefit their 
neighbours, “but a community banded together for a 
common object will desire something pro bono publico, and 
therefore all concerned should see it their duty to take part 
in it.” Professor Gilbert Murray in his recently published 
work, “ The Rise of the Greek Epic,” has shown how the 
idea of service to the community was more deeply rooted in 
the Greeks than in us. Judging by their literature the 
question they always asked about statesmen and such-like 
was, “Does he help to make men better 1” And what a 
high view Plato took of the subject is shown by the remark 
which he puts in the mouth of Socrates in the ‘ ‘ Gorgias, ” 


where, talking of the great democratic statesmen of Athens, 
he denies that they have made Athens better or happier. 
“For they have filled the city full of harbours and docks 
and revenues and all that, and have left no room 
for justice and temperance.” (Jowett’s translation.) 
Modern municipalities may well ponder this saying. 
Speaking of international aspiration Dr. Grant was naturally 
led to mention how the nations of this world are gradually 
drawing nearer together to work for the common good. The 
recent Peace Congress at the Hague, the Parliament of 
Religions that met at Chicago during the last exhibition, and 
the various international congresses all point to the fact of a 
desire for the common good. Dr. Grant, however, is no 
misty idealist, for he realised to the full the fact that after 
all “preservationis the first law of Nature and that we must 

occasionally trample on each other’s corns. But we may 

all help to minimise the pain and the unpleasantness,” and, 
concluded Dr. Grant, “ those who can see visions of the new 
Jerusalem can at least work in the purifying spirit of hope¬ 
fulness for the universal acceptance of those larger ideals 
and deeper conceptions that in the course of time may bring 
us nearer to the kingdom of Heaven upon earth.” These 
ideals may well be before us at this beginning of a new 
year and the medical profession in particular has a great 
task before it in striving to lessen the amount of sickness, 
of infantile mortality, of drunkenness, of bad housing, and of 
prostitution. Both legislators and medical men may take to 
heart those wonderful stanzas of Blake :— 

“ Bring me my bow of burning gold ! 

Bring me my arrows of desire! » 

Bring me my spear: O clouds, unfold I 
Bring me my chariot of lire ! 

“ I will not cease from mental fight, 

Nor shall my aword sleep in my hand. 

Till we have built Jerusalem 
In England's green and pleasant land.” 

That is the spirit of the true reformer and the one in which 
all of us should work. _ 


SIXTY-ONE EYE OPERATIONS IN ONE DAY. 

An anonymous correspondent recently made, by means of 
the Indian lay press, the extraordinary statement that 
Indian civil surgeons had no incentive to keep up their pro¬ 
fessional knowledge and consequently degenerated into 
medical fossils who would fairly startle their brethren at 
home. Although writers of this stamp never add weight to 
their assertions by citing concrete instances but rely entirely 
upon specious generalities, they do occasionally meet with 
credence among honourable people who naturally assume 
that the calumniators are as honourable as they are them¬ 
selves. In order to show the utter lack of foundation for 
this disgraceful charge it is only necessary to refer to the 
Indian Medical Gazette, a journal of the highest class, which 
since the year 1865 has been edited and mainly supported by 
officers of the Indian Medical Service. In the December 
number Oaptain H. A. J. Gidney, I.M.S., publishes a remark¬ 
able article under the heading which we have borrowed, 
dealing with an ophthalmic surgeon’s work in the mofussil 
and incidentally showing some of the difficulties which he 
had to Burmount. On Sept. 85th last Captain Gidney pro¬ 
ceeded to an outlying village, about 20 miles from his station, 
and commenced work at 8 A.M., continuing, with half an 
hour’s interval for lunch, until 4 p.m. when the light began 
to fail. He had no ambition to achieve a record but worked 
steadily on, devoting from six to eight minutes to each case. 
Had the light remained be could have performed nearly 100 
operations but as it was he found on ceasing work for 
the day that no fewer than 61 cases had been attended 
to, as follows: extraction of senile cataracts, 52; 
extraction of congenital cataracts, six ; iridectomy, 
two; and pterygium, one. Of these 61 operations 60 were 
entirely successful. The sixty-first was a partial failure 







122 The Lancet,] 


“DRUNK OR DYING. 


[Jan. 11, 1908. 


because the operator’s De Wecker’s scissors had got blunt 
and tore the iris instead of making a clean cut. When 
Captain Gidney arrived at the village he found about 250 
blind people waiting for him. Of these, “ at least 100 
had been operated on by that well known destroyer 
of eyes—i.e., the ‘rawal,’ or village eye-quack." After 
examination of the whole number about 100 were set 
apart as suitable for operation. An assistant was then 
deputed to prepare the eyes by cutting the lashes of 
both upper and lower lids. He also washed the patient’s 
faces with soap and water and applied a weak solution 
of corrosive sublimate not only over the skin but also 
to the conjunctivas. The cases were then ranged in 
rows for the insertion of cocaine seriatim. “ By the time 
the first case had been operated on the next eye was 
thoroughly cocainised.” Finally, Captain Gidney, having 
first assured himself that the lacrymal sac was healthy, again 
disinfected the eye which he was about to open. He also 
applied a drop of adrenalin solution and effected “ another 
instillation of cocaine.” No time was lost but there was no 
hurry, each of the several steps being methodically carried 
out. In its editorial columns the Indian Medical Gazette 
refers to Captain Gidney's indictment of the itinerant 
“ couchers ” who roam from village to village in every province 
in India and do incalculable harm by destroying eyes which 
could otherwise have been properly treated by civil surgeons 
and their assistants in the various Government dispensaries. 
Our contemporary invites correspondence on the subject and 
is of opinion that if a sufficiently good case can be made out 
the Government will probably take steps to check the 
unrestrained practices of these people. 


THE ROLE OF NITROGEN AS FOOD, POISON, 
AND EXPLOSIVE. 

Every student of elementary chemistry will remember 
how comparatively uninteresting nitrogen gas appeared to be. 
It seemed to him to have no characteristics, it did not burn 
under ordinary conditions, it did not assist combustion, it was 
colourless and odourless, and on the whole its properties 
as an elementary gas were decidedly negative, and its 
occurrence seemed to be only capable of proof by 
showing that all other gases were absent. Y’et its 
very inertness is probably the secret of its potentiality. 
Nitrogen lores to be free; it declines in so many of 
its compounds to stay long in a state of combination with 
other elements, and so the familiar nitro-explosives are very 
powerful. It evinces, however, a more restful condition 
when it is associated with carbon and hydrogen, and 
especially when oxygen is absent. But here again it 
represents a very powerful combination in the shape of that 
great and important class of bodies the proteins, which are 
indispensable for the nourishment of the body. The same 
elements, however, may be combined to form a powerful 
poison instead of a food. Frussio acid, like protein, con¬ 
tains the three elements, nitrogen, carbon, and hydrogen, 
but in different proportions. We find nitrogen appear¬ 
ing, therefore, now in a powerful explosive, now in 
a poison, again in a food, and, finally, as a harmless 
diluent of the oxygen in the air which we breathe. It 
ministers to the needs of both peace and war, it may serve 
the purpose of the poisoner, it may fill the hungry with good 
things, and the greatest source of it is the pure and 
apparently innocent atmosphere. Human ingenuity is 
successfully converting the nitrogen of the air into nitrates 
wherewith to feed the plant and the same substances may be 
utilised also to make the powerful weapons of modern 
warfare. In times gone by another chemical element— 
to wit, iron—served equally in the cause either of peace 
or war. " They shall beat their swords into ploughshares 
and their spears into pruning hooks; nations shall not lift 


up sword against nation, neither shall they learn war any 
more.” Nitrogen is now rapidly replacing the sword in 
warfare and the question whether that element goes to the 
benignant usages of the soil or to the malignant purposes of 
the shell depends upon whether it is peace or war. Nitrogen 
is thus, so to speak, the modern ploughshare or sword as the 
case may be. _ 

“DRUNK OR DYING.” 

Another of those unfortunate cases has occurred in 
which a house surgeon after thoroughly examining a patient 
suffering from a condition which might be due to alcoholic 
intoxication or to injury concludes that the former is the 
case and dismisses him from hospital with the result that he 
dies at his own home a few hours later. The present 
instance occurred at the Northampton General Hospital, to 
which a poor fellow was taken with the story that the 
wheels of a loaded wagon weighing 21 tonB had passed 
over his body and face. He was twice thoroughly 
examined by two resident medical officers who found that 
the accident could not possibly have occurred as it was 
described by his friends, for there was no trace of a wheel- 
mark on the clothes or the body. From his general con¬ 
dition they considered that he had been drinking heavily and 
this impression was corroborated by the appearance of a 
gang of men who crowded into the receiving-room with him 
and had to be dismissed. No fracture was found and accord¬ 
ing to the evidence of the house surgeon the man’s condition 
was typically “alcoholic,” the only evidences of an accident 
being some epistaxis, a little bruising in the right groin, and 
pain in the right thigh. No bones were found broken. After 
the man had been detained for one and three-quarter hours 
he was discharged by the assent of the two house officers, 
but on reaching home he became much worse and a medical 
man hastily summoned arrived only in time to see him die. 
This gentleman Btated at the inquest that the cause of death 
was, in his opinion, shock due to the injuries received by a 
man in poor health. He did not consider that the deceased 
was under the influence of alcohol when he first saw him but 
he knew that he always spoke peculiarly and he himself 
had sometimes thought him to be under the influence 
of drink when such was not the case. He had per¬ 
formed a post-mortem examination and he was sure 
the wheel could not have passed over the deceased 
as had been described. The thorax, the ribs, and the 
abdomen were perfectly sound but the lower part of the 
body was bruised and “seriously injured internally." It 
would, he considered, be impossible to discover this on the 
first examination. The coroner questioned this witness and 
the house surgeon very closely on the man’s dismissal from 
the hospital. The jury found the cause of death to be 
accidental and added a rider to their verdict to the effect 
that they thought the doctors were wrong and inhuman to 
send the deceased out of the hospital in a dying state and 
they saw no reason to believe that he was under the 
influence of alcohol at the time. We are glad to be able 
to add that the board of management of the hospital 
having thoroughly investigated the matter has reported 
that both the resident medical officers acted with the 
greatest skill and kindness, and has communicated to 
the local newspapers the following resolution, which was 
passed unanimously :— 

That t lie board having received this report from its chairman con- 
nected with the death of Joseph Marks is of opinion that the charge 
of inhumanity brought against the resident medical officers is without 
foundation ; that they appear to have made a very careful examina¬ 
tion of the injured man and to have found no serious injury of 
any kind; and this fact was fully borne out by the post-mortem 
examination. 

We are very pleased to record that the hospital has sup¬ 
ported its resident medical officers so strongly and sym¬ 
pathise with those gentlemen on the unfortunate incident. 
Anyone who has ever been a house surgeon must know the 




The Lancet,] 


MEDICINE AND THE LAW.—LOOKING BACK. 


[Jan. 11, 1908. 123 


appalling difficulty of these cases, the moral of which seems 
to be that they had better be kept in for 24 honrs if there is 
a shadow of a doubt about their nature, even if an extra bed 
has to be made up to accommodate them. 


An important paper will be read at the meeting of the 
Surgical Section of the Royal Society of Medicine to be held 
at 20, Hanover-square, London, W., on Tuesday, Jan. 14th. 
at 5 30 p.m„ by Mr. Harold L. Barnard, on Some Aspects 
of Subphrenic Abscess. The paper is based upon 76 con¬ 
secutive cases, of which 21 were operated upon by Mr. 
Barnard. It is expected that a good discussion of this 
serious condition will be elicited by this communication. 
Among many points of interest Mr. Barnard's statistics show 
that of the cases not operated upon all died. The subject is 
one which concerns the physician no less than the surgeon 
and it is hoped that members of the Medical Section will be 
present and will take part in the discussion. 


A telegram from the Governor of the Mauritius received 
at the Colonial Office on Jan. 3rd states that for the week 
ending Jan. 2nd there were 3 cases of plague and 3 deaths 
from the disease. 


MEDICINE AND THE LAW. 


The Burning and Overlying of Children. 

A report in the Daily Telegraph recently stated that a 
coroner’s jury in St. Pancras had before it not one but several 
inquests in which the suffocation of children had oocurred 
from their sleeping in their parents’ beds and that when the 
same jury had taken part in another inquiry concerning the 
death of a child from burning due to the absence of a fire¬ 
guard an opportunity was afforded to the coroner for calling 
their attention to the Bill recently before Parliament 
affecting these two dangers to infant life. As a result 
the jury added to their verdict of accidental death in 
the burning case a rider intimating their strong approval 
of the proposed legislation. We note that the same news¬ 
paper has since reported other cases of the burning of 
children and it is to be hoped that attention may in this 
way be drawn to the matter, so that the support of favour¬ 
able public opinion may be accorded to a measure which 
will no doubt be reintroduced during the coming Parlia¬ 
mentary session. The Bill in question may be described as 
a coroners' Bill, due to the experience acquired by these 
gentlemen in presiding over inquiries which owing to their 
sameness and frequency are often not accorded publicity 
and it therefore has a great weight of expert opinion 
behind it. It is, however, a private Member's Bill 
and as such its passing is likely to be postponed in¬ 
definitely unless it can secure support from the Govern¬ 
ment, which, so far as it is possible to judge, will 
find its time fully occupied in pressing forward its own 
political measures in the face of opposition. The Bill 
to which we have referred has in its favour the fact 
that it has no political bearing but proposes only to protect 
helpless children from suffering and death, and that it im¬ 
poses fresh duties of care upon their parents in terms so brief 
that lengthened discussion with regard to them can hardly 
take place. If public opinion were to be aroused and ex¬ 
pressed in its favour it would no doubt obtain that recogni¬ 
tion at the hands of those in power which, as we have 
suggested, it deserves, and it is to be hoped that possibly 
it may do this on its merits. In such an event it can hardly 
be likely that it would meet with direct opposition of any 
importance in either House. 

Malt Vinegar. 

A fine of £1 was imposed recently by the Acton magis¬ 
trates upon a tradesman convicted of selling as ‘ 1 malt 
vinegar " a liquid consisting of 30 per cent, only of malt 
vinegar combined with vinegar prepared from aoetic acid 
and colouring matter. The defence was to the effect that 
that which was handed to the inspector was sold as “ wood 
vinegar,” but his evidence was that he had asked for malt 
vinegar and had paid 2d. for a pint of the liquid which was 


in a vessel not labelled. Evidence was given that one pound 
of acetic acid, costing 4 d., would make two gallons of 
“ vinegar.” 

Death from Heat on Board Ship held to he an Accident. 

Among the most important extension of compensation 
under the Dew Workmen's Compensation Act is undoubtedly 
that which enables seamen to claim for the accidents in¬ 
cidental to their calling. An interesting case has recently 
been decided at Belfast by his honour Judge Fitzgibbon who 
has held that the death of a stoker who died on board 
the White Star steamship Majestic in mid-Atlantic from 
the effect of heat was due to an “accident” within 
the meaning of the Act and accordingly conferred the 
right to compensation upon his widow. The case is 
one upon which there will naturally be an appeal 
arising, as so many have arisen already, out of the use 
of the popular and somewhat indefinite word “ accident.” 
The facts were hardly in dispute. The deceased was a small 
man, not naturally of strong physique, who had endured 
privations and hunger in New York and bad been shipped in 
order that he might work his passage home through the 
intervention of a seamen's mission. When in the stokehold 
raking the furnaces at a temperature where he stood of 
96° F. »nd where, close by, the thermometer reached 114°, 
he had been seen to fall suddenly and had died in 
the hospital two hours later. He was buried at sea on 
the same day and the cause of his death was entered in 
the log as “ heat-stroke and exhaustion.” The question for 
the county court judge therefore resolved itself into whether 
the effect of the heat of the boilere upon the workman wbb 
an accident arising out of his employment which would 
entitle his widow to recover. The medical officer of the 
ship stated in cross-examination that during four years be 
had seen four cases of death from similar causes. The result 
of the decision, if it is upheld upon appeal, will no doubt be 
to render employers unwilling to engage men whose physical 
condition is unsuited to the strain likely to be imposed upon 
them, and another difficulty will be placed in the way of 
middle-aged men obtaining work. Employers will also be 
alert to improve as far as possible the circumstances in 
which their work is carried out, but it will be impossible to 
render the conditions of stoking anything but excessively 
arduous. 


Xookina Back, 


FROM 

THE LANCET, SATURDAY, Jan. 9th, 1830. 


I may mention generally, that in the treatment of ulcers, 
such as require that the patient should be confined to his 
chamber and not to bed, it may be necessary that he should 
be on what we call a sick diet. It is totally improper to let 
him be living on animal food and fermented liquors. If you 
allow that, it will frustrate all your means. A strange 
notion exists in the minds of medical men, that where they 
see a sore which is discharging, it is necessary to give nutri¬ 
tious diet, and allow wine and bo forth, to support the system 
under that discharge, when in fact the evil probably proceeds 
from an already over-full state of the constitution. This is a 
most injudicious way of treating such cases. On the contrary, 
you will very frequently find it necessary to take blood, and 
to reduce the diet still further, in the progress of affections 
of this kind. 

I should mention to you further, that when large ulcers are 
healing very rapidly, it is necessary to pay great attention to 
the same points, in order to prevent the occurrence of other 
serious mischief. When an active disease of this kind, in any 
part of the body, is put a stop to, unless great attention is 
paid to all the points I have mentioned, there is much reason 
to apprehend that some other parts of the frame will become 
affected : and I have known many instances, under such 
circumstances, where persons have been allowed a full diet, 
that the healing of the ulcer has been speedily followed by 
an attack o{ palsy, or some serious disease either in the chest 
or abdomen. 1 


1 Excerpt from “Lectures on Surgery, Medical and Operative, 
delivered at St. Bartholomew’s Hospital; By Mr. Lawrence. Leo- 
ture XV. Ulceration.'' 





124 The Lancet,] 


BORIC ACID IN CREAM. 


[Jan. 11, 1908. 


BORIC ACID IN CREAM. 


Cullen v. McXair. 

This was an appeal from a conviction by Mr. Curtis Bennett at 
Westminster police court for selling cream containing boric acid to 
an extent injurious to health (Sale of Food and Drugs Act, 1875, Sec. 3). 

Mr. W. R. Bousfield. K.C., Mr. K. Page, K.C., and Mr. G. Elliott 
appeared for the appellant, instructed by Messrs. Neve, Beck, and 
Kirby. 

Mr. McCall, K.C., Mr. Courthope Munro, and Mr. W. F. Clark, 
instructed by Messrs. Allen and Son, represented the respondents—the 
Westminster city council. 

Thecase was heard by Mr. Robert Wallace, K.C., and other justices at 
Glerkenwell on Oct. 31st, Nov. 8th, and 18th, 1907. when a large number 
of witnesses were called on both sides. The cream in question was sold in 
a pot on which wab a label to the effect that it contained a small 
percentage of boron preservative to retard sourness. The amount of 
boric acid found in it by Mr. C. E. Cassal, the public analyst, was 
21*91 grains to the pound; and ho stated in evidence that in his opinion 
if a preservative was present In a sufficient, amount to exert a substantial 
antiseptic action on iood it must of necessity injuriously interfere with 
the process of digestion. The cream contained 52 per cent, of fat. 

Mr. Reginald Harrison. F.R.C.S., narrated his experience with boric 
acid in connexion with urinary fever. 1 He had found that by its use 
operations on the urethra aod bladder could be performed without 
fever resulting, but he was forced to abandon its use because the 
patients w’ere made ill otherwise by the remedy. Flatulence, nausea, 
and often disturbance of the heart’s action resulted and occasionally 
eruptions on the body and other symptoms occurred. As boric acid was 
chiefly excreted by the kidneys be had not the slightest doubt that 
boric acid in the proportion contained in this cream, and even in 
smaller quantities, would tend to Intensify any disease of the kidney 
even in an incipient stage. The long-continued exhibition of small 
doses appeared to produce the same result as the use of large doses 
extended over a shorter period. The witness did not agree with the 
conclusions of Liebrechand Tunnicliffe. Experiments extended over a 
comparatively short time were not to be compared with what occurred 
in every day life when people went on for mouths and months con¬ 
suming quantities of boric acid in their food. 

Dr. W. D. Halliburton, professor of physiology in King’s College, 
London, stated that in his opinion the consumption of boric acid in any 
quantity was injurious ; it brought about digestive disturbances, but of 
course different people were differently affected. Its addition to milk 
caused the lime salts to be thrown out and in this way if cream be 
added to milk, as was now very generally done, in order to make cow ’s 
milk approximate more nearly to human milk the presence of the acid 
would destroy the value of the lime, making it absolutely insoluble. In 
this way persons consuming the mixture did not get their fair propor¬ 
tion of the lime which went towards making bone, and rickets might 
result. He agreed with Mr. Harrison as to the effect on the kidneys 
and also »b to the fallacy of conclusions drawn from short experiments 
such as those of Tunnicliffe. Questioned as to the results obtained by 
Chittenden, he pointed out that the experiments were made on dogs 
and that they have a very resistant alimentary canal. 

Dr. Ralph Vincent, one of the physicians to the Infants’ Hospital, 
said that if milk and cream were kept at a temperature of 40° F., there 
would be no necessity to use any preservative. The addition of boric 
acid to the foods of infants was likely to have more serious effects from 
the fact that as the feeding had to take place At short intervals the 
kidneys and digestive organs were continuously under the influence of 
the drug. The first effect produced in digestion in the stomach of the 
infant was the precipitation of the curd; boric acid interfered with this, 
and the child eventually suffered from sickness, diarrhera alternating 
with constipation, which led to a condition of marasmus in which 
the child could no longer digest anything Cream had largely taken the 
place of cod-liver oil and it was essential that it should be pure. 

Dr. H. R. Kenwood, professor of hygiene and public health in Uni¬ 
versity College, London, considered the addition of boric acid to food as 
a positive danger. He had made some experiments on himself in 
1903 and again in 1905 and on each occasion suffered from a train of 
symptoms now* generally recognised as “borism." He attached high 
value to the experiments of Dr. Wiley, considering them by far the 
best which had ever been carried out with reference to boric acid. 
Reference w as made to the report of the Commission of 1899 in which 
it was suggested that it might be permissible to allow 174 grains to 
the pound. It had also been stated that the Local Government Board 
had issued a circular allowing a larger amount, but the witness pointed 
out that this w as wrong, for if the amount (40 grains to the gallon) be 
worked out on the same basis it came to 3 ’88 grains per pound, which 
the Board now held Bhould raise the presumption of injury to health. 
From hiB experience as a medical officerol health he was of opinion that 
in average homes a label on a jar afforded very poor protection. Medical 
men who recommended cream for their patients might not be aware 
that they were taking a boricised article. 

Mr. Henry Droop Richmond, F.I.O., appeared on subpoena. He 
said that the Aylesbury Dairy Company, for which he had been 
analyst for 15 years, gave up the use of preservatives in cream 
12 years ago. Previous to that time a small quantity of boric acid 
(0*2 per cent, or 14 grains to the pound) was used. ‘ The company 
sent out cream to customers twice or three times a day. If 
cream was kept it got thicker, reaching its maximum thickness 
about the third day. He had made experiments and found 
that cream to which 174 grains of boric acid had been added would 
keep for five and a half days at a temperature of 60° F.; with 
21 g ains it would keep six and a half days ; with 24 grains, seven and 
a half days ; and with 35 grains, ten days. Without any preservative 
cream Bhould keep good for about two days at the same temperature— 
viz., 60°. If put in cold storage for a day the cream would keep fresh 
for one and a half days after being sent out. 40° was the best tempera¬ 
ture at which to keep cream, as if the temperature was near the freezing 
point then the cream on being taken out was apt to show a tendency to 
become churned hy handling. As to the price, witness calculated that 
this boridBed cream was sold at the rate of 4fr. 6d. a quart, taking a pint 
of cream of the consistence of 52 per cent, of fat to weigh 21 ounces. 

Dr . F. J. Allan, medical officer of health of the Cit»y of Westminster, 


i Bee paper in The Lancet, Sept. 22Ad, 1906. 


said that his experience of the use of boricised cream on normal persona 
was that indigestion was produced. He believed that many people 
thought they could not digest cream, whereas it was the boric acid which 
upset them. Boric acid added to polluted creAm might hinder the 
multiplication of organisms, but so soon as the cream was taken into 
the stomach the preservative would be absorbed and the organisms 
would have full play. Boric acid was not a severe poison but it was an 
insidious one, and its use continued over a lengthened period pro¬ 
duced a detrimental effect on the organs of the body. 

For the appellant evidence was given as follows. 

Dr. J. C. Thresh, medical officer of the county of Essex, said that boric 
acid was not a poison in the popular sense any more than saltpetre was. 
If these or even common salt were given in extravagant quantities in¬ 
jurious effects w ould be caused. He considered that a reasonable amount 
of boric acid. Bay from eight to ten grains per day. would be innocuous. 
He considered that Dr. Wiley in bis experiments made a fatal mistake in 
giving the preservative in large doses. Because large doses of any 
subBtanco produced harmful effects It did not follow that small dosea 
would have less injurious effects. He thought that boric acid might 
play a useful part in children's diet if it prevented the too rapid 
curdling of the milk, but he had had no experience of the feeding of 
infants with cream. 

In cross-examination Dr. Thresh Btated that he considered that 
22 grains w f as more than he thought Bhould be allowed in cream, 174 
grains would be preferable. He objected to preservatives in milk 
entirely. He objected to boric acid in quantities likely to be of any 
use in preserving milk. He thought that the use of boric acid was 
dangerous for people suffering from kidney disease and that it was 
likely to be so for those who had a tendency to kidney trouble. He 
objected to It being administered to invalids, dyspeptics, and babies, 
except under medical supervision, and certainly not by an ignorant 
milkman. 

Dr. R. Hutchisox, physician to the London Hospital, did not think 
that if as much as a quarter of a pound of this cream were taken in a 
day the amount of boric acid would do any harm to anyone. He 
knew of no medical evidence to prove that this drug was an aborti- 
facient. Assuming that there was a choice of cream with and without 
boric acid he would rather order that without, because lie did not see 
the use of admitting a foreign substance into the body if one was not 
obliged to, but he did not think that five grains a day administered to 
an infant would have any effect. 

Dr. H. Campbell Thomson, physician to the Hospital for Paralysis 
and Epilepsy, said that he had prescribed borax preparations in con¬ 
siderable quantities over considerable periods without observing any 
ill effects. He believed that If anyone suffered from small doses of 
boric acid it must be due to idiosyncrasy. 

Dr. T. F. Vaisey, medical officer of the WinBlowr district, where 
Messrs. Edwards’s creamery is situated, said that the cream was prepared 
with the greatest care. He had used the cream for children who did 
not thrive on ordinary milk. 

Dr A. P. Luff, physician to St. Mary’s Hospital and one of the 
scientific advisers to the Home Office, did not consider the amount of 
boric acid in this cream would be Injurious to the health of normal 
persons. He preferred to take boricised cream himself in summer time 
but he drew a sharp distinction between the general public and infants 
and invalids. He would allow up to 0 5 per cent, in cream but would 
draw the line there. 

Mr. Richard Bannister, F.I.O., formerly of the Inland Revenue 
Laboratory, said that It would be impossible to bring cream to London 
without the ubo of a preservative unless it were sold at once. He did 
not think that refrigeration was practicable. 

Professor Lloyd agreed in this. 

Mr. C. A. Gates, chairman of the Cream Trade Association and of 
the West Surrey Dairy Company, said his firm first supplied cream 
with preservative added 22 years ago. They used 0 75 per cent., for 
many years without any complaints. When the Departmental Com¬ 
mittee reported that only 174 grains should be used they reduced their 
amount, but finding that cream would not keep long enough with 
that quantity they again increased it to 35 grains. Tbe exigencies of 
the trade required that potted cream should keep sweet for six or 
seven days. The boric acid was added to the cream immediately after 
separation. 

Mr. John Allsopp, manager of Edwards’s Creamery at Winslow, 
Bucks, said they received milk twice a day from 80 to 100 farmers. 
On arrival it was filtered and separated and the cream which resulted was 
pasteurised and then the boric acid was added. With milk arriving at 
8 a.m. the cream should be in London by 4 p.m. It was put in a cold' 
room at their London depot till next morning. Cream was now used 
much more than formerly for culinary purposes; probably about three- 
fourths of the cream sold was so used. 35 grains of boric acid w as necessary, 
in his opinion. He used a special powder and added eight ounces to 
17 gallons. It was put to him that this amount did not give 35 grains 
of boric acid to the pound but only 21 grains, which ooincided with the 
amount found in the sample. Witness did not know but did not 
consider it was enough. 

Mr. Reginald Butler, managing director of the Wilta United 
Dairies, and Mr. E. D. Harden, director of Aplin and Barrett and tho 
Western Counties Creamery, Limited, considered that 35 grains of 
boric acid was necessary in order to allow for the time in transit from 
creamery to customer. 

Mr. Bousfield, K.C., at the close of the evidence, said this was a 
trade created within the last 25 years in preserved cream, not fresh 
cream ; it was only rendered possible by the use of preservatives and 
all the evidence went to show that boric acid was the least harmful of 
all preservatives. What had to be decided was whether this article 
containing from 21 to 22 grains of boric acid to the pound was 
injurious to tbe health of normal persons in normal quantities. The 
evidence of the appellant's witnesses was that it was not injurious 
to health In the quantity used. 

Mr. McCall, K.G., for the respondents, said the Sale of Food and 
Drugs Act was intended to protect the community as a whole and not. 
a particular class. Did the facts of this case bring it within the Act p- 
He did not rely entiiely on the witnesses for the respondents. Dr. 
Thresh, a witness for the appellant, had admitted that boric acid 
would be likely to be injurious to people suffering from kidney dis¬ 
orders, consumption, and indigestion, and that in some Instances it 
waa a slow poison. He thought the trade could easily meet the difficulty 
by more frequent delivery and by making more use of other methods,, 
such &b cold storage. 




Tn Lancet,] 


VITAL STATISTICS. 


[Jan. 11,1908. 125 


Tlie Chairmaw, in giving judgment, said : In this case the appellant 
was convicted before the learned police magistrate under Section 3 of 
the Pood and Drugs Act as selling an article of food mixed, to put it 
shortly, so as to be injurious to health, and from that decision he has 
appealed to this court. Now, first some discussion has arisen in regard 
te the meaning of the Act itself. Section 3, and we have considered 
who the class of persona are w hose health might, or may be. Injured by 
the article of food so sold. In our opinion the persons included 
are flrat what we may call normal persons and not an invalid 
in the ordinary sense—that though this article thus mixed would 
he unprejudiclal to the health of the general community, even 
when it might be prejudicial to persons afflicted with particular 
diseases, we do not think that it would como within the terms of the 
section ; on the other hand, we do think and for this reason because 
of certain findings of fact which I am about to go into, we do think 
that it includes cases of children and infants, and wo think so because 
■we think that now cream has become part of the food used by infants 
more than formerly. As a question of fact we find that this section 
only, of course, applies to foods and to the classes who use those foods, 
and if cream was not ordinarily used by infants then this section would 
have no application, but sb we think that now infants do use cream 
mixed with their milk we think that this section applies to infants 
as well, and I may say In regard to that that if there is any desire 
expressed as to the ground on which we include infants in the 
classes we will state a case to anyone who is dissatisfied with our 
finding in respect to this matter. The finding of fact remains 
of course. We find as a fact that cream is now an article of diet used 
by the class to whom we referred—the class of children—as an 
article of food. We are of opinion in regard to this matter that cream 
if mixed with boric acid equivalent to that found In this case is as 
regards grown men and women uninjurious, but we are of opinion 
that it is injurious to the health of children and Invalids. I ncod not 
refer to the class of invalids as for the reason given we do not think that 
they are referred to in the section, and holding that view that it is 
injurious to children—to infants and children—and that infants and 
children are a class to whom this section can be taken as those by 
whom this food is used and to whom this section applies, we hold 
in these circumstances that the conviction mnst be affirmed and 
the appeal dismissed with costs. 


VITAL STATISTICS. 


HEALTH OF ENGLISH TOWNS. 

IN 76 of the largest English towns 9608 births and 6354 
deaths were registered daring the week ending Jan. 4th. 
The annnal rate of mortality in these towns, which had 
averaged 16 • 8 and 14 • 7 per 1000 in the two preceding weeks, 
rose again to 16 • 9 in the week under notice. Daring the 13 
weeks of last quarter the death-rate in these towns averaged 
16 • 5 per 1000, the rate during the same period being 14'9 
in London. The lowest annnal death-rates in the 76 towns 
last week were 6'1 in Handsworth, 8 7 in Walthamstow, 
9 • 0 in Hornsey, and 9 • I in Tottenham; the rates in the 
other towns ranged upwards to 24 • 2 in Wallasey, 24 • 3 in 
Rhondda, and 26’4 in Newport (Mon.). The 5264 deaths 
registered in the 76 towns during the week under 
notice showed an increase of 727 upon the number in 
the previous week, partly due to delay of registra¬ 
tion during Christmas week, and included 393 which were 
referred to the principal epidemio diseases, against 398 and 
372 in the last two weeks of 1907; of these 393 deaths 103 
resulted from measles, 92 from whooping-cough, 75 from 
diphtheria, 49 from scarlet fever, 48 from diarrhoea, 26 from 
“ fever ” (principally enteric), but not one from small-pox. 
The deaths from these epidemic diseases in the 76 towns 
were equal to an annual rate of 1 • 3 per 1000, the rate from 
the same diseases in London being 1'2. No death from 
any of these epidemic diseases was registered last week 
in 11 of the smaller towns, including Norwich, Bourne¬ 
mouth, Bury, Rotherham, Plymouth, and Devonport; 
the annual death-rate from these diseases ranged 
upwards in the other towns to 3 4 per 1000 in Merthyr 
Tydfil, 3 - 5 in Ipswich, 3 9 in Rhondda, and 5-7 in Tyne¬ 
mouth. The fatal cases of measles, which had been 124 and 
104 in the two preceding weeks, declined to 103 last week, 
but caused annual death-rates ranging upwards to 2'0 per 
1000 in Stockton, 2 8 in Ipswich, 3 0 in York, and 5 7 in 
Tynemouth. The deaths from whooping-cough, which had 
been 94 and 89 in the two preceding weeks, rote again to 
92 in the week under notice, the highest death-rates 
from this disease being 1 • 2 in Wigan, 1 ■ 4 in Newport 
and in Merthyr Tydfil, and 1'5 in Smethwick. The 75 
deaths attributed to diphtheria showed a further in¬ 
crease upon the numbers returned in the three preceding 
weeks, which were 57, 62, and 71; this disease caused seven 
deaths in East and West Ham, three in Nottingham, six in 
Liverpool, five in Manchester and Salford, and two in 
Rhondda. The 49 fatal cases of scarlet fever exceeded the 
number in the previous week by eight and caused the highest 
death-rate, 1 ’ 5 per 1000, in Wallasey; 17 deaths from the 


disease were registered in London and five in Liverpool. 
The 48 deaths from diarrhoea all but corresponded with the 
numbers in recent weeks. The deaths referred to “fever” 
(principally enteric) were 26 in the week under notice, against 
28, 20. and 23 in the three preceding weeks ; the annual 
death-rate from this disease was equal to 1 ’ 2 per 1000 in 
Rhondda and 1-4 in Merthyr Tydfil. The number of 
scarlet fever patients under treatment in the Metropolitan 
Asylums Hospitals was 4684 on Jan. 4th, against numbers 
declining from 5581 to 4999 at the end of the four pre¬ 
ceding weeks ; 440 new cases were admitted to these 
hospitals during last week, against 447 and 353 in the 
two preceding weeks. The deaths in London referred to 
pneumonia and other diseases of the respiratory organs, 
which had been 347 and 317 in the two previous weeks, were 
333 last week and were 159 below the corrected average 
number in the corresponding periods of the five years 
1903-07. The causes of 56, or 1-1 per cent., of the deaths 
registered in the 76 towns were not certified either by a 
registered medical practitioner or by a coroner. All the 
causes of death were duly certified in London, Leeds, 
Bristol, West Ham, Hull, and in 45 of the other towns ; 12 
uncertified causes of death were, however, registered in 
Liverpool, nine in Birmingham, and five of the 47 deaths in 
South Shields. _ 


HEALTH OF SCOTCH TOWNS. 

The annual rate of mortality in eight of the principal 
Scotch towns, which bad been equal to 20 "0, 20'8, and 
18 • 2 per 1000 in the last three weeks of 1907, rose 
again to 20 ■ 6 during the week ending Jan. 4th, and 
was 3-7 above the mean rate in the 76 large English 
towns during the same week. Among the eight Scotch 
towns the death-rates last week raDged from 17 ■ 3 and 
17'7 per 1000 in Aberdeen and Edinburgh to 24 • 8 in 
Dundee and 30 • 5 in Greenock. The 725 deaths in these 
eight towns last week showed an increase of 93 upon those 
registered during Christmas week, and included 127 which 
were referred to the principal epidemio diseases, against 
116 and 109 in the two previous weeks; of these, 
65 resulted from measles, 23 from whooping-cough, 15 
from diarrhoea, 11 from diphtheria, seven from scarlet 
fever, five from “fever,” and one from smallpox. These 
127 deaths were equal to an annual rate of 3 1 6 per 
1000, which was no less than 2 • 3 above the mean 
rate from the same diseases last week in the 76 
English towns. The fatal cases of measles in these 
Scotch town3, which had been 53 in each of the two 
previous weeks, rose last week to 65, of which 47 occurred 
in Glasgow, six both in Aberdeen and in Greenock, three in 
Dundee, and two in Paisley. The 23 deaths from whooping- 
cough showed a slight decline from recent weekly 
numbers ; ten occurred in Glasgow, four in Dundee, and 
three in Leith and in Perth. The 15 deaths attributed 
to diarrhoea included six in Glasgow and five in 
Dundee. Of the 11 fatal cases of diphtheria, five occurred 
in Glasgow and three in Paisley. Five of the seven deaths 
from scarlet fever were returned in Glasgow, as were all 
the five deaths referred to “fever,” of which four were 
certified as enteric and one as cerebro-spinal meningitis. 
The fatal case of small-pox occurred in Leith. The 
deaths referred to diseases of the respiratory organs 
in these eight towns, which had been 158 and 127 in the 
two preceding weeks, were 128 in the week under notice, 
and were 55 below the number from the same diseases in the 
corresponding week of last year. The causes of 37, or 5'1 
per cent., of the deaths in these towns last week were not 
certified or not Btated ; in the 76 English towns the pro¬ 
portion ot uncertified deaths did not exceed 1 • 1 per cent. 


HEALTH OF DUBLIN. 

The annual rate of mortality in Dublin, which had been 
equal to 25 0 and 19 • 8 per 1000 in the two preceding weeks, 
rose to 25'5 in the week ending Jan. 4th. During the 13 
weeks of last quarter the death-rate in the city averaged 
21 • 5 per 1000, the rates during the lame period being only 
14'9 in London and 14'8 in Edinburgh, The 193 deaths of 
Dublin residents registered last week exceeded the number 
in Christmas week by 45, and included ten which were 
referred to the principal epidemic diseases, against ten and 
five in the two preceding weeks ; of these, six resulted from 
whooping-cough, three from diarrhoea, one from diphtheria, 
but not one from small-pox, measles, scarlet fever, or 




126 The Lancet,] 


THE SERVICES. 


[Jan. 11, 19C8. 


“ fever." These ten deaths were equal to an annual rate 
of 1 • 3 per 1000, the death-rates from the same diseases last 
week being 1 • 2 in London and 1 • 0 in Edinburgh. The six 
deaths from whooping-cough in Doblin last week showed a 
considerable increase upon the numbers in recent weeks. The 
193 deaths from all causes in Dublin included 39 of infants 
under one year of age and 59 of persons aged upwards of 60 
years; the deaths of elderly persons showed a marked 
increase. Eight inquest cases and five deaths from violence 
were registered, and 61, or 31’6 per cent., of the deaths 
occurred in public institutions. The causes of four, or 
2‘2 per cent., of the deaths in Dublin last week were not 
certified ; in London the causes of all the 1526 deaths were 
duly certified, while in Edinburgh the proportion of un¬ 
certified causes of death was equal to 8'5 per cent. 


THE SERVICES. 


Royal Navy Medical Service. 

The following appointments are .notified:—Deputy 
Inspeotor-General F. J. Lilly to Plymouth Hospital. Fleet 
Surgeons: J. Moore to the Indus; G. H. Foott to the 
President , additional, for three months’ course at West 
London Hospital. Staff Surgeon J. C. Darston to the 
Blenheim. 

Royal Army Medical Corps. 

Lieutenant Arthur S. Arthur to be Captain (dated Oct. 1st, 
1907). Captain Horace H. Kiddle, from the Indian Medical 
Service, to be Captain vice William H. Odium, who 
exchanges (dated Dec. 18th, 1907). Lieutenant H. T. Treves, 
Lieutenant W. R. O’Farrell, and Lieutenant T. F. Lamb have 
been appointed to the London district from Jan. 1st. 

Royal Army Medical Corps in India. 

The following tour-expired officers have proceeded to 
England :—Major R. C. Lewis, Captain J. E. Hodgson, and 
Captain W. S. Crosthwait, on the hospital ship Plasty , from 
Bombay, on Nov. 1st, 1907. Lieutenant-Colonel W. Turner, 
Captain L. W. Harrison, and Captain H. Rogers, on transport 
Reiva, from Karachi, on Nov. 16th, 1907. Lieutenant- 
Colonel D. F. Franklin, Captain L. L. G. Thorpe, and Captain 
F. E. Rowan-RobinBon, on transport Assaye, from Bombay, 
on Dec. 6tb, 1907. 

Lieutenant-Colonel A. S. Rose, on return to India from 
leave on medical certificate in England, has been posted to 
the 8th (Lucknow) Division. Lieutenant-Colonel W. T. 
SwaD, on transfer from 3rd (Lahore) Division to 7th (Meerut) 
Division, has been posted to the Station Hospital, Meerut, for 
duty. Major E. M. Morphew has been transferred from Kailaina 
to command the Station Hospital at Delhi. Captain A. C. 
Osbnrn and Lieutenant J. P. Lynch have been transferred 
from the 7th (Meeiut) Division to Burma Division on duty. 
Lieutenant F. Scatchard has been transferred from Agra to 
command the Station Hospital at Fategarh. On the arrival 
at Shahjahanpur of Captain Crisp from England for a tour of 
dnty in India Lieutenant M. Keane has been posted to the 
Station Hospital, Meerut, for duty. Captain E. Blake Knox, 
has been appointed staff officer Medical Mobilisation Stores 
7th (Meerut) Division. 

Indian Medical Service. 

Brigade Surgeon-Lieutenant-Colonel David D. Cunningham, 
C.I.E., retired pay, Honorary Physician to the King, is 
granted the honorary rank of Colonel (dated Deo. 4th, 1907). 

Army Medical Reserve of Officers. 

Surgeon Major Walter C. James to be Snrgeon-Lientenant- 
Colonel (dated Dec. 10th, 1907). Surgeon-Captain Arthur D, 
Ducat to be Surgeon-Major (dated Dec. 25th, 1907). 

Imperial Yeomanry. 

Royal 1st Devon : Surgeon-Lieutenant F. E. Little resigns 
his commission (dated Dec. 6th, 1907). 

Volunteer Corps. 

Royal Garrison Artillery (Volunteers) ; 1st Berwickshire : 
Surgeon-Lieutenant W. D. Forsyth resigns his commission 
(dated Nov. 26th, 1907). 1st Midlothian: Surgeon-Lieu¬ 
tenant W. G. Porter resigns his commission (dated Nov. 26tb, 
1907). William Guthrie Porter (late Surgeon-Lieutenant) to 
be Second Lieutenant (dated Nov. 26th, 1907). 1st New- 
castle-on-Tyne: Surgeon-Lieutenant-Colonel A. T. Wear 
resigns his commission, with permission to retain his rank 


and to wear the prescribed uniform (dated Nov. 7th, 1907). 
Royal Engineers ( Volunteers): East London (Tower Hamlets): 
Surgeon-Lieutenant M. P. M. Collier to be Surgeon-Captain 
(dated Nov. 16tb, 1907). t- **■ 

Rifle: 1st Volunteer Battalion, The Lancashire Fusiliers: 
Supernumerary Surgeon-Captain A. P. Nuttall to be Surgeon. 
Major, remaining supernumerary (dated Nov. 29th, 1907)- 
5th Volunteer Battalion, The Cheshire Regiment: Surgeon- 
Major J. H. Hacking is granted the honorary rank of Surgeon- 
Lieutenant Colonel (dated Dec. 7tb, 1907). 4th Volunteer 
Battalion, The CameroniaDs (Scottish Rifles) : The under¬ 
mentioned officer resigns his commission : Surgeon-Captain 
J. S. McKendrick (dated Nov. 2nd, 1907). 1st (City 
of Dundee) Volunteer Battalion, The Black Watch 
(Royal Highlanders): Supernumerary Surgeon-Lieutenant- 
Colonel D. Lennox is granted the honorary rank of Surgeon- 
Colonel (dated Dec. 5th, 1907). Surgeon-Captain J. 8. Y. 
Rogers to be Surgeon-Major (dated Dec. 5th, 1907). 3rd 
(City of) London Volunteer Rifle Corps: Surgeon-Captain 
T. W. Parry resigns his commission (dated Dec. 3rd, 1907). 
20th Middlesex (Artists') Volunteer Rifle Corps: Surgeon- 
Major H. D. Brook is granted the honorary rank of Surgeon- 
Lieutenant-Colonel (dated Dec. 3rd, 1907). 

Royal Army Medical Corps (Volunteers). 

4th or City of London Bearer Company : Lieutenant J. 
Forbes to be Captain (dated Nov. 28th, 1907). 

On Feb. 1st, at the headquarters of the Royal Army 
Medical Corps (Volunteers) (London companies), 51, Cal- 
thorpe-street, Gray's Inn-road, W.C., Lady Keogh will dis¬ 
tribute the prizes won by the men and non-commissioned 
officers of the corps during the past year. The distribution 
of prizes will be followed by a dance. 

Royal Territorial Medical Corps. 

It has been decided that the medical arm of the Territorial 
Force shall be called the Royal Territorial Medical Corps. 

Tub Army Medical Staff. 

Promotion to the higher ranks of the Army Medical Staff 
will be accelerated this year owing to six surgeon- generals 
being retired under the age rules—viz., Surgeon-General A. 8. 
Reid, C.B., Surgeon-General W. J. Fawcett, O.B.. Surgeon- 
General W. J. Chariton, Surgeon-General J. D. Edge, C B., 
Surgeon-General R. H. Quill, and Surgeon-General W. B. 
Slaughter. 

The Convalescent Home for Officers at Osborne. 

The King has approved the appointment of the under¬ 
mentioned to the consulting staff of the convalescent home 
for officers of his Majesty’s Navy and Army, Osborne, Isle of 
Wight, as from Dec. 8th, 1907 : Sir T. Clifford Allbutt, 
F.R.S.; Sir William H. Bennett; Lieutenant-Colonel Sir R. 
Havelock Charles; Mr. W. Watson Cheyne, F.R.S.; Dr. 
David Ferrier, F.R.S. ; Dr. James F. Goodhart; and Mr. 
A. Pearce Gould. 

The Veterans' Relief Fund. 

From time to time efforts have been made to disturb 
the inertia of the public conscience with regard to those who, 
having fought for their country in times of war, are allowed 
to starve or to drift into the workhouse when their services are 
no longer required. There is now, we are glad to note, 
some hope that this state of things will be remedied. 
Lord Roberts has written a letter to the press in which, 
referring to the recent review of Indian Mutiny veterans in 
Hyde Park, he says : “ I found, to my regret, that no small 
number of them had come up that morning from the work- 
house, and at the end of the day had only the workhouse to 
look forward to for the remainder of their lives.” Lord 
Roberts also calls attention to "the Veterans’ Relief Fund the 
object of which is to collect a sufficiently large sum to 
insure every Crimean or Indian Mutiny veteran being released 
from the workhouse, and then to make him such a weekly 
allowance as will enable the eld sailor or soldier to spend his 
remaining days in moderate comfort and respectability, or 
ensure some amelioration of hiB circumstances if, from age 
or infirmity, he is obliged to remain in the work- 
house infirmary.” The King haa consented to become 
patron of the fund and has opened the list of 
subscribers with a donation of 1000 guineas. The 
vice-patrons are the Prince of Wales, the Duke of 
Connaught, and Prince Christian of Schleswig-Holstein, and 
the committee includes the names of a large number of 
influential persons of rank and wealth. Contributions may 
be sent either to the account of " The Veterans’ Relief Fund,” 






The Lancet,] 


THE SERVICES—PLEURAL EFFUSION AND ITS TREATMENT. [Jan. 11, 1908. 127 


at Messrs. Cox and Co., Charing Cross, London, S.W. ; 
Messrs. Henry S. King and Co., Pall Mall, London, S.W. ; 
and Messrs. Grindlay and Co., Parliament-street, London, 
S.W.; or to the honorary secretary and treasurer, Colonel 
Harlock Pritchard, C.8.I., Eaglesfield, Camberley, Surrey; 
or to Lord Roberts, at Englemere, Ascot, Although the 
letter of Lord Roberts makes special reference to the 
veterans of the Crimea and Indian Mutiny we hops that the 
Fund may have eventually a wider scope and include within 
its beneficent ministrations any deserving man who, having 
fought in his country’s cause, has fallen upon evil days. 

Rat3 and Guinea-Pigs as “ Plague Barometers.” 

Writing in the Indian Medical Gazette for December, 1907, 
Captain R. 0. Saigo), I.M.S., strongly recommends the 
keeping of rats and guinea-pigs to act, firstly, as “plague 
barometers"; secondly, as flea catchers and retainers; and 
thirdly, as locality indicators. Starting with the postulate 
that rat extermination is impossible in India, Captain Saigol 
proceeds to condemn all schemes for the control of plague 
that aim at destruction of the rodents. If plague, to which 
they are so obnoxious, cannot kill them off, he says, or even 
seriously diminish their numbers, nothing that we can do 
will have much effect. Among the schemes which Captain 
Saigol regards as abortive he includes cat keeping, 
which of late has had numerous supporters, but as 
we understand the matter multiplication of cats has 
not been advocated with a view to the extermination 
of flea-harbouring rats but in order that they may 
be driven out of human habitations by their natural 
enemies. Captain Saigol's recommendation is “ that each 
household should be induced to keep guinea-pigs or three 
or more cages (according to the sire and number of 
rooms) containing at least three rats in each cage,” and 
if the measure could be enforced perhaps some of the 
results which he anticipates might be obtained. It is, 
however, practically certain that the effective maintenance 
of rats could not be enforced. The people who often find it 
hard to feed themselves could not be expected to feed and to 
maintain a considerable number of loathsome creatures. A 
cat which can forage fo: itself, partially so at all events, and 
is, moreover, more or less attractive, would probably prove 
acceptable to the population in general, but the wasting of 
good food upon voracious rats would most certainly be 
objected to. Captain Saigol's idea, if unpractical, is 
decidedly ingenious. Caged rats, if fully accessible, would 
probably “act as flea catchers and retainers ” ; and if one of 
the captive rats should die from plague its death ought un¬ 
questionably to serve as a warning to the household. As 
we have said, however, we see no reason for hope that the 
scheme could ever obtain recognition as a practical plague 
preventive. 

Htciene and Sanitation. 

A new Army Order directs that general officers com¬ 
manding-in-chief shall arrange for at least one annual 
course of lectures in sanitation for officers. The lectures 
will be given at the headquarters of the command by 
the command sanitary officer and at other stations 
by selected officers of the Royal Army Medical Corps 
quartered at those stations. All officers who can be 
spared shall attend the lectures at their own stations. 
A manual of sanitation has been prepared and has 
been issued to all concerned and instructions and 
examinations will be primarily based upon this manual. 
An examination in sanitation based upon the official 
manual will be included after March 31st next in the 
final examinations of cadets in the senior division. In 
Plymouth Coast Defence Orders on Jan. 3rd it was 
announced that the second senior course of lectures on 
hygiene and sanitation will consist of six lectures, the 
subjects being “Food,” “Water,” "Air," “Clothing and 
Alcohol,” “ Barrack Sanitation," and “ Field Sanitation and 
Diseases of Troops on Service.” 


Royal Portsmouth Hospital.— It is proposed 
to continue the new buildings of the Royal Portsmouth Hos¬ 
pital by the addition of a new block for children’s wards. At 
a court of governors held on Jan. 3rd, Mr. T. A. Bramsdon, 
M.P., in the chair, a tender for £5320 was accepted. There 
will be some extras to provide and the furnishing to follow. 
The total cost will be about £6000. To meet this a sum of 
£5000 has been raised. 


Comspoitbme. 


"Audi alteram partem.” 

PLEURAL EFFUSION AND ITS 
TREATMENT. 

To the Editor of The Lancet. 

Sir,— Sir James Barr is not quite right in saying that I 
‘ ‘ strongly object to the phrase 1 traction on the thoracic walls.’ ” 
I merely suggested that it might be preferable to speak of 
the lungs as exercising “suction” on the circumjacent 
parts. I do, however, demur to Sir James Barr’s use of 
the term “ elasticity ” in his Bradshaw lecture. While it is 
not my intention “ to attempt to improve the English 
language in giving a definite and limited meaning to each 
word,” I would point out that in the science of physics the 
term “ elasticity ” possesses a definite as well as limited 
meaning, and that in discussing a question of physics it is 
needful to employ this term in the sense in which physicists 
employ it. This Sir James Barr has not done. The 
“elasticity” of the lungs dees not, as Sir James Barr 
assumes, rise and fall aB these organs expand and contract 
in respiration, but remains the same. What does rise and fall 
under these conditions is the pull which the longs exert on 
the visceral plemas. 

I should not, however, have called attention to Sir James 
Barr’s ambiguous employment of this term—few writers are 
guiltless of ambiguity—were it not that he assumes, or appears 
to assume, that the suction, or let us say traction, which the 
luogs exert on the circumjacent parts is necessarily bound up 
with their elasticity. Such, as I pointed out in my letter, is 
not the case. ThiB traction is in direct proportion to the 
degree to which the lungs are rendered taut—for the more 
taut the pulmonary tissue the greater is the tug exerted on 
the visceral pleura—but comparatively non-elastic lungs, 
such as those seamed with scar tissue, are capable of being 
rendered more taut, and thus of exerting more traction on 
circum jacent parts, than normal, highly elastio lungs. 

In illustration of this proposition I cited the case of fibroid 
phthisis. I assumed the non-adherence of the pleura 
simply for the convenience of being able to refer to intra¬ 
pleural pressure. Otherwise my purpose is equally well 
served by taking an actual case in which the pleurse are 
adherent. In such a case the traction which the lungs exert 
on surrounding structures is considerably in excess of the 
normal, and this excess is due partly to the contraction of 
the scar tissue but still more to the preponderating action of 
the inspiratory muscles. Sir James Barr says : “In cases of 
fibroid lung there are no powerfully acting inspiratory 
muscles; any dyspnoea is represented by quick, short, and 
shallow inspirations; the pleura.' are adherent; any stretching 
of the lungs is caused by the pressure of the air within them 
and they are no more pulled out by * powerfully acting 
inspiratory muscles’ than the 56 pounds weight in my experi¬ 
ment is pulled up by the bookshelf and vaseline.” I submit 
that this passage contains two false propositions. 

1. In fibroid phthUis the inupiratory mmoles do not act 
powerfully . —I assert from personal observation that they do. 
It is, moreover, possible to prove deductively that they do; 
in many cases of fibroid phthisis the mean size of the thorax 
is increased, and this in spite of the fact that the lungs are 
less than normally yielding to a stretching force. How could 
such an increase be effected but by a supernormal activity 
of the inspiratory muscles ? 

2. The stretching of the lungs it earned by the pressure of 
air within them. —What, I would ask, has the averaee intra- 
pulmonary air pressure got to do with the stretching of the 
lungs when the pleurrc are adherent ? Manifestly nothing 
whatever. It is true that in the case of non-adherent 
pleurse the lungs would not be stretched with the inspiratory 
expansion of the chest without the push of the intrapulmonary 
air pressure, but such inspiratory Btretcbing cannot be said to 
be brought about by this internal push ; this latter is 
counterbalanced by the external push exerted by the extra¬ 
corporeal atmosphere. Clearly, then, the force which 
stretches the lungs is provided by the inspiratory muscles. 
Take a piece of cord (— lung), let it be attached to a 
ring in the wall (= root of lung), let the other end of the 
cord be attached to a ring fixed to a small smooth steel 
plate (= visceral pletua), let the plate be fixed by means 





The Lancet,] 


THE PERSONAL FACTOR IN DIET. 


[Jan. 11, 1908. 129 


not maintain that apomorphine will cure an inebriate, but it 
is a very useful drug upon occasion. Lieutenant-Colonel 
Douglas admits that bromide is sometimes useful. In this I 
heartily agree with him. When a patient has been drinking 
freely and his system is thoroughly saturated with alcohol 
it is very good practice to keep him in bed for two or three 
days under the iniluence of huge doses of bromide. A 
drinkiDg bout can be cut short in this way. But the most 
useful drug, the one which can be relied upon in the treat¬ 
ment of inebriety, is atropine. This should be administered 
by hypodermic injection with strychnine twice a day. In 
this way it is possible to treat inebriates successfully, both 
men and women, and that without the aid of any institution. 
They will give up their alcohol while living in houses where 
others take it and they will safely pass public-houses on 
their way to and fro for the treatment. Gradually their 
power of self-control becomes established and they become 
permanent abstainers. I have cases now of more than two 
years’ standing who have been treated in this way. If 
Lieutenant-Colonel Douglas could spare a day to visit 
Nottingham I could bring case after case and prove to his 
satisfaction that the drug treatment for inebriety is a 
brilliant success. I am, Sir, yours faithfully, 

Mansfield-roaii, Nottingham, Jan. 7th, 1908. JOS. S. BOLTON. 


THE PERSONAL FACTOR IN DIET. 

To the Editor of The Lancet. 

Sir.—W hile I desire to thank Dr. C. J. Macalister for hiB 
very kindly mention of my writings in his address 1 I should 
also like to make a few remarks on what he speaks of as my 
“ mistake.” 

I do not deny that there is such a thing as idiosyncrasy, 
but to postulate it is to take refuge in the unknown. 
Further, I think that what Dr. Macalister includes under 
this heading is often a mere result of the relation of uric 
acid to its solvents in the bloodstream. For those whose 
blood is in a condition to dissolve considerable quantities of 
uric acid are at once depressed by its administration and 
exhibit slow capillary circulation, headache, lethargy, and 
depression ; while those whose blood is not a good solvent 
are stimulated by it, showing quick capillary circulation and 
well-being. This has, no doubt, often been taken for idio¬ 
syncrasy, but that it is not so is proved by the fact that 
both effects may be seen in the same individual under 
different conditions of season, climate, or general nutrition, 
sometimes merely at different times of day. I have in¬ 
jected considerable quantities of urate into the blood 
stream and yet found that the same blood drawn a 
few minutes later contained less than usual. What had 
happened here 7 The injected urate had been re¬ 
tained in the liver, spleen, &c. (Sir A. Garrod), and it 
had there acted as a uric acid filter and cleared the blood of 
the quantity usually present, just as lime added to a hard 
water precipitates all the lime it contains. Here the 
administration of uric acid acted as a stimulant and every¬ 
thing that clears the blood of uric acid does the same. On 
the other hand, if the blood is in a condition to dissolve 
uric acid freely an identical administration will act as a 
depressant and the blood will be found to contain more than 
usual. The result of a given dose is always dependent on 
the solvent powers of the blood ; it is not a matter of idio¬ 
syncrasy but of chemistry. Hence the dyspeptic and 
debilitated with his blood highly alkaline is depressed by the 
same dose that acts as a tonic and stimulant to the strong 
and well nourished. Yet the strong and well nourished has 
not burnt up or destroyed his uric acid ; he has merely 
retained it, as in the above-mentioned experiment, and it is 
all excreted later when solvents are available. Subject to 
the conditions that affect solubility the quantity of uric acid 
in the blood and its effect on the circulation can be con¬ 
trolled and demonstrated in anyone in two or three hours, 
but Dr. Macalister does not appear to have repeated even my 
more simple experiments on this subject. He freely acknow¬ 
ledges that a purin-free diet cures the cases I have described, 
yet he does not tell us how it acts, while the visible effects 
of uric acid on the circulation, which he appears to have 
overlooked, suffice to explain everything. Everyone has his 
circulation slowed by uric acid when it is in his blood and 
not merely retained in his liver or fibrous tissues. 


1 The Lascet, Dec. 28th, 1907, p. 1807. 


Oxygen which Dr. Macalister mentions is but another 
instance of the same thing, for the effect of oxidation (i.e., 
acid formation) is to diminish the alkalinity of the blood 
and so the solubility and excretion of uric acid. Conversely 
deficient oxidation increases the excretion of uric acid but 
this, like all excretion under solvents, gets less the longer 
the solvent is continued, i.e., as the stores in the glands and 
tissues are reduced. If it were formation it should continue 
at the same level in relation to urea—that is, to the general 
level of metabolism. Further, if the above named diseases 
were due to excessive formation of uric acid no change of 
diet could relieve them. On p. 1808 he mentions the case of 
a man whose recipe for a long and happy life was “ live 
on milk.” It may be remembered that the late Professor 
Humphry found that the centenarians whose diet he investi¬ 
gated had mostly been in tlip habit of contenting themselves 
with very small quantities of flesh and alcohol. The flesh 
they left out was no doubt replaced by an increase of bread- 
stuffs, milk, and cheese, so that there was no diminution of 
albumin or of carbohydrates. May we not conclude that Dr. 
Macalister's case was not idiosyncrasy, but one instance of 
a general rule 7 

Lastly, may I say that my thesis is not that uric acid is the 
cause of all disease, but that it is the cause of some ; that 
it is the cause of some cases of headache, tits, depression, 
,fcc„ when these are not due to obvious organic disease. Such 
troubles when due to uric acid are generally temporary or 
periodic and are relieved by a uric-acid-free diet. 

I am, Sir, yours faithfully. 

Brook-street, W., Dec. 30th, 1937. ALEXANDER HAIG. 


HYPERTROPHIC STENOSIS OF THE 
PYLORUS. 

To the Editor of THE LANCET. 

Sir, —Daring the last year I have had two oases of this 
affection under my care and they make me donbt two state¬ 
ments I have recently read in medical journals. The first 
appeared in The Lancet a few weeks ago and was to the 
effect that this affection is to be diagnosed from other infan¬ 
tile affections of the stomach by (amongst other signs) 
•palpating the enlarged pylorus. The second statement 
appeared in the Clinical Journal, “as regards the severe 
cases in which lavage fails, the only recourse is to try opera¬ 
tive relief.” Both my cases were typical of hypertrophic 
stenosis. Born healthy, a few weeks after birth the “ pump¬ 
ing ” vomiting commenced, with rapid wasting, peristaltic 
waves passing from left to right across the epigastrium, the 
sunken lower and distended upper abdomen, constipation, 
and when the bowels did act small bard motions, and with 
all these hunger directly after the vomiting. 

After trying almost every food advised for infants I 
operated on the first case, hoping that I might be able to 
dilate the pylorus by invaginating with my finger. The much 
enlarged and elongated pylorus was completely covered by 
the large infantile liver and demonstrated conclusively how 
impossible it would be to palpate a pylorus in such a 
position. It was as hard as cartilage and invagination was 
out of the question, so that I performed pyloroplasty as 
quickly as I could. The child unfortunately died about 
seven hours after the operation. The second child I did not 
expect to recover. He wasted to pounds and the parents 
longed for his death as he was “ too awful to look at.” On 
several occasions he was thought to be dead. No pylorus 
could be felt. 

As a last resort all nourishment by the month was stopped 
and for a week or ten days only salt and water injections by 
the rectum were given and a “dummy” of cotton-wool 
dipped in water to moisten the lips. Of course, all vomiting 
ceased as a result of this. Nourishment by the month was 
resumed very gradually and the saline given less frequently. 
The child is now seven months old and from a photograph 
I have just received I should say he weighs between 12 and 
14 pounds. In my opinion, stopping all food by the mouth 
enabled the spasm to subside and the hypertrophy with it. 
I should certainly give this treatment first place should I 
have a third case. Operation would have killed this child 
without any doubt. 1 mu6t not omit to add that Dr. E. J. 
Cave gave me invaluable aid in the first case and Dr. F. C. 
Fosbery in the second. 

One should not rush to conclusions from two cases only, 

| but it would be interesting to hear what pathologists 




130 The Lancet,] 


AMYL NITRITE IN HAEMOPTYSIS.—THE DRUCE CASE. 


[Jan. XI, 1908. 


attached to children’s hospitals have to say about the posi¬ 
tion of the pylorus and liver in infants and the possibility 
of being able to palpate the hypertrophic pylorus. 

I am, Sir, yours faithfully, 

Bath, Dec. 31st, 1907. IV. H. COOKE. 


AMYL NITRITE IN HEMOPTYSIS. 

To the Editor of The Lancet. 

Sir,—I n a lecture delivered at the Medical Graduates’ 
College and Polyclinic and published in the Clinical Journal 
on Oct. 2nd last, and which has only just reached us in the 
Antipodes, Dr. Leonard Williams uttered a very decided 
opinion condemning the use of amyl nitrite in hmmoptyais 
due to pulmonary tuberculosis. 

If It is one of the pulmonary vessels proper which is ruptured, 
nitrite of amyl will do no good, because to induce a widespread 
systemic v&so-dilation will have no necessary or even probable effect 
upon the pressure of the vessels in the lungs. If the haemorrhage be 
from one of the bronchial arteries, then the administration of nitrite 
of amyl, by withdrawing the blood from the bleeding point, may cer¬ 
tainly serve to check the haemorrhage. But we have to remember that 
it is possible to pay too high a price for this kind of styptic. The blood 
pressure in tuberculosis is already low, in advanced tuberculosis it may 
be dangerously low, bo that if by administering nitrite of amyl we still 
further reduce it we are in danger of lowering it to the point at which 
the medulla is insufficiently supplied with blood and the patient dies. 
Before administering nitrite of amyl therefore we ought first of all to 
obtain Borne idea of the height of the blood pressure in the case we are 
treating, and if we decide to use the drug we should be careful to give 
no more of it than will serve to reduce the pressure to some point at I 

which the medulla is still adequately supplied. I prefer to have I 

my cases treated on lines which do not demand such niceties. 

A theory is useful when it helps to explain observed facts 
or when it leads to the discovery of new facts. Dr. 
Williams’s theory does neither. In the case of haemoptysis 
from pulmonary tuberculosis the fact is that amyl nitrite 
actually does check hemoptysis. During the last three 
years I have treated at least 90 cases of haemoptysis from 
pulmonary tuberculosis by the immediate administration of 
amyl nitrite With few exceptions the remedy has been 
promptly effective. I have not known it to do harm, and it 
certainly has not caused the deatli of any of my patients. I 
have found it safer than morphia, for I have seen at least 
two cases of haemoptysis in whom a fatal issue could reason¬ 
ably be ascribed to the administration of morphia. The 
lung was flooded with blood and a form of pneumonia rapidly 
supervened. 

Amyl nitrite can be used at the earliest possible moment 
by the patient himself before the arrival of the doctor. A 
patient who is subject to hiemoptysis must derive much 
comfort from the knowledge that he carries in his pocket a 
remedy which has once stood him in good stead, and that will 
probably be as effective again should he have occasion to 
make use of it. Dr. Williams’s lecture is calculated to 
deprive some patients of a valuable remedy and of the peace 
of mind which its possession secures. I am sure he would 
rather modify his theory than commit such an error. 

I am, Sir, yours faithfully, 

C. Reissmann, M.A., M.D. Cantab., 
B.Sc.. M.R.C.P. Lond. 

Adelaide, South Australia, Nov. 25th, 1907. 


THE DRUCE CASE. 

To the Editor of The Lancet. 

Sir, —As a constant reader of your valuable journal I 
was interested in your annotation this week re the exhuma¬ 
tion of the body of Mr. T. C'. Druce. When commenting on 
the suit tried before Mr. Justice Gorell Barnes you say, 
“ there was an irregularity in the certificate of the cause of 
death in that it did not bear the signature of any medical 
man, the simple explanation being that in 1864 the law did 
not require death certificates to be signed.” 

In the year 1874 the Births and Deaths Registration Act 
was passed and came into force. In this measure it was 
enacted that the name and qualifications of the certifying 
practitioner should be entered in the space allotted to the 
cause of death in the death registration book, so that 
previous to the year 1874 such entry would not appear—I 
presume this is what you refer to in your annotation 7 I 
cannot comprehend what legal status a death certificate 
would possess without the signature of the practitioner 
granting it either before or after the passing of the said 
Registration Act. I commenced practice in 1871 and 


signatures were always required to the death certificate 
forms supplied under the old Act. 

I am, Sir, yours faithfully, 

Edward A. Picigott, L.R.C.P. Edin., Ate. 

Clare, Suffolk, Jan. 4th, 1908. 


THE NEEDS OF LONDON MEDICAL 
STUDENTS. 

To the Editor of The Lancet. 

Sir,— In answer to the two correspondents In this week's 
issue of The Lancet under the heading "The Needs of 
London Medical Students ” I submit that the London 
Conjoint diplomate does undergo a course equal to that of 
the average university graduate. In support of this pro¬ 
position I quote from the report of the committee of 
delegates appointed by the Royal Colleges in 1885 and 
signed by the late Sir William Jenner :— 

That the curriculum of study and the examinations to be undergone 
for the Licence of the Royal College of Physicians of London and the 
Diploma of the Royal College oi Surgeons of England are equal to those 
required by most of the universities for degrees in medicine and 
surgery. 

Having dealt with the course of study which takes the average 
London Conjoint student about seven years to complete, now 
I will deal with the successes of graduates and Conjoint 
diploraates respectively in the public service competitive 
examinations. Without going into all the statistics for the 
last 20 years, which are equally favourable to the London 
Conjoint diplomate, allow me to draw attention to those 
of 1907 1 and under the heading “Percentage rejected” 
will be found the following figures 

Percentage 

rejected, 

English Conjoint diploma alone. 4-1 

English degree aione . 20 0 

Irish degree alone . 21'8 

Scottish degree alone . 22 0 

In the face of these statistics how can it be contended that 
the London diplomate is inferior to the graduate ! One might 
say the opposite, and that the diplomate has superior pro¬ 
fessional attainments. 

In conclusion, allow me to quote from Professor W. 
Osier's remarks recently uttered at St. Mary’s Hospital: 
“ Finally, he expressed regret that so many students passed 
examinations which were in all respects equal to those 
passed by provincial students but nevertheless did not 
thereby obtain the degree of M.D.” ; and also Sir W. H. 
Allchin who, as an examiner, affirms that “ the stringency 
of university examinations is scarcely bo real or the test so 
far-reaching as is commonly imagined, and that the examina¬ 
tions of the Conjoint Board are. taken as a whole, as satis¬ 
factory as any and more so than many.” 

I am, Sir, yours faithfully, 

Acton Hill, tv., Jan. 4th, 1908. P- W. COLLING WOOD. 


To the Editor of The Lancet. 

Sir,—T here has been so much written from time to time 
under the above heading that it would seem almost useless to 
attempt to write anything fresh upon the subject in question ; 
there is, however, something which I believe has been left 
unsaid, and that is my reason for sending you this. One of 
your correspondents actually goes so far as to state that the 
public prefers to go to a man who lias the degree of M.D. 
That, I think, is quite a mistaken idea ; 99 per cent, of the 
public don’t care twopence whether their medical attendant 
has the degree or not, and probably would not know if they 
were asked ; but what they do know, and what every one of 
them could tell you, would be what physician or surgeon 
they had the greatest faith in. The general practitioner 
who is most beloved by his patients and in whose opinion 
they place their faith is not always a man who lias obtained 
the highest honours at college or hospital; he is rather one 
who by a careful study of his fellow men has been able to 
use such knowledge and skill as he may possess, when 
freshly registered, to the best advantage. 

The best general practitioner I ever knew told me that the 
quickest way to get on in practice was to forget the old 
abrupt “ hospital manner ” ; to forget the hundred and one 
theories and doubts of modem medicine ; to remember the 

x See Supplement of the Brit. Med. Jour., Nov- 30th, 1907. 






The Lancet,] 


NOTES UPON HEALTH RESORTS: JAMAICA. 


[Jan. 11, 1908. 131 


cases you saw in the clinical wards, and to remember that 
your patients were human beings with “feelings,” not objects 
merely for “interesting discussions”; and lastly, that no 
matter what your degrees might be it was essential to be 
above all things a gentleman. What was true then is true 
to-day. Any young fellow of average intelligence who has 
obtained a sound qualification and who does not imagine 
that his education has already finished, will by attention to 
his profession learn a great deal in from five to ten years 
from the date of his qualifying ; indeed, he will be in a 
better position to treat successfully a case than the newly 
graduated Doctor of Medicine. The young M.D. in time 
will be just as good at his work, and the stage at which a 
practitioner becomes a really good man is fixed not by his 
position in the schools or his place in the examination lists, 
or by his degree or diploma, but after a few years of careful 
study and daily practice. So that, we may take it, all medical 
men who are any good at all will be about equal, so far as 
the actual knowledge of their calling is concerned, at some 
time or another. Then comes the great point of all: it is the 
man himself ; and so far from craving for a title which many 
of us, very many of us, have never attempted to obtain, we 
rather pride ourselves that besides being physicians or 
surgeons we are also fellow men with our patients, and it 
is better to be a successful general practitioner with the 
plain title of Esq. than an unsuccessful one who can add 
M.D. after his name. When your correspondent says that 
Mr. Smith, M.R.C.S., is ashamed of his qualification and 
jealous of Dr. Jones, he must mean perhaps one man out 
of the many who, like myself, have not a university degree. 

It is the man, not the degree, and never was it more 
important than at the present time for all of us to try to 
keep up the honour of our calling and to unite as one rather 
than have these petty disputes. We are all medical men, and 
the great aim of each and every one of us should be to 
prevent and to combat disease and help those who ask our 
aid ; and, above all, let us try to behave as gentlemen, let 
there be less quarrelling and fewer complaints of our hard¬ 
ships and our wants. After all, we do not practise merely to 
make money, and if a new patient should prefer to call in 
Dr. Jones, well, Mr. Smith, M.R.C.S., may be able to have 
the next one, and perhaps Dr. Jones may not care for a day’s 
shooting or hunting, and Mr. Smith not having to see the 
new patient at home may find several more on the hunting- 
field. Dr. or Mr., let us try to forget all this and behave 
anyhow as sportsmen and play the game. 

I am, Sir, yours faithfully, 

Suffolk, Jan. 4th, 1908. COUNTRY SURGEON. 


THE LOCAL MEDICAL PROFESSION AND 
THE HAMPSTEAD GENERAL 
HOSPITAL. 

To the Editor of The Lancet. 

Sir, —I am directed by the committee appointed to re¬ 
present the local medical profession to ask you to insert a 
brief account of the steps which my committee has recently 
taken in regard to the Hampstead Hospital question. 

As you are aware, the council of the hospital has decided, 
on the strength of a very narrow majority of subscribers, to 
accept the terms offered by the King Edward's Hospital 
Fund for London, which include the amalgamation of the 
North-West London and Hampstead General Hospitals and 
the appointment of a staff of consultants to the exclusion of 
the local practitioners. 

In response to this decision of the hospital council my 
committee issued a circular on Dec. 12th, 1907, to the indi¬ 
vidual members of the local medical profession, asking for 
their approval of the following resolution which had been 
adopted at a meeting on July 3rd, 1907, namely :— 

That this meeting considers that the Hampstead Hospital should 
always have a visiting staff of local practitioners, and in consideration 
of this opinion calls upon tho members of the medical profession to 
refuse to accept any office on the staff on terms which are not con¬ 
sidered satisfactory by the local profession A 

Of 191 local practitioners receiving the circular no fewer 
than 132 (i.e., 68 per cent.) appended their signatures to the 
resolution, of whom 75 are members of the British Medical 
Association and 57 are not members. This result was so 
striking that my committee thereupon felt justified in insert¬ 
ing a warning notice in the British Medical Journal (since 


1 This resolution is not intended to preclude the appointment of 
consultants. 


accepted by The Lancet). Finally, on learning the opinion 
of such a large majority of their colleagues the members of 
the acting medical staff and the anesthetists have tendered 
their resignations to the council of the hospital. 

I am, Sir, yours faithfully, 

Reginald A. Yeld, M.D. Cantab., 
Honorary Secretary of the Hampstead division of the British 
Medical Association and of the Joint Committee appointed 
to represent the local medical profession. 

Jan. 8th, 1908. 


NOTES UPON HEALTH RESORTS: 
JAMAICA. 

To the Editor of The Lancet. 

Sir,—A s one who practised in Jamaica between 30 and 40 
years I have been deeply interested in your Special Cor¬ 
respondent’s letters on “ Jamaica as a Health Resort. ’ The 
letter dealing with the value of its medicinal springs is well 
worthy of particular attention, for none bat those long 
resident in the island are aware of the great value to be 
derived from their use in chronic cases of certain diseases. 
It is much to be regretted that the accommodation, 
both at the Milk River and the St. Thomas Baths, 
is so unsuitable and inadequate. 1 our correspondent, 
however, apparently did not hear of a very remark¬ 
able medicinal spring at Windsor in the parish of 
St. Ann’s, which 40 years ago attracted a great deal of 
attention and to which thousands of negroes flocked from all 
parts of the island. That the use of it effected many 
remarkable cures there can be no doubt, any more than that 
the too liberal and injudicious use of it caused many deaths. 
At that time I sent you a quantity of the water which you 
had analysed by Dr. Attffeld and gave the results in a para¬ 
graph in The Lancet of Dec. 21st, 1867, page 795, under 
the title of “A Remarkable Medicinal Spring.” The spring 
I am now referring to is “ the second spring discovered 
recently,” and Dr. Attfield states that “it contains 
2493f grains of solid matter” to the gallon, and that 
“ spring water containing such a large amount of 
solid matter has probably never been met with.” The 
water contains 3j ounces of chloride of calcium and 2 ounces 
of chloride of sodium in the gallon. 

Chloride of calcium is at present much more used in 
medical practice than formerly, and I would suggest that 
someone interested in the matter might import some of the 
water and give it a fair trial. Probably some old negroes 
resident in the district could point out its exact locality, for 
in recent years it was not much resorted to. Perhaps, how¬ 
ever, the recent earthquake has destroyed it or diverted its 
course. I am, Sir, yours faithfully, 

Dec. 29th, 1907. M D - EDIN. 

We publish with pleasure our correspondent’s inter¬ 
esting letter, which we have submitted to our special com¬ 
missioner who visited Jamaica recently. He had no 
information of such a noteworthy mineral spring in St. 
Ann’s, and as there is no record of it in the Hon. J. Phillipo’s 
monograph on “The Mineral Springs of Jamaica,” which was 
published in 1891, he concludes that it has fallen into disuse. 
We are convinced of the great utility of the Jamaican springs 
in the treatment of disease, and when the accommodation 
provided for invalids who visit them has been improved they 
should prove a valuable means of attracting visitors to the 
island. Our correspondent’s reference to out columns is 
correct.—E d. L. 


THE MEDICAL DIRECTORY, 1908. 

To the Editor of Thb Lancet. 

Sir,—T he publishers of the Medical Directory are not 
likely to pay attention to an individual complaint. I should 
like to ask whether others do not find a great inconvenience 
in the system introduced this year in the “ London Local 
List.” All street names are discarded, and the names alone, 
without address, crammed alphabetically in a single para¬ 
graph. There is no Russell-square or Southampton-street. 
If a doctor near the Strand is wanted all those names under 
“ Bloomsbury,” between the Thames and King's Cross, must 
be looked up. So with "Camberwell," &c. For many pur¬ 
poses this makes the Directory useless, as I have found to-day, 
to the grave misfortune of a friend and myself. Moreover, we 



132 The Lancet,] 


MEDICAL MEN AND LEGISLATION.—BIRMINGHAM. 


[Jan. 11, 1908. 


hare nothing else to turn to ; if this feature continues I hope 
it will not be long before we have. 

I am, Sir, yours faithfully, 

Jan. 4th, 1908. F.R.C.P. 

*,* We cannot agree with our correspondent that “all 
street names have been discarded ” j for instance, Welbeck-, 
Wimpole-, and Weymouth-streets are all given, while to 
Mansfield-street is appended “ see Portland-place." We note, 
however, that the name of at least one practitioner in 
Mansfieldstreet is given under Cavendish-square. The new 
arrangement is by no means so convenient as the old.—E d. L. 


MEDICAL MEN AND LEGISLATION. 

To the Editor of The Lancet. 

Sir, —There have been several letters in The Lancet 
during the past year pointing out how recent Acts of Parlia¬ 
ment impose new duties on the medical profession whether 
they like it or not, in some cases under penalty, without 
making any provision for the remuneration of the members of 
the profession for the work they may be compelled to do. 
The profession seems to be unanimous in thinking that this is 
objectionable. If the tendency of recent legislation con¬ 
tinues it is difficult to see where it will end or what will be 
the condition of the profession in a few years. Up to the 
present medical men seem to have only discovered the 
objections to various Acts of Parliament after they have been 
passed. It would surely be better to do this before the 
Acts have been passed. It is far easier to amend a 
Bill before Parliament than to remedy the defects of 
an Act which is already in force. To do this it 
is necessary that there should be a body of men capable of 
doing such work carefully to scrutinise every Bill brought 
before Parliament which may affect the medical profession. 


South Devon and East Cornwali/tIosittal.— 

During 1907 the Sunday schools in JTymoutt/ and the district 
collected £60 in aid of the children’s rdtrd of the South 
- Devon and East Cornwall Hospital. / 


BIRMINGHAM. 

[From our own Correspondent.) 


Christmas festivities. 

Christmas has passed in mnch the usual manner in the 
hospitals and public institutions in the city and district. 
Anticipation, brightness, enjoyment, and increased hope 
have prevailed everywhere and for a time at least the weary 
and pain-stricken have forgotten their troubles and have 
rejoiced in an exhilarating atmosphere which must have had 
a tonic effect. The decorations in the various institutions 
have been admirable and the entertainments provided were 
well and thoughtfully chosen and well carried out; naturally 
they have varied in different hospitals but in all they were 
successful and the pleasure so obviously enjoyed well repaid 
those who had worked so strenuously to make the annual 
festival so pleasant a time to those who were debarred from 
home pleasures. In the midst of the general rejoicing the 
cripples were not forgotten, for a crippled children’s party 
and an adult cripples' party were held in the town hall. At 
the former party 500 cripples under the age of 16 years 
were entertained and at the latter 230 adults. The expenses 
in the case of the children were defrayed by Mr. Ansell and 
in the case of the adnlts by subscriptions collected by Miss 
E. L. Jones. 

The Sanatorium for Consumptives. 

The scheme which the health committee has devised for 
the utilisation of the Salterby Grange Estate, which was 
recently acquired by the city for the purpose of providing a 
sanatorium, seems in all respects admirable. The committee 
suggests that the existing house shall become the administra¬ 
tive block. It will provide quarters for the medical officer, 
matron, nurses, and servants, as well as an excellent dining¬ 
room and a recreation room. The present kitchen will need 
enlarging, but that is the only alteration of importance 
which will be required. For the accommodation and treat¬ 
ment of the 40 patients for whom it is proposed provision 
should at once be made the committee suggests that fonr 
blocks of brickwork chalets shall be erected, two blocks to 
contain 16 patients each and two for four patients each. The 
committee favours grouped rather than separate chalets on 
the grounds of easier and more efficient administration, 
diminished expense, and greater accessibility to the 
sanitary blocks, and it recommends brick rather than 
wooden bulldiDgs, because the former will not cost much 
more to erect in the first instance, will be more durable, 
less costly for maintenance, and equally sanitary ; more¬ 
over, they can be erected by loan, whilst wooden 
buildings must be provided out of revenue. The 
chalets will face south and be protected by rising ground 
from the north and east winds. They will open on to a 
terrace on to which the beds can be wheeled directly out of 
the rooms. The patients’ rooms will measure 12 feet by 
10 feet. They will be provided with through ventilation and 
they will communicate by covered passages with the sanitary 
blocks. It is presumed that, as a rule, heating will be 
unnecessary in the chalets but small stoves will be provided 
for use in exceptional cases. The water-supply is provided 
for by an excellent well and it is proposed that the sewage 
shall be dealt with by means of a septic tank and a bacteria 
bed, the effluent being discharged on to the land. 

The Milk-supply. 

Since my last letter further details of the medical officer’s 
report concerning the tuberculous infection of the city’s 
milk-supply have become available and certain interesting 
details are disclosed. It appears, as previously stated, that 
14 per cent, of the milk delivered at the railway stations 
contains tubercle germs and it may be said that about 
10 per cent, of the whole supply is infected. In associa¬ 
tion with this infection it is pointed out that the tuber¬ 
culous death-rate during 1906 was 162, and, further, it 
is shown that during the past five years 431 children 
under one year and 487 under five years died from 
tuberculous diseases, tuberculous meningitis and tuber¬ 
culous diseases of the intestines being particularly 
numerous in children under five years. It is suggested 
that possibly the frequency of tuberculosis of the intestines 
in children is due to the milk supply. This suggestion would 
have greater force if it could be shown that the children who 
die from tuberculous diseases were born and lived in bouses 
which could be considered healthy, or at all events in which 


With the profession or even a majority of it behind them 
such a body of men could do a very great deal to safeguard 
the interests of the profession. The legal profession very 
successfully safeguards its interests in this way. It is surely 
time the medical profession awoke to the fact that unless it 
possesses some organisation for the purpose of watching legis¬ 
lation with a view to safeguarding its interests it will before 
long find that its interests have suffered seriously. 

I am, Sir, yours faithfully, 

Jan. 2nd, 190S. __ M.D. 

A PROPOSED SHIPS’ SURGEONS 
ASSOCIATION. 

To the Editor of The LANCET. 

Bir, —Having observed in The Lancet of August 25th 
last that a British Association for Ships’ Surgeons has been 
formed in London with the object of establishing and im¬ 
proving the status of ships’ surgeons, I take the liberty of 
suggesting that it would be an excellent thing for all fnlly 
qualified men holding certificates from one of the British 
universities if a similar institution were formed in the Far 
East, so that the position, prospects, and pay of medical 
officers on board ship might be recognised as being of equal 
value with those held by medical men ashore. At present 
shipowners and agents fail to grant the legitimate demands 
of those members of the profession who become ships’ 
surgeons, wholly ignoring the labour and responsibility which 
attach to the office. Medical practitioners who elect to 
prove their abilities on board ship should, in my opinion, 
certainly form themselves into an association to enforce their 
rights and secure at least public recognition. And there is 
no place where such an association would prove of greater 
influence than in the Far East, with Hong-Kong as the centre 
and headquarters.—1 am, Sir, yours faithfully, 

D. R. P., L.R.C.P., L.R.C.8., L.M, 

Hong-Kong, Nov. 19th, 1907. 

PS.—Should brother practitioners agree with this sug¬ 
gestion they might communicate with me, care of the Editor 
of The Lanoet. /D. R. P. 





Thb Lancet,] 


WALES AND WESTERN COUNTIES NOTES —SCOTLAND. 


[Jan. 11,190& 185 


other source of tuberculous infection was not present. It is 
clear, however, that this infection is present in the milk, and 
as it is quite certain that under given conditions it could be 
entirely eliminated and a source of possible infection re¬ 
moved, the health committee is quite justified in taking steps 
to deal effectively with the problem. It may be doubted, 
however, if tuberculous diseases will ever be conquered 
unless infected human beings are strictly segregated. 

The Staffordshire Education Committee a/nd the Medical 
Inspection of School Children. 

The subcommittee appointed to report upon the medical 
inspection of school children recently presented its report to 
the education committee and alter pointing out that the duty 
of providing for the medical inspection of school children 
had been laid upon the local education authority recom¬ 
mended that school medical officers should be appointed to 
devote the whole of their time to the work of medical in¬ 
spection ; that a minor subcommittee should be appointed 
to make recommendations as to the number of officers to be 
appointed and the salaries to be paid ; and that, in order to 
establish the initial organisation of school medical inspection 
as soon as possible after Jan. 1st the minor subcommittee 
should be authorised to appoint a qualified person who shall 
act as senior officer. The recommendations met with 
vigorous opposition for various reasons but eventually the 
amendments directed against them were defeated and all the 
recommendations were folly approved. 

Jan. 7th. 


WALES AND WESTERN COUNTIES NOTES. 

(From our own Correspondents.) 


The Medical Inspection of School Children. 

The county council of Brecknock has appointed about 
14 medical practitioners in different parts of the county to 
carry out the provisions of Section 13 of the Education 
(Administrative Provisions) Act, 1907. There is no county 
medical officer of health and the various schools in the 
county have been allocated to these 14 gentlemen, some 
of whom are the district medical officers of health. 
For the same purpose the education committee of the 
city of Hereford has appointed five general practi¬ 
tioners in the town. The fees to be paid to the latter 
are at the rate of Is. for each examination, a sum 
which was agreed upon as satisfactory at a recently held 
meeting of the Hereford members of the Herefordshire 
Medical Association. The average number of births in 
Hereford is under 500 yearly. In the county of Hereford no 
decision has yet been come to as to how the Aot shall be 
administered. The question was discussed by the education 
committee bat was ultimately referred to the county council 
for decision. There is no county medical officer of health 
and some members of the council appear to favour the 
appointment of this officer and to place upon him the 
duties involved in the carrying out of the Act. At 
a meeting of the Herefordshire division of the British 
Medical Association held on Dec. 30th last it was unani¬ 
mously resolved that the payment of the school medical 
officer should be at the rate of not less than £60 per 
annum for an attendance of one-half a school day a 
week, one-half a school day being defined to be two 
hours, and that where practicable he should not be a 
practitioner interested in the practice of the district. The 
Gloucestershire county council has not come to any 
decision as to the administration of the Act and has 
adjourned the consideration of the matter until the next 
meeting of the council. There is no whole-time medical 
officer of health for Gloucestershire but Dr. J. Middleton 
Martin, who is the medical officer of health of several 
districts in the county, makes an annual report upon the whole 
county to the council and his services are also available for 
other purposes. At a meeting of the county council held on 
Jan. 6th certain proposals of a special committee were 
referred back for further consideration. These included the 
appointment of Dr. Martin at an annual salary of £470, 
permission being given to him to retain his district appoint¬ 
ments. It was further proposed to engage two or three 
assistants who, with Dr. Martin, would undertake the 
medical inspection of the school children throughout the 
county. The estimated cost during the first year of this 
scheme was £1370, though it was anticipated that that 


amount would be increased in future years. There are 396 
schools in the administrative county of Gloucester attended 
by over 50,000 children and it is considered probable that 
the number of inspections during the present year will be 
about 12,000. The Somerset county council has decided to- 
appoint a chief medical inspector of school children at a 
salary of £500 per annum in addition to his travelling and 
other expenses. The officer appointed will be required to 
devote his whole time to his duties. This decision was not 
come to unanimously ; 40 members of the council voted in 
its favour and 30 were opposed to it. The Merthyr Tydfil 
education authority, at a meeting held on Jan. 3rd, resolved 
to ascertain from the local members of the medical pro¬ 
fession whether they would undertake the work of inspecting 
the school children, and if so, what fees would be charged, 
the suggestion being that there should be a lixed charge per 
head and that certain schools should be assigned to different 
medical inspectors. 

Gift of a Motor A mbulance to Swansea. 

A motor ambulance has lately been handed over to the 
Swansea corporation, the purchase money (£600) having 
been raised by private subscriptions. It is a 20 to 25 horse¬ 
power four-cylinder Panhard and the ambulance proper will 
accommodate four stretchers in two tiers. The uppermost 
can be folded to the sides of the ambulance when not 
in use, while any one of them oan be placed upon a 
small hand ambulance upon rubber-tyred wheels, and this 
can be run into the motor ambulance along rails which 
can be folded np against the back of the carriage 
when out of use. The inside of the vehicle is lighted 
and warmed by electricity. A folding lavatory basin in 
connexion with which there is a snppiy of hot and cold 
water is provided, and there are cupboards which contain 
such appliances as are required for first aid. Mr. W. F. 
Brook is responsible for many of the details which 
have been very carefully and thoughtfully carried out. If 
arrangements are made for it to be available promptly this 
ambulance should prove of the greatest service in a district 
of the character of Swansea where the nature of the 
industries is such as to render the workpeople employed in 
them particularly liable to accidents. 

Vaccination Fees. 

At a meeting of the Launceston (Cornwall) board of 
guardians held on Dec. 28th, 1907, the subject of the fees of 
public vaccinators again came under discussion. The public 
vaccinators will not accept the minimum fee of 3». 6 d. and it 
was proposed that they should receive 5s. ns previously. 
This, however, was defeated by a large majority of the 
guardians and it was eventually decided to refer the matter 
to the Local Government Board. 

Jan. 7tb. __ 


SCOTLAND. 

(From our own Correspondents.) 


The Edinburgh Eoyal Infirmary Hoard and the lata 
Surgeons. 

At the ordinary meeting of the board of managers of the 
Edinburgh Royal Infirmary held on Dec. 30th, 1907, it was 
resolved to insert in the minntes the following resolutions 
and to send copies to the relatives of the deceased :— 


The Late Sib Patrick Heron Watsok. 

The managers of the Royal Infirmary have received with deep regret 
the announcement of the death of Sir Patrick Heron Watson. 
Although long since retired from the active work of the infirmary, Sir 
Patrick Watson was st.il 1 a member of the staff as a consulting surgeon. 
Elected assistant surgeon in 1860, he became full surgeon in 18S3, and 
so highly appreciated were his services in this capacity that on the 
expirv of his term of office in 1878 the managers appointed him w 
extra surgeon to the Koval Infirmary for a period of five years. The 
managers feel that work of such notable and outstanding character as 
that performed bv Sir Patrick Heron Watson 1ms contributed in no 
small measure to enhance the reputation of the Royal Infirmary ; and 
in expressing their sorrow at his death, they desire to pay their 
grateful and respectful tribute to his memory. 


Tuk Late Professor Annandale. 

The managers ol the Royal Infirmary desire to express their deep 
use of the lose the institution 1ms sustained by the death ol Mr. 
mums Annandale, professor of clinical surgery, and the senior 
ting member of tbe surgical stafl. Mr Annandale became connected 
ilh the Royal Infirmary as assistant surgeon In 1865 '. was promoted 
be full surgeon in 1869; and has held the chair ot olinlcal surgery 
nee 1877, having charge of the wards assigned to this chair fur [be 
ng period of JO years. No medical officer ot the Royal Infirmary haa 

ndered it more devoted and loyal service than Mr. Annandale. 




134 The Lancet,] 


IRELAND.—ITALY. 


[Jan. 11, 1908. 


Ills eminence as a Burgeon and clinical teacher was widely re¬ 
cognised, and during his long career his skill and experience were 
instrumental in relieving or removing an incalculable amount of 
human suffering. Mr. Annandale showed throughout a warm int erest 
in all matters bearing upon the welfare and the usefulness of the 
Iloy&l Infirmary, while his personal courtesy and kindly bearing to all 
with whom be came in contact had ever a happy influence in the 
institution. While lamenting his sudden removal, the managers feel 
assured that Mr. Annandalc's memory will long be cherished as one 
among the distinguished men who have given of their best to the 
service of the Koyal Infirmary. 

Regret was expressed at the meeting on the retiral of Dr. 
C. E. Underhill, Dr. .T. 0. AlHeck, and Professor C. Hunter 
Stewart from the board. 

Forbes Dispensary , Inverness. 

At the annual meeting of the managers of the Forbes Dis¬ 
pensary, Inverness, held on Dec. 31st, 1907, in the council 
chamber, the annual report by Dr. G. A. Lang, medical officer, 
was submitted. During the year ending Oct. 31st, 1907, 1637 
patients were admitted. Of these 1335 were treated by the 
medical officer with the following results : Patients cured, 
1076 ; relieved, 56; died, 9 ; sent to infirmary, 85 ; remain¬ 
ing under treatment, 46; infants vaccinated, 63—total, 
1335; number of patients recommended for medicine by 
other medical practitioners, 302—total for year as above, 
1637. The number admitted during 1906 was 1780, while 
since the establishment of the dispensary in 1832 up to date 
there had been admitted 83,312. There seemed to have 
been fewer cases of a serious nature than in former years. 
The report was adopted. 

Cerebrospinal Meningitis in Aberdeen. 

The return of the medical officer of health for the last week 
of 1907 contains one case of cerebro-spinal meningitis. The 
case occurred in King-street, Aberdeen, and Dr. Matthew 
Hay reports that the case was verified bacteriologically. 

Strange Story of a Needle. 

The Aberdeen Daily Free Press reports the following 
curious story of the travels of a needle. Over 30 years ago 
an Aberdeen lady accidentally got a sewing needle knocked 
into her left foot, and owing to its having somehow shifted 
in the interval that elapsed before a medical man was in 
attendance it could not be removed. Time passed and the 
incident was forgotten. Early in the morning, however, a 
few days ago, the lady felt something always catching her 
dress at the right elbow and on looking at the cause was 
surprised to find the Bharp end of a needle projecting from 
the flesh, and this her husband removed without much diffi¬ 
culty. The needle is about two inches in length. 

Jan. 8th. _ 


IRELAND. 

(From opr own Correspondent.) 


The Tuberculosis Exhibition. 

On Monday last, Jan. 6th, the Lord Lieutenant and the 
Countess of Aberdeen paid a State visit to Portadown where 
they attended a public meeting at which Her Excellency the 
Countess of Aberdeen gave an address, the occasion being 
the opening in that place of the Tuberculosis Exhibition. 

Unusually High Death-rate in Belfast. 

At a meeting of the Belfast city council held on 
Jan. 1st it was reported that between Nov. 17th and 
Dec. 14th, 1907, 310 deaths occurred from chest diseases, 
64 from pulmonary tuberculosis, 84 from pneumonia, 
and 162 from diseases of the respiratory organs exclusive 
of pneumonia. For the four weeks ended Dec. 14th 
Belfast also unfortunately possessed the highest death- 
rate of the five principal sanitary districts of Ireland. 
But since the meeting of the Health Commission in Belfast 
and the great awakening of the public with regard to the 
health matters of their city progress is being made by the 
health authorities, though an immense deal still remains to 
be done owing to the fact that Belfast had slipped behind 
the times. During the past year the infantile mortality has 
fallen to 134, as compared with 143 during 1906, and the 
death-rate from pulmonary tuberculosis has fallen from 3 5 
per 1000 in 1905 and 2'7 in 1906 to 2 5 in 1907. That is to 
say, that Belfast in 1907 has reached a death-rate from 
pulmonary tuberculosis which was recorded in England 
generally 21 years ago. This is a consideration which the 
health authorities of Belfast and the inhabitants of the city 
must keep steadily before them when they feel inclined to 


allow their proper rejoicing in the improvement of sanitary 
affairs to get ahead of the facts. 

School Accommodation in Belfast. 

At a meeting of managers of the primary schools held on 
Jan. 2nd in the Municipal Technical institute, Belfast, under 
the presidency of the Lord Mayor (the Earl of Shaftesbury), 
it was decided to approach by a deputation the Commissioners 
of National Education to ask for a liberal grant towards the 
improvement of primary school accommodation in Belfast. 
The Lord Mayor said that additional accommodation was 
required for something like 7000 children, and taking the 
estimated cost at £6 per head a sum of £42,000 was needed, 
which spread over three years would mean a sum of £14,000 
per year. The primary schools in Belfast, from the point of 
view of architecture, overcrowding, and hygiene, are very 
much behind the times. 

Jan.7th. _ 


ITALY. 

(From our own Correspondent.) 


The Hygiene of Pilgrimages. 

Most characteristic of all peregrinations of the religious 
devotee is the annual pilgrimage to Loreto in the Adriatic 
province of Piceno. At Christmastide in 1294—so runs the 
legend—the modest abode of the Nazarene carpenter Joseph 
was transported miraculously from Palestine to Italy where 
it was actually seen in a beatific vision by the reigning 
Pontiff to be deposited from the hands of the angels who 
bore it in a laurel grove near Recanati. Nay, a century 
before St. Francis had foretold the transfer of the house with 
the prophetic word “ Picmnum,” which the Church there¬ 
after interpreted as containing the initial letters of the 
phrase— 

“ Portatur Iuxta Concrum .Edicula 

Nazarena Uirginis Marias.” 

(The Nazarene house of the Virgin Mary is carried to the neighbour¬ 
hood of Coucro.) 

Thus attested by a Pope and a saint the house became 
naturally the resort of the faithful who year by year flocked 
to it in thousands to receive the blessing of the priest in 
charge and to carry away whatever hallowing association 
they could extract from the structure and its appurtenances. 
The Christmastide of 1907 witnessed no falling off in the 
numbers of those devotees—nay, the crowd was so great that, 
in the words of a correspondent who was present, the interior 
of the house, in point of ventilation, was little better than 
the Black Hole of Calcutta. Packed within a few square 
yards of space, under a roof so low that it might be touched 
by the hand of any moderate-sized person, in a darkness 
made visible by a sparing assortment of candles and lamps, 
still further exhausting the already vitiated air, the pilgrims 
were seen to kiss the humid walls, to lick the dust of the 
floor, to carry what they could of it to their lips, even to 
scrape the damp mould from any object near them and to 
press it to their mouths. And all this, continues my 
correspondent, at a time when the Board of Public 
Hygiene is doing its utmost to inform the people as to 
the risks which they run from contaminated air, from the 
“septic touch," and from the pathogenic microbes always 
abundant in crowds not given to personal cleanliness 
and often bringing from the insanitary tenements in 
which they huddle the germs of disease inherited or 
acquired 1 An appeal is already being made to the Adminis¬ 
tration of the Sanctuary (as the officiating custodians of the 
tiouse are called) to ventilate the interior, to disinfect the 
damp, viscous walls, and to bring the whole edifice under the 
influence of sanitary law. This appeal (to which the said 
“ Amministrazione" cannot surely be deaf) is strengthened 
by the citation of instances where in much more spacious 
resorts—even in cathedrals or basilicas—infective diseases 
are often contracted, to say nothing of the holy water 
sparingly renewed and dabbed overthe faces of the devout 
till ailments, often of a loathsome kind, are courted and 
incurred from it. 

Death of Professor Biagi, 

New Year’s day witnessed the death in the Policlinico in 
Rome of Dr. Nello Biagi, professor of surgical pathology 
and piediatry in the Istituto dl Stndi Superiori of Florence 
and surgeon-in-chief of the Mayer Hospital in the same city. 
On a visit to Rome of but a few days’ duration and while 





The Lancet,] 


VIENNA.—NEW ZEALAND. 


[Jan. 11, 1908. 135 


enjoying the society of old friends and colleagues associated 
with him in the Clinique of the Senator Dr. Durante, of whom 
he had been the chief assistant, he “ caught a chill ” and 
succumbed to the sequel® in spite of every care of physician 
and nurse. Professor Biagi was but 32 years of age and had 
obtained the post which he held in the Florentine Institute 
after a competition in which his scientific knowledge and 
practical skill made him the easy winner. His mortal 
remains were transported to the railway station, followed 
by all the more distinguished of the profession in Rome, 
whence they were carried by train to Florence for interment 
in the family vault. 

Jan 4th. _ 


VIENNA. 

(From our own Correspondent.) 


Perforation of the Pulmonary Artery by a Migrating JVeedle. 

At a coroner's inquiry, which also included a post-mortem 
examination of the body, held recently in Vienna, some 
remarkable facts became known. A labourer, aged 43 years, 
was found dead in his room, having ten minutes previously 
appeared to be in perfect health. In the subcutaneous fat 
of the abdominal walls there were found at the necropsy four 
pieces of needles, each about one inch long. Two of these 
were encapsulated in connective tissue and two were free. 
The pericardial sac was filled with liquid blood and on its 
anterior and posterior walls there was found a small pene¬ 
trating slit-like opening. Two similar openings were found 
in the intrapericardial part of the pulmonary artery, just 
above the anterior and the right valve. These slits must 
have been caused by the migration of such needles as were 
found in the abdominal walls, but neither in the heart ncr 
in the lungs could a needle be found. It is not impossible 
that it was carried away during the necropsy by the constant 
stream of water, but it must be admitted that one of the 
needles found in the abdominal wall may have caused the 
perforations. 

Solerodermia. 

At a recent meeting of the Dermatological Society Dr. 
Heines showed a patient who suffered from solerodermia in 
the stage of generalisation. The patient, a woman, aged 36 
years, began to suffer from headaches nine months ago. 
This was soon followed bv pains and swelling of the upper 
extremities which caused her to become an in-patient of a 
hospital and thus the progress of the “rheumatoid" affec¬ 
tion could be watched. Her temperature was subfebrile. The 
acute inflammatory conditions soon disappeared, but the 
swelling and tenderness persisted, and the face of the patient 
assumed the peculiar wax-like aspect. Gradually the skin 
became sclerotic, the movements of the joints of the arms 
and fingers as well as the neck were less and less extensive, 
and the colour of the nails turned a peculiar yellow. Pressure 
of the finger on the infiltrated skin did not cause any pitting 
but only a slowly-disappearing yellowish-red patch. In such 
cases the administration of thyroidin (extract of the thyroid 
gland of sheep or goats) and the uviol or quartz lamp had 
been used with much benefit. As a rule cases of universal 
solerodermia were very refractory to treatment. Massage, 
salol, and hot air were the beBt for them. Circumscribed areas 
affected with the disease were very much improved by 
thyroidin. 

Surgical Treatment of Rhinnphyma. 

The results of the operation for the serious disfigurement 
caused by the large red wart-like enlargement of rhinophyma 
have hitherto been not very satisfactory on account of the 
subsequent discolouration of the parts and transplantation of 
healthy skin from other regions gave the patient an unsightly 
appearance owing to the contrast between the acne of the 
face and the pale new covering of the nose. Professor 
Gersuny, therefore, worked out the following method and 
used it with great success on a very marked case of rhino- 
pbyma. The operation was performed under local anaes¬ 
thesia produced by a solution of cocaine of 1 per cent, 
strength, only a few grains of the alkaloid being used. The 
tumours were incised near their border so that the 
underlying cartilage was exposed. Then the skin was under¬ 
mined all around and the tumour removed, thus leaving 
a free narrow edge of true skin everywhere. This free 
edge was fixed to the wound by a few sutures. The saving 
of this free edge is important as it serves as a margin for the 
tip and the edge of the nose. Then the remaining wound 


was covered by flaps of epidermis taken from the extirpated 
tumours. The dressing consists of gutta-percha tissue fixed 
to the skin by means of chloroform. The dressing can be 
removed after four or five days. The chief advantages of 
this method are: (1) the natural appearance of the nose is 
preserved after the operation because there is no difference 
in colour between the new skin and the surrounding parts of 
the face ; and (2) the removal of the large masses tends to 
improve the vascular condition in the face, so that the often 
concomitant acne rosacea disappears or is much diminished. 
Seven patients have hitherto been operated upon by this 
method with very good results. 

The Tfveidy-fifth Congress of Internal Medicine. 

The Twenty-fifth Congress of Internal Medicine will be 
held in Vienna from April 6th to 9th. Professor von 
Muller (Munich) will be the President. The following pro¬ 
gramme of subjects to be discussed has been agreed upon : 
(1) The Correlation between the Female Genital Organs and 
Internal Diseases, to be introduced by Dr. von Rosthorn 
(Heidelberg) and Dr. Lenhartz (Hamburg); (2) The Methods 
of Examination of the Function of the Intestines, to be intro¬ 
duced by Dr. Schmidt (Halle) ; and (3) Diseases of Circula¬ 
tion and the Blood Pressure. An exhibition of instruments, 
preparations, and apparatus so far as they pertain to internal 
medicine will be held at the same time as the congress 
and will be in charge of Professor Schlesinger (Vienna I.). 
The number of papers promised is already about 100, so that 
the transactions will cover a very large field. 

Extirpation of the Saphenous Vein . 

At a recent meeting of the Gescllschaft der Aerzte 
Professor Schnitzler showed two women on whom he had 
operated for phlebitis of the saphenous vein. The first case 
was one of acute phlebitis during the third month of 
pregnancy. The woman had suffered repeatedly from the 
phlebitis and as the attacks had lasted lor a long time the 
operation was readily consented to. Professor Schnitzler 
made an incision from Ponpart’s ligament down to the 
internal malleolus, and the thrombosed vein, which 
appeared cordlike and had many nodules, was extir¬ 
pated, after which the wound was sutured. Primary 
union took place and an uneventful recovery was 
followed by complete relief. The second case was 
operated upon during the absence of acute symptoms. In 
such cases it was possible to remove the whole vein by a 
series of small incisions from four to six centimetres (two to 
three inches) long separated from each other by intervals 
varying from 8 to 15 centimetres (four to seven inches) ; the 
next stage consisted in mobilising the vein and loosening it 
from its attachments. The small incisions caused less 
disfigurement and were followed by quicker healing. 
Professor Schnitzler was very satisfied with the results of this 
operation for varicose veins whether inflamed or not. The 
danger of embolism was lessened by primary high ligature of 
the veins. 

Carcinoma of the Penis. 

At the same meeting Professor Spiegler showed a case of 
epithelioma of the penis of a strong, otherwise healthy, man 
aged 38 years. It was of the size of a chestnut, was said to 
have originated eight months ago, and was situated on the 
inner wall of the prepuce. Its place of oriign was probably one 
of the sebaceous glands. The removal of such epitheliomata, 
he said, was very easy and if done early enough it might be 
followed by complete freedom from relapse. It was interest¬ 
ing to note that even large epitheliomata did not often inter¬ 
fere with cohabitation because they were attended with little, 
if any, pain, whilst the flat tumour caused no pressure. 

Jan. 3rd. _ 

NEW ZEALAND. 

(From our own Correspondent.) 

The Sale of Food and Drugs Bill. 

After careful consideration by the Members of the Lower 
House this measure was sent on to the Legislative Council. 
There some important amendments were made which have 
resulted in the Bill being improved. Its original title, “Pure 
Foods Bill,” was objected to by many because it suggested— 
shall it be said to the unthinking ?—that only foods and drugs 
unmixed with anything else could be sold. As its object 
was to secure wholesome food, nothing was lost by the 



136 The Lancet,] 


NEW ZEALAND.—OBITUARY. 


[Jan. 11,1908. 


: Honourable George Fowlds, Minister of Public Health, agree¬ 
ing to the alteration of the name. In some ways its sphere 
was enlarged by an amendment which brought cigars, 
oigarettes, and tobacco under the Act. The excellent Act 
which was passed last year by the Victorian Legislature has 
been largely followed but in many ways advanced upon. 
'The interpretation clauses in the Act are of a very wide 
nature, and the merchant who wants to drive the proverbial 
“coach and four” through the statute will have to be well 
coached. The definition of “sell’' includes in its widest 
sense that set out by the latest English text-book :— 

“Sale” or “Bell” includes barter, and also includes offering or 
attempting to sell or receiving for sale, or having in possession for 
sale, or exposing for sale, or sending or delivering tor sale, or causing 
or allowing to t>e sold, offered, or exposed for sale, and refers only to 
sale for human consumption or use. 

Within recent years a large number of prosecutions for the 
sale of watered milk fell through, because, in answer to the 
vendor, the inspector who bought the samples admitted that 
■they were bought for analysis. This was held to exclude 
the possibility of their having been sold for human consump¬ 
tion, and so the cases were dismissed. In the new Act the 
wording has been altered to— 

The officer purchasing or otherwise procuring It shall before or 
forthwith after procuring it inform the seller or his agent selling the 
article that he intends to have the same analysed by an analyst. 

In addition to the usual power of entering upon premises for 
the examination and collection of samples of suspected foods 
and drugs the chief health officer has power to make copies 
of any books kept by any merchant whom he has cause to 
suspect to be dealing in goods the sale of which is prohibited 
by the Act. Then, again, while the interests of the vendor 
.are conserved special powers are given to the health officials 
to destroy food or drugs which are found unsound. 
Section 13 run as follows :— 

1. Every person commits an offence who sells any adulterated food or 
adulterated drug without fully informing the purchaser at the time of 
the Bale of trbe nat ure of the adulteration, unless the package in which 
it is sold has conspicuously printed thereon a true description of the 
composition of Buch food or drug. 

2. Every person commits an offence who sells any food or drug In any 
packago which bears or has attached thereto anv false nr misleading 
statement, word, brand, label, or mark purporting to indicate the 
nature, quality, strength, purity, composition, weight, origin, age, 
or proportion of the article contained in the package or of any 
ingredient thereof. 

A. Every person commits an offence who sells any food or drug con¬ 
taining any substance the addition of which is prohibited by regulations 
made under the authority of thia Act. 

4. Every person commits an offence who sells any food or drug con¬ 
taining a greater proportion of any substance than Is permitted by 
regulations made under the authority of this Act. 

5. Every person commits an offence who sells any food which con¬ 
tains methyl alcohol, or which, not having paid Customs or excise duty, 
contains more than two parts of proof spirit per centum. 

6. Every person commits an offence who Bells any food which is un¬ 
bound or unfit for human consumption. 

7- Every person committing any offence mentioned in this section is 
liable for the first offence to a fine not exceeding fifty pounds, and for 
any subsequent offence under the said section (whether of the same or 
a different nature) to a fine not exceeding two hundred pounds: Pro¬ 
vided that if any such offence is wilfully committed, the person so 
committing it is liable to a fine not exceeding two hundred pounds or 
to three months' imprisonment, although it may be a first offence. 

8. The provisions of subsection one of this section are subject to such 
exceptions as may be prescribed by regulations made by the Governor 
in Council and gazetted. 

It will be seen from this that the seller of an adulterated 
article, while he is quite free to sell it, must at the time of 
sale make it quite clear to the buyer that it is, say, a mixture 
of starch and pepper or chicory and coffee that he is selling. 
Provided he does this he is liable to no penalty. The ques¬ 
tion of reliance upon a warranty is fully dealt with and 
■'Where the proximate vendor sells under a warranty he can 
enter such warranty as a defence, provided he gives the 
prosecutor notice of his intention to rely upon such 
warranty. No warranty granted outside the dominion would 
be of any avail. A vendor of an adulterated article living in 
another country could Dot, of course, be attached in any 
action taken in New Zealand, and hence the indentor 
of the maker in the dominion must be made responsible. 
Section 27, which really contains the essence of the Bill, is 
far-reaching and ought to make largely for the betterment of 
the food-stuffs consumed in New Zealand. For many years 
the system of supervision exercised over beef, mutton, butter, 
cheese, &c., for export has been most thorough. The same 
has not obtained with regard to the food-stuffs consumed 
within the dominion. 

Section 27 (1). The Governor may from time to time, by Order in 
Council gazetted, make regulations—(a) Prescribing the standard of 
strength, weight, quality, or quantity of any food or drug, or of any 
f ingredient or component part thereof; ( b ) prohibiting the addition of 


any specified thing, or of more than the specified quantity or propor¬ 
tion thereof, to any food or drug; (c) prohibiting any modes of manu¬ 
facture, preparation, or preservation of any food or drug ; (d) securing 
the cleanliness and freedom from contamination of any food or drug in 
the course of its manufacture, preparation, storage, packing, carriage, 
delivery . or exposure for gale, and securing the cleanliness of places, 
receptacles, appliances, and vehicles used in such manufacture, prepara¬ 
tion, storage, packing, carriage, ordelivery; (e) prescribing the mode of 
labelling food or drugs sold in packages and the matter to be contained, 
or not lo be contained, in such lal>els; (/) prescribing the method of 
analysis of any food or drug; (g) fixing fees to be paid in respect of the 
analysis of any food or drug by an analyst; (A) prohibiting the sale of 
specified articles of food otherwise than by weight; (!) prescribing 
lines not exceeding fifty pounds for the breach of any regulation; and 
(j) generally for carrying out the purposes of this Act. 

2. Any such regulation may be made applicable either to food or 
drugs generally or to specified foods or drugs only. 

The power to set op standards for foods and drugs is similar 
to that in Victoria and some of the American States, but 
New Zealand goes further in some ways than any statutes 
which I have been able to study. There would seem at 
first sight to be no valid reason why many articles of food 
now sold by “pairs” should not be sold by weight. 
Potatoes are 6old by weight, yet eggs by the dozen; 
ordinary bread by weight, yet fancy bread by the piece ; 
turkey is sold by weight but chickens are not; and 
so on. Power is given in this Act to say what 
articles shall be sold by weight. The sections deal¬ 
ing with the alleged 2 pound and 4 pound loaf 
have been framed with very great care and will tend to 
check some of the frauds through short weight. If a loaf is 
less than 2 pounds and more than 1 pound the vendor shall 
be deemed to have sold a 2 pound loaf; if it is more than 
3 pounds and less than 4 pounds he shall be deemed to 
have sold a 4 pound loaf. Many buyers would only ask for 
“ a large loaf ” or “a small loaf,” and but for such a clause 
as this it would be difficult to prove that the vendor sold the 
loaf as a 2 pound or a 4 pound. Carelessness on the part of 
the buyer will not now protect the seller if the loaf is under 
weight. 

Nov. 22nd, 1907. _ 



WILLIAM ARCHIBALD LOGAN, M.B., B.8. New Zeal., 
F.RC.S. Eng. 

The medical profession in New Zealand has suffered a 
severe loss in the death of Mr. William A. Logan, which 
occurred in London on Dec. 21st, 1907. Mr. Logan was one 
of the most brilliant students whom the University of New 
Zealand has ever produced. He graduated as M B. and B.8. at 
Dunedin in 1898, held the house appointment in the Danedin 
Hospital in that year, and then came to London, where he 
tcok the diploma of M.R.C.S. Eng., and in 1900 that of 
F.H.C.S. Eng. Returning to New Zealand he was for a time 
surgeon to the Timaru Hospital and then settled in practice 
in Wellington where his ability as a surgeon soon became 
widely known and secured for him an extensive practice. 
Early in 1907 he returned to London where he successfully 
underwent an operation for gastric ulcer and remained to 
increase his surgical knowledge. A few weeks ago he 
developed signs of mastoid trouble which, in spite of prompt 
surgical interference, terminated fatally. A valuable life and 
the promise of a great surgeon were thus cut short at the 
early age of 33 years, and New Zealand has lost a typical 
example of the class of man of which any country might be 
proud. _ 

HARRY ALCOCK DIXON, M.R.C.S. Eng. 

Mr. Harry Alcock Dixon of Burnley died there at his resi¬ 
dence in Oxford-road on Dec. 24th, 1907, after about a 
week’s illness. He was born at Rose Cottage in the same 
town in 1849, bis father being Mr. John Alcock Dixon, a 
solicitor. The later portion of his school education was 
received at Rossall College and Stonyhurst College, and 
he was subsequently apprenticed for seven years at 
the Royal Infirmary, Manchester, being the last senior 
apprentice connected with that institution. In 1880 he 
took the diploma of M.R.C.S. Eng. and immediately com¬ 
menced practice in Burnley at Mabel-terrace, Oxford-road. 
Mr. Dixon was a Freemason and an Oddfellow and was for 
some time churchwarden of St. Stephen’s Church, Burnley. 
In 1890 he had an unusual experience as a candidate for 
municipal honours ; on the first counting of the votes he was 
declared to be elected, but on a recount being made he was 




The Lancet,] 


OBITUARY.—MEDICAL NEWS. 


[Jan. 11, 1908. 137 


found to have a minority of votes. Some time ago he 
received a presentation in recognition of his services as an 
instructor of ambulance classes. Mr. Dixon was a widower 
and has left two sons, one of whom is a medical man. The 
funeral took place at St. Peter's churchyard on Dec. 27th 
and was largely attended. _ 


JAMES FORSYTH, M.R.C.S. Exc. 

Mr. James Forsyth of Eyemouth, a small seaport town in 
Berwickshire, died on Dec. 29th, 1907, at the age of 79 
years. He received his professional training at the Uni¬ 
versity of Edinburgh and took the diploma of M.R.C.S. Eng. 
in 1855. He was one of the oldest practising medical men 
in his part of the country. For nearly 50 years he had acted 
as medical officer for the district and also held the appoint¬ 
ment of Admiralty surgeon and agent. He was also the 
oldest member of the local lodge of Freemasons and was for 
many years senior elder of St. John’s United Presbyterian 
Church. 


Deaths of Eminent Foreign Medical Men.—T he 
deaths of the following eminent foreign medical men are 
announced : —Dr. Unruh of the Children’s Hospital, Dresden. 
—Dr. William B. Belcher, lecturer on materia medica at 
Long Island College Hospital, Brooklyn. 


gtebiral JUfos. 


University of Oxford.— At examinations held 
recently the following candidates passed in the subjects 
indicated:— 

Mechanics and Physics.—C. F. Beeson, non-collegiate; C. M. Berlein, 
New College; B. Blackman. Queen’s; C. M. Burrell, University 
College; A. F. Coventry. Magdalen; C. L. Gumming. Trinity; 
J. C. Ellis, Jesus; E. A- Fisher, Balliol; J. G. Fry, Exeter ; R. A. 
Gillis, St. JoHu’s; W. It. Grose, Keble; K. Hancock, Lincoln; 

R. St. A. Heath cote. New College; S. Ilollidav ami Lai. C. Khosla, 
non-collegiate; II. S. Knowlton, Keble; A. M. Munro, St. John’s ; 
A. L. Parson, Christ Church; J. L. It. Pasttield, Worcester; H. 
Ross, non-collegiate; E G. Swann. St. Edmund Hall; J. It. 
Thomas, Jesus; W. W. Waller, New College; and J. W. Woodrow, 
Queens. 

Animal Physiology. —D. H. Jones, Jesus. 

Botany.— K. C. Briscoe, St. John's; A. M. M. Davies, University 
College; W. K. Flemner, Trinity; F. A. Hampton, Now College; 

G. T. Hebert, Christ Church; A. Jackson, Queeu's; M. M. 
M&ch&ya and F. M. Oliphant. St.John's; W. J. Pearson, Univer¬ 
sity College ; E. D. Rose, St. John's; and J. S&insbury, Oriel. 

Chemistry. —II. D. Barnes, Magdalen; C. F. Beeson, non-collegiate; 
C. M. Berlein. New’ College; It. C. Briscoe, St. John's; J. Broin- 
lield-Williams, Exeter; C. M. Burrell, University College; E. W. 
Carrington, Keble; A. F. Coventry, Magdalen ; C. L. Gumming, 
Trinity; J. C. Davies, New College; C. Dean and II. C. Doyne, 
Trinity ; J. C. B. Ellis, Jesus : F. H. Gee, non collegiate ; R. A. D. 
Gillis and A. C. Godson. St. John's; O. H. Gotch, New College; 
W. R. Grose, Keble; J. M. Guilfoyle, B.N.C.; K. Hancock, Lincoln ; 

H. L. Harvey, Oriel ; O. J. Hobbs, Merton; K W. N. Hobhouse. 
New College; O. Jackson, Queen's; I). 11. Jones, Jesus; II. S. 
Knowlton, Keble; F. C. Lacaita. Balliol; W. Lawton, St. John's ; T. 
Lindsay, Balliol; F. S MacNalty, Worcester; G. A. Mating, 
Kxeter; A. M. Munro, St. John's; A L. Parson, Christ Church; 
J. L. Pastfield, Keble ; A. L. Pearce Gould, Christ Church ; G. B. R. 
Pease, University College; C. G. Roach. G. S. Robinson, and 
II. A. C. Sim. Exeter ; E. R. Speyer, New College ; J. W. G. Steel), 
Trinity ; E. G. Swann, St. Edmund Hall; B. Tunstall Behrens, 
Pembroke; B. II. Walker, Queen's; B. E. Wall, Lincoln; and W. 
D’Arcy Ward. Trinity. 

Organic Chemistry.— W. A. Cooke. Worcester; G. Cranstoun, Oriel; 
A. A. M. Davies, University College; A. W. Dennis, Keble ; It. C. 
Fairbairn, Exeter ; G. T. Hebert, Christ Church ; A. Juett. B.N.C.; 
E. G. Martin, New College; E. E Mather, Exeter; E. O’Connor, 
Lincoln; K. L. Pearce Gould, Christ Church; W. J. Pearson, 
University College; U. M. Pope, Lincoln ; M. O. Raven, Trinity; 

J. Sainsbury, Oriel ; G. Stanger, Lincoln ; T. O. Thompson, 
St. Johns ; J. F. Venables, Magdalen; and S. White, Keble. 

Materia Medica and Pharmacy.—A. Booth, Keble; and W. F. 
Harvey. Balliol. 

Human Anatomy and Human Physiology.— S. F. Mutch. B.N.C.; 

K. P. Boultou, Balliol; A. T. S. S lad den, Jesus ; and A. E. Taylor, 
Trinity. 

Pathology.- M. Bates, St. John’s; C. N. Binney, Corpus Christ!; 
N. Flower, Exeter; II. M. C. Green, Wad ham ; W. D. Kennedy, 
University College; and B. A. W. Stone, B.N.C. 

Forensic Medicine and Public Health.—XL. Bates, St. John’s; G. D. 
Carpenter, nou-collegiate; K 1*.jCumberhatch, Keble; N. Flower, 
Exeter; D. B. Todd, Lincoln; S. E. Whltnall, Magdalen; and 
A. P. Yonge. Exeter. 

Medicine , Midwifery, and Surgery.— C. G. Douglas, Magdalen; 

S. Hartill, Exeter ; O. M. Johnson, Magdalen; B. G. Klein, Corpus 
Christ! ; and S. E. Whltnall, Magdalen. 

Longevity. —Mrs. B. Bushen of Minehead, 
Somerset, recently celebrated the hundredth anniversary of 
her birthday. 


Medical Magistrate.— Mr. .T. Macdonald 

Brown, M.D. Edin., F’.R.C.S. Eng., has been appointed a 
justice of the peace for the county of London. 

Bristol Medical Charities.— During 1907 the 

employees of the W. D. and H. O. Wills branch of the 
Imperial Tobacco Company at Bristol voluntarily collected 
£605 for the Bristol medical charities. 

We regret to announce the death of Mr. 
William H. S. Wood, the senior member of the firm of 
Messrs. William Wood and Co., medical publishers, New York, 
who died on Dec. 11th, 1907. Messrs. William Wood and Co. 
have acted as the special agents in New York for the dis¬ 
tribution of The Lancet for many years. 

Literary Intelligence. — Messrs. W. B. 

Saunders and Company have in the press for early publics - 
tion a Manual of the Practical Application of Bier's 
Hyperemio Treatment in Surgery, Medicine, and the Special¬ 
ties, by Dr. Willy Meyer, professor of surgery in New York 
Post-Graduate School, and Professor Victor Schmeider of the 
Surgical Clinic, University of Berlin. 

Tiie Lees and Raper Memorial Lecture, 1908. 

—The eighth Lees and Riper Memorial Lecture will be 
delivered in the Town Hall, Oxford, by Mr. William 
McAdam Eccles, on Tuesday, Feb. 4th, at 8 pm. The 
subject chosen is “The Relation of Alcohol to Physical 
Deterioration and National Efficiency.” The chair will be 
taken by the Regius Professor of Medicine in the University 
of Oxford, Professor William Osier. Further information 
and invitation cards can be obtained from the honorary secre¬ 
tary to the trustees, Mr. John Kempster, Broad Sanctuary 
Chambers, 20, Tothill-street, Westminster, S.W. 

Leicester’s Infants’ Milk Depot.— At the 
last meeting of the Leicester town council a report was 
presented on the working of the corporation’s infants’ milk 
depot, which was inaugurated with the primary object of 
reducing the infant mortality of the borough. Since July, 
19C6, when the depot was opened, 782 infants have 
been supplied with specially prepared milk, cases which 
remained on the books for not more than one week being 
excluded from the returns. Of the 782 infants 202 were still 
on the books on Dec. 31st, 1907, the average time during 
which the remainder were fed from the depot being 12 weeks. 
The total quantity of prepared milk sold since the inaugura¬ 
tion of the institution had been just over 20,000 gallons. 
Not the least important part of the work done at the depot 
is the giving of advice to mothers on the feeding and 
care of infants. In this particular department the medical 
officer of health has received valuable assistance from the 
Leicester Health Society, which has placed a trained and 
qualified “visitor” at his disposal. The fact that the 
summer of 1906 was very hot and that of 1907 oold and wet 
makes it difficult to demonstrate statistically how much has 
been effected by the depot in reducing infant mortality. 
The sanitary committee of the town council, however, is of 
the opinion that the depot is accomplishing a useful work 
and is justifying the expenditure incurred. 

British Honduras.— In a report dated Nov. 1st, 
1907, Mr. Wilfred Collet, C.M.G., Colonial Secretary of 
British Honduras, states that during the year 1906 the colony 
was free from yellow fever. In the previous history of the 
colony an outbreak of yellow fever, such as occurred in 1905, 
was always followed by a less severe outbreak in the follow¬ 
ing year. The colony has been more fortunate in this respeot 
than its neighbours, for in all the neighbouring republics 
cases of yellow fever presented themselves in 1906. The 
immunity of British Honduras is probably due to the practice 
of fumigating all the small vessels coming from infected 
places and so destroying infected mosquitoes. An ordinance 
to enforce the screening of vats and the taking of other 
measures for preventing the breeding of the stegomyia 
fasciata came into force in January, 1906, in Belize, and 
later in other towns of the colony. The work was slow, 
as nearly all the vats had to be covered and prepared to take 
the wire gauze. The fitting of the gauze is an easy matter if 
the vat is properly constructed and covered. It was noticed 
that when the vats in any block were screened neighbouring 
houses were visited with flights of stegomyia, evidently 
looking for new breeding grounds. These migrations con¬ 
tinued till the screening was completed. Some very bad 
low-lying lots in Belize have been filled in and breeding 





138 Thh Lancet,] APPOINTMENTS—VACANCIES.—BIRTHS, MARRIAGES, AND DEATH8. [Jan. 11. 1908. 


grounds of anopheles to some extent diminished. The 
estimated mean population of the colony for the year 1906 
was 41,007, consisting of 20,942 males and 20,065 females. 
The birth-rate was 32 ■ 9 and the mortality 29 • 9 per 1000. 
The number of illegitimate births was 630 out of a total of 
1403. The average rainfall for the ten years 1897-1906 in 
Belize was 89 • 74 inches, the maximum—114 • 21 inches— 
being in 1900, and the minimum—65 • 89 inches—in 1902. 


appointments. 


Successful applicants for Vacancies, Secretaries of Public Institutions, 
and others possessing information suitable for this column, are 
invited to forward to The Lancet Office, directed to the Sub- 
Editor, not later than 9 o’clock on the Thursday morning of each 
week, such information tor gratuitous publication. 


Anklesaria, IIirjee Nowro.ii, F.R.C.S. Edin., L.R.C.P. Edln., 
L.F.P.S. Glssg.. L.M. & S., has boon appointed Honorary Surgeon 
to the Sir Jarnsetjee Jee.jeebhoy Hospital, Bombay. 

Badcock, E. B., M.R.C.S., L.K.C.P. Lond., has been appointed Surgeon 
to the General Post Office, Wandsworth Sub district 

Bateman, H. E., L.R.C.P, Lond., M.R.C.S., has been appointed to the 
Charge of the X Ray Department of the York County Hospital. 

Bergin, Prank Gower, L.R.C.P. Lond., M.R.O.S., has been appointed 
Medical Officer to the Bristol Dispensary. 

Cuthbekt, John, L.H.C.S. Irel., L.K.C.P. Edin., has been appointed 
Assistant Surgeon io the Perth Public Hospital, Western 
Australia. 

Gaynhr, J. S., L.R.C.P. Lond., M.lt.C.S., has been appointed Anaes¬ 
thetist to the York County Hospital. 

Gray, A. Montague H.. M.D., B.S. Lond., M.R.C.P. Lond., has been 
appointed Obstetric Registrar to University College Hospital. 

Gregor, Alexander, M.D., C.M. A herd., has been appointed Medical 
Officer of Health of Falmouth. 

Habkness, Edward, L.R.C.P. & S. Edin., has been appointed Public 
Vaccinator for the South-Eastern District of Victoria, Australia. 

Harris, Dudley Raymond, M.R.C.S., L.K.C.P. Lond., has been 
appointed Medical Officer for the Falmouth District and Work- 
house by the Falmouth Board of Guardians. 

Jewfsbury, Reginald C., M.A., M.B., B.Ch. Oxon., M.R.C.P. Lond., 
has been appointed Physician to Out-patients at the Victoria 
Hospital for Children, Chelsea. 

McDonald, Gilbert Reginald, LRC.P., L.K.C.S.. L M. Irel., has 
been appointed District Medical Officer by the Tiverton (Devon) 
Board of Guardians. 

Nobbs, Athklstane, M.D.Edin., has been appointed Surgeon to the 
General Post Office, Putney Sub district. 

Nyulasy. A. J., M.R.C.S. Eng., L.R.C.P. Lond.. has been appointed 
Gynaecologist to the Perth Public Hospital, Western Australia. 

Price, Florence, M.B., B.S. Edin., has been appointed to the 
Bacteriological Department at Swansea Hospital. 

Ramsay, J. E., M.B. Lond., has been appointed Surgeon to the Perth 
Public Hospital, Western Australia. 

Thomas. H. Darby, M.R.C.S., L.R.C.P. Lond., has been appointed 
Assistant House Surgeon at the Royal Surrey County Hospital, 
Guildford. 

Vise, John Neville Blithe, M.R.C.S., L.R.C.P. Lond., has been 
appointed Medical Officer of Health of Chard (Somerset). 

Walker, George Francis Clegg, M.B., Ch.B. Viet., has been 
appointed Medical Officer of Health for the Haverfordwest 
(Pembrokeshire) Rural District. 

Williams, Lionel Henry, M.D.Durh., M.R.C.S., L.S.A., has been 
appointed Medical Officer for the Thornbury District and Work- 
house by the Thornbury (Gloucestershire) Board of Guardians. 



For further information regarding each vacancy reference should be 
made to the advertisement (see Index). 


Bangor, Carnarvonshire and Anglesey Infirmary. — House 
Surgeon. Salary £80 per annum, with board, washing, and 
lodging. 

Borough of Aston Manor, Education Committee.— Medical Officer 
(female). Salary £200 per annum. 

Brecon and Radnor Joint Counties Asylum, Talgarth, R.S.O.. 
Breconshire.-Assistant Medical Officer, unmarried. Salary £170 
per annum, with apartments, board, washing, and attendance. 

Bridge of Weir, Consumption Sanatoria.— Assistant Resident 
Medical Officer (female). 

Brighton, Sussex County Hospital.— Second House Surgeon, un¬ 
married. Salary £60 per annum, with board and residence. 

Brighton Throat and Ear Hospital, Church-street, Queen’s-mad. 
—Non-resident House Surgeon for six months, renewable. Salary 
at rate of £75 per annum. 

Bury Infirmary.— Junior House Surgeon. Salary £80, increasing to 
£90 after six months, with board, residence, aud attendance. 

Carmarthen. Joint Counties Lunatic Asylum.— Assistant Medical 
Officer. Salary £200 per annum, with board, lodging, washing, and 
attendance. 

Chesterfield and North Derbyshire Hospital.— Senior House 
Surgeon. Salary £120 per year, with board, apartments, and 
laundress. 

City Dispensary, 29 and 30, College-street, Dowgate-hill, E.C.— 
Surgeon. 

COLCHESTKB, ESSEX AND COLCHESTER GENERAL HOSPITAL.— House 
Physician. Salary £60 per annum, with board, residence, and 
washing. 


Derby, Derbyshire Royal Infirmary*.— Assistant House Surgeon 
for six mouths. Salary at rate of £60 per annum, with board, 
residence, and washing. 

Deyonport, Koy'ai. Albert Hospital. —Resident Medical Officer, 
unmarried. Salary £100 per annum, with apartments, board, Ac. 

Enniskillen. Fermanagh County Hospital.— House Surgeon. 
Salary £52 per annum. 

Great Northern Central Hospital, llolloway-road, N.— Patho¬ 
logist and Curator. Salary £103 per annum. 

Hartlepools Hospital. —House Surgeon. Salary £100 per annum, 
with board, washing, and lodging. 

Hull, Royal Infirmary.— Two Casualty House Surgeons. Salary at 
rate of £60 per annum for six months and of £80 for 12 months, 
with board and lodging. 

Infams’ Hospital. V lucent-square, Westminster, S.W.—Qualified 
Clinical Assistant. 

Leeds. Hospital for Women and Children.— House Surgeon. 
Salary at rate of £50 per annum, with board. 

Leeds Public Dispensary.— Junior Resident Medical Officer. Salary 
£100, with board and lodging. 

London Fever Hospital, Liverpool-road, N.—Resident Medical 
Officer. Salary £250 per annum, with board and residence. 

Maidstone, Kent County* Asylum.— Fourth Assistant Medical 
Officer, unmarried. Salary £175 per annum, with quarters, attend¬ 
ance. coal, gas. Ac. 

Mount Vernon Hospital for Consumption and Diseases of the 
Chest, Hampstead and Northwood, Middlesex.—Junior Resident 
Medical Officer. Salary £50 per annum, with board, lodging, Ac. 

National Hospital for the Relief and Cure of the Paralysed 
and Epileptic, Queen-square, Bloomsbury.—Assistant Physician 
for Out-patients 

Northampton, Berry Wood Asylum —Junior Assistant Medical 
Officer, unmarried. Salary £150, Increasing to £200, with board, 
lodging, and washing. 

Northampton General Hospital. — Assistant House Surgeon, un¬ 
married. Salary £50 per annum, with apartments, board, w ashing, 
and attendance. 

North-Eastern Hospital for Children, Hackney-road, Bethnal 
Green, K.— Assistant Physician. 

Paddington Green Childrens Hospital, London, W.—Honorary 
Anaesthetist, also Honorary Radiographer. 

Poplar Workhouse, Forest-lane, Forest Gate.—Medical Officer. Salary 
£100 per annum. 

St. George’s Hospital, S.W.—Physician, also Assistant Physician. 

Sr. Fancras Infirmary and Workhouse. Pancras-road.—Junior 
Assistant Medical Superintendent and Medical Officer (female). 
Joint salary £80 per annum, with board, apartments, and washing. 

Somerset County* Council. —Chief Medical Inspector of Schools. 
Salary £500 per annum, with necessary out-of-pocket expenses. 

SUNDKKLAND, MoNKWEARMOUTH AND SOUTHWICK HOSPITAL.—House 
Surgeon. Salary £100 per annum, with board, lodging, and 
washing. 

Tiverton, Devonshire, Infirmary* and Dispensary. —House Surgeon 
and Dispenser. Salary £80 and all found. 

Ventnor, Royal National Hospital for Consumption and Diseases 
of the Chest on tiie Separate Principle.—Two Assistant 
Resident Medical Officers, unmarried. Salary £100 per annum, with 
board and lodging. 

Victoria Hospital for Children, Tite-street, Chelsea, S.W.—Senior 
Resident Medical Officer. Salary £105 per annum, with board, 
residence, and washing. 

West-End Hospital for Disfases of the Nervous System. 
Paralysis, and Epilepsy, 73, Welbeck-street, London, W .— 
Physician to Out-patients. _____ 

The Chief Inspector of Factories, Home Office, S.W., gives notice of 
vacancies as Certifying Surgeons under the Factory and Work¬ 
shop Act at Rathfriland. in the county of Down ; and at Str&th- 
miglo, in the county of Fife. 


JStarriap, anfe $fatjjs. 


BIRTHS. 

Addinsell.— On Jan. 3rd, at 6, St. James’-road, Surbiton, the wife of 
John Howard Addinsell, M.R.C.8., L.R.C.P.. of a son. 

Bentley.— On Dec. 27th, 1907, at Haworth. Mitcham, the wife of 
Harold Bentley, B.A. Camb., M.R.C.S., L.R.C.P., of a daughter. 

Flemming.— On Jan. 7th, at 34, Alma-road, Clifton, Bristol, the wife 
of A. L. Flemming, L.R.C.P , M.It.C S., of a daughter. 

May*.— On Jan. 2nd, at Woodleigh, Ware, Herts, the wife of George 
Ernest May, M.R.C.S., L.R.C.P., of a son. 

Morlkt.—O n Jan. 6th, at 29, Gower-street, Bed ford-square, the wife of 
Arthur S. Morley, of a son. 

Thorne Thorne.— On Jan. 3rd, at •* Grasmere,” Mount Vernon-road, 
Woking, the wife of Berthold Thorne Thorne, M. D., of & daughter. 

Townsend.— On Dec. 31st, 1907, at Barnwood, near Gloucester, the 
wife of Arthur A. I). Townsend, M.D., of a son. 

Wolfe. —On Dec. 14th, 1907, at P&arl, Cape of Good Hope, the wife of 
Robert Inglewood Wolfe, J.P., District Surgeon, of a son. 


DEATHS 

Birch.— On Jan. 1st, at St. Lconards-on-6ea, Scholes Butler Birch, 
M.D., M.R.C.P. Lond., in his 82nd year. 

Phillips.— On Dec. 27th. 1937, at Cairo, Egypt, Gwyneth Helen 
Powell Phillips, the only child of Dr. and Mrs. Llewellyn Phillips, 
aged two years and four months. 

Toonk-Smith.— On Jan. 6th, at West Chapel-street, Mayfair, T. W. 
Toone-Smith, M.D., M.R.C.S., in his 71st year, 

Turner.— On Jan. 8th, at 6, Eton-terrace. Edinburgh, Agnes Logan, 
wife of Sir William Turner, K.C.B., Principal of the University. 


N.B.—A fee of be. is charged for the insertion of Notices of Births, 
Marriages , and Deaths. 





The Lancet,] NOTES, SHORT COMMENTS, AND ANSWERS TO CORRESPONDENTS. [Jan. 11, 1908. 139 


Stotts, Sjwrt Conraunts, aito pastors 
to Corrtsponknls. 

A LAMENT FOR THE WARMING-PAN. 

A frkquekt correspondent writesDuring the Arctic weather of last 
week many people after spending the evening in a warm and cheerful 
room must have contemplated with shuddering distaste the necessity 
of leaving their armchair for an unwarmed bedroom and a plunge 
into icy sheets. Such a one, putting off until the latest moment the 
unwelcome ascent, may have seen a ruddy gleam of light re¬ 
flected from his fire upon the patterned copper disc of a 
long-disused warming-pan. for these articles, having for many 
years been divorced from their special purpose, now form the 
ridiculous adornment of many dining-rooms or halls. Such 
a man may well have sighed to think that in his grandfather’s 
days that warming-pan would have had an intrinsic glow and 
ministered to more primitive senses than the aesthetic eye. And 
going upstairs at last he has either, like hundreds of thousands of 
his fellows, used for half-an-hour an ill-spared portion of his body 
heat in warming his bed-clothes, or perhaps has so far forfeited his 
self-respect as to take to bed with him a hot-water bottle which 
formed a scorching focus in a tiny area surrounded by an 
infinite Icy waste, made all the colder by contrast with 
that unsatisfactory source of excessive local heat, a device 
which was either of earthenware and extremely clumsy, or of 
indiarubber, and very possibly leaky. Can the advantages of such 
an unsatisfactory contrivance—which Is hardly more ingenious 
than the primitive hot brick and of which no man would readily 
acknowledge the use—be compared with those of the old-fashioned 
brazier with which the old-fashioned domestic was wont to prepare 
tho beds of chilly people? It warmed the bed-clothes thoroughly 
and evenly, it left no foreign body in the bed to shock the feet with 
its lukewarmness in the cold hours of the morning, and It preserved 
the Bel f-respect of those who benefited by it. for no man could 
object to enter sheets w armed, as it were, providentially against his 
arrival. I acknowledge the Inevitability of the passing of the 
warming-pan into the limbo of a more leisurely age, for I am con¬ 
vinced that no modern serving-maid would take kindly to its use; 
but it is well to know' that science has to some extent made good 
its loss. I understand that an electrical warming-pan, the superiority 
of which to its predecessor is obvious, has been made for several years 
but of course it is available only for him who has an installation 
of the electric light. Equally of course it is a luxury, but to many 
old people it would be a real boon to get nightly into well-warmed 
sheets in cold weather, and such may profit by the modern 
warming-pan and need no more cast regretful eyes at the picturesque 
relic on their walls. 

THE ALABONE TREATMENT. 

To the Editor of The Lakcet. 

Sir,— Objection has been taken by Mr. E. W. Alabone to paragraph 158 
of the Annual Report of the London and Counties Medical Protection 
Society, Limited, for the year 1906, on the ground that it conveys the 
Impression that Mr. E. W. Alabone has converted his practice, in the 
treatment of consumption, into a company. Mr. E. W. Alal>one wishes 
it known that this is not so. 

Will you kindly allow me to convey this information to your readers. 
I am, Sir, yours faithfully, 

Huoh Woods, M.D. Dub., 

General Secretary, London and Counties Medical 
Protection Society, Limited. 

•** We publish this letter at the request of that excellent professional 
institution, the London and Counties Medical Protection Society, 
Limited. We must, however, point out that our readers have no 
interest whatever in the information.— Ed. L. 

A MEDICAL ADVERTISEMENT. 

Wk have received a copy of the Roman Herald , of date Dec. 14th, 
1907. This is a weekly newspaper written in English and published 
in Rome "for the use and assistance of tourists and residents in 
Italy.” In the issue in question there occurs in a column headed 
‘•Round about Rome” an advertisement of a registered British 
practitioner, under the cross-heading "Dr. Grace Mackinnon,” in 
very bold type. The paragraph beneath states that this lady has 
arrived in Romo, which city is to be congratulated on the 
event, as she has had great experience in the diseases of 
,. women and children in her hospital in India and general 
practise (sic); that she was for a time the head of the Con¬ 
sumption Hospital at the Bridge of Weir, Scotland ; and 
that the Government of India has bestowed upon her the 
order of the Kalsar-i-Hind in acknowledgment of her services in that 
country. We find ttakt the lftdy was educated at the London School 
oi Medicine for Women and has been medical superintendent at the 
Consumption Hospital at Bridge of Weir and the Duchess of Teck 
Hospital at Patna, India. Her qualifications are L.R.C.P., L.R.C.S. 
Bdin., 1889. Doubtless the advertisement is the work of some 
injudicious friend of Miss Mackinnon who should promptly 
repudiate it. 


CATS AND PLAGUE. 

To the Editor of The Lahcst. 

Sir,—J enner was led to his immortal discovery by the fact that the 
Gloucestershire dairymaids were exempt from small-pox. It would 
be a remarkable coincidence if the discovery of an antidote for the 
plague in India should be traceable to the freedom from that pesti¬ 
lence enjoyed by the inhabitants of villages where milch cattle 
abound. In January, 1907, the attention of Lieutenant-Colonel 
Andrew Buchanan, I.M.S., was drawn to a village named 
Airla, which was situated by the side of the road between Nagpur 
and Kalmesbwar. Plague was rife in the two latter places, but the 
former was, and always had been, immune. He made inquiries and 
found that the Inhabitants of Airla all kept buffaloes. Milk was 
abundant and the village consequently swarmed with cate which 
were attracted by it. Colonel Buchanan then made inquiries in other 
villages, first in the Nagpur district and then in the Amraoti district, 
and found it was the rule that where there were many buffaloes there 
were many cats and seldom or never a case of plague. This interesting 
information is to be found in an article by Colonel Buchanan in 
the Indian Medical Gazette for October. In this article the writer 
amplifies his previous statements regarding his cat census and 
mentions some more of its striking results. Among othor noteworthy 
facts the following is peculiarly interesting. “ A village named Wandl 
was reported to have 61 per cent, of cats and yet 13 cases of plague 
occurred. Special inquiries were made in this village and it was 
found that many of tho cats had been introduced after plague 
had occurred. There were 13 houses with cats before the plague 
began and no case occurred in any of these houses.” In 
another letter which is published in the Pioneer Mail of Oct. 11th 
Colonel Buchanan replies to the contention of a correspondent in 
England to the effect that cats can convey the infection of plague from 
rats to the human subject and are therefore a source of danger to the 
public health. Cats are liable to plague, he admits, but they do not 
spread it. In the instance quoted by the correspondent there is 
nothing to show that the lady and the cat did not both acquire the 
disease from the same rat. lie understands that at the Parel 
Laboratory it was ascertained that the cat flea does not convey plague 
as the rat Ilea does. Of course, it is possible that a rat flea may 
have been conveyed on a cat, but the fact that a flea had been 
carried in a coat would not be accepted as an argument against 
wearing clothes. Where cats abound there will be no plague 
because in that case the rats will avoid entering the houses. 
The following incidents related by Colonel Buchanan are strongly 
confirmatory of his theory. " I passed to-day through Asegaon, a 
village with a population of 700. Plague began there about a month 
ago, and there had been 35 cases before tne inhabitants evacuated. 
Inquiries were made from eight men who happened to be on the 
road side. In the houses of seven there had been cats and no plague; 
in the house of the other there had been plague but no cat." 
“ D&ryapur, a town in tho west of the district, was visited by a severe 
epidemic last plague season. An American missionary, who is a 
believer in Faith curing, lived near the middle of the town and when 
nearly all the people went out he and his family remained. None 
of them took plague and, no doubt, he would have quoted himself and 
family as instances of the value of his partioular form of belief had 
it not happened that, quite casually, he mentioned to me that 
when the people left the town his household was troubled with 
13 or 14 cats that kept coming to the house, and that his wife occasion¬ 
ally fed them. To the question, ‘ Has it never occurred to you that you 
and your family owe your lives to these cats?’ lie replied that the 
thought had never struck .him.” " The Quasasal Ambia is a well- 
known religious book of the Mahomedans. In it there is an account of 
the Great Flood, of the building of the ark by Noah, of the creation of 
rats (N.B. by the Devil), of their rapid multiplication, of their eating 
holes in the ark so that the lives of all on board were in danger, and of 
the creation of cats (N.B. at the suggestion of the Angel Gabriel) for 
the special purpose of destroying the rats. The cats killed off the rats 
and saved the ark, and there is no more effectual way of appealing to 
the Mahomedans than to draw a comparison between the danger that 
Noah experienced from rats and the risks which they now undergo from 
the same animals. They, at any rate, will not believe that cats spread 
plague." In conclusion. Colonel Buchanan says.- “It will be under, 
stood that the observations which have been given here have been 
made In a limited area, and I hope that others will make inquiries in 
other parts of India and record how far the cat would account for 
reedom from plague, or the reverse." I hope so too, for it certainly 
appears that Colonel Buchanan has made out a strong primd facie case 
in favour of the cat. I am, Sir, yours faithfully, 

V ETERAN. 

THE STERILISATION OF CATHETERS AND CYSTOSCOPBS. 
At the Congress of the German Urological Society recently held in 
Vienna Dr. Arthur Weiss of Vienna read a paper on an Apparatus 
for Sterilising Catheters and Cystoscopes by exposure to the vapour 
of "autan." From a copy of his paper which he has sent to us it 
appears that this substance is a preparation of formaldehyde and 
that in the application of it steam was simultaneously evolved by 
which the polymerisation of formaldehyde into paraform was pre¬ 
vented. In his experiments he infected catheters of different sixes 
by passing through them solutions containing many kinds of 
virulent bacteria. On exposure to the vapour of autan all the 
catheters, even those of the smallest calibre, were completely 
sterilised. Pure cultures of tubercle bacilli were effectually killed by 




[Jan. 11,1908. 


140 The Lancet,] NOTES, SHORT COMMENTS, AND ANSWERS TO CORRESPONDENTS. 


the vapour, as was proved by injocling the cultures so treated into t he 
peritoneum of K uinea pi K s : the animals lived for six weeks in perfoct. 
health and when killed they showed no trace of tuberculous disease. 
Dr. Weiss has designed an apparatus in which catheters to be 
sterilised are placed in a glass tube connected with a glass vessel in 
which form aldehyde gas is evolved by stirring with water a powder 
oomposed of a metallic peroxide and paraform. An exposure of two 
hours for large catheters and three hours for small ones suffices for 
complete sterilisation. 


THE TREATMENT OF PILES. 

To the Editor of The Lancet. 

sha11 b ? Rreatly obli K ed il any of your readers will favour me 
with their experience of the treatment of piles by injection with car¬ 
bolic acid or any other treatment otherwise than operative, and shall 
be especially thankful to know if the treatment by injection is 
dangerous. I am Sir youra (aiUl ( ul |y 

Jan. 6th, 1908. jj D 


FRIDAY (17th).—London (2 p.m.), St. Bartholomew's (1.30 p.m.), St. 
Thomas's (3.30 r. M.), Guy's (1.30 p.m.), Middlesex (1.30 p.m.). Charing 
Cross (3p.m.), St. George’s (1 p.m.). King's College (2p.m.), St. Mary’s 
(2 P.M. ), Ophthalmic (10 A.M.), Cancer (2 p.m.), Chelsea (2 p.m.), Gt. 
Northern Central (2.30 p.m.), West London (2.30 p.m.), London 
Throat (9 30 a.m.), Samaritan (9 30 a.m. and 2.30 p.m.), Throat, 
Golden-square (9.30 a.m.), City Orthopedic (2.30 p.m.). Sohosquare 
(2 p.m.). Central London Throat and Ear >2 p.m.). Children, Gt. 
Ormond street (9 a.m., Aural, 2 p.m.), Tottenham (2 30 p.m ), St. 
Peter's (2 p.m.). 

SATURDAY (18th.)—Royal Free (9 a.m.), London (2 p.m.), Middlesex 
(1.30 p.m.), St. Thomas's (2 p.m.). University College (9.15 a.m.). 
Charing Cross (2 p.m.), St. George's (1 p.m.)'. St. Mary's (10 a.m.), 
Throat, Golden-square i9.30a.m.), Guy’s (1.30 p.m.), Children, Gt. 
Ormond street (9.39 a m.). 

At the Royal Bvc Hospital (2 p.m.), the Royal London Ophthalmic 
(10 a.m.), the Royal Westminster Ophthalmic (1.30 p.m.), and the 
Central London Ophthalmic Hospitals operations are performed daily. 


SOCIETIES. 


House Surgeon .—We should say that a reasonable fee would be lialf-a- 
guinea. The question-to whom should the fee go-depends upon 
the rule of the hospital at which the medical officer holds his 
appointment. At most hospitals the resident medical officers are 
considered entitled to the fees which they may eRrn in this or 
similar ways, but, of course if there is any deiinite'rule on the matter 
at the particular hospital in question our correspondent must 
abide by it. 

Medical Council has no jurisdiction over medical 
" arae8 n °fc appear on the Register. A prosecution 
might lie against this person if he were pretending to have medical 
qualifications which he did not possess, but if he is a graduate in 
medicine and is not on the Register his position is unassailable. 

<tc *~ We ^approve highly of the dissemination of such 
handbills but we cannot accuse in our columns a member of the 
medical profession of improper advertisement upon tho information 
supplied to us. Our correspondent desires to remain anonymous and 
does not give us the name of his informant. 

Erratum.- Dr. J. 8. Purdy of the Public Health Service of New 
Zealand has written to correct an error in an annotation on the 
Treatment of Gonorrhea in The Lancht of May 18th, 1907, p. 1377. 
This article referred to a previous contribution by Dr Purdy in 
The Lancet of Dec. 19th, 1903, p. 1716. concerning which we wrote : 
“ Dr. Purdy has previously published his experience in the treatment 
of gonorrhoea with the new organic compound of silver, protargol 
at the Lock Hospital." In place of protargol we should have written 
argyrol. 


ROYAL SOCIETY OF MEDICINE, 20. Ilanover-square, W. 

Tuesday.— {(Surgical Section). 5.30 p.m., Mr. H. L. Barnard 
Some Surgical Aspects of Subphrenic Abscess. 

MEDICAL SOCIETY' OF LONDON, 11, Chanrlos-street, Cavendish- 
square, W. 

Monday—8.30 pm.. Dr. A. C. Inman: The Opsonic Index in 
Tuberculous Patients engaged in Physical Exercise. Dr. M. S. 
Paterson: Graduated Labour in Pulmonary Tuberculosis. 

SOCIETY FOR THE STUDY OF INEBRIETY, 11, Chandos street, 
Cavendish square, W. 

Tuesday. —3.30 p.m.. Council Meeting. 4 p.m.. Discussion on the 
Teaching of Hygiene and Temperance in Schools and Colleges 
(opened by Mr. W. N. Edwards). 

ROYAL MICROSCOPICAL SOCIETY, 20, Hanover-square, W. 

Wednesday.— 8 p.m., Mr. W. Wescht-: On the Microscope as an 
Aid to the Study of the Biology of Insects, with Special Refer¬ 
ence to the Food. Mr. J. C. Barnard: Exhibition and Descrip¬ 
tion of an Improved Type of Mercury Vapour Lamp for Use 
with the Microscope. 

SOCIETY OF TROPICAL MEDICINE AND HYGIENE, 20, Hanover- 
square, W. 

Friday.—8 30 p.m.. Dr. G. C. Low: The Unequal Distribution of 
Filariasis in the Tropics. Dr. C. Brown : Biographical Sketch of 
the late Professor Fritz Schaudinn. 

SOCIETY FOR THE STUDY OF DISEASE IN CHILDREN. 11, 
Chandos street. Cavendish square, W. 

Friday.-4 30 p.m., Dr. G. Carpenter Successful Medical Treat¬ 
ment of Congenita! Hypertrophic Obstruction of the Pylorus., 
Dr. K. Cautley: Pathology of Congenital Hypertrophy of the 
Pylorus in Relation to Treatment. Dr. Whipbam, Dr. P. 
Parkinson, Dr. Carpenter, and others: Cases. 


Commits"[cations not noticed In our present issue will receive attention 
in our next. 


It tVunl (Oiiinr for % rnsitiitg dtllfcfi. 

OPERATIONS. 

vouo.v,.^, metropolitan HOSPITALS. 

m London (2 P.M.), St. Bartholomew’s (1.30 p.m.), St 

Thomas s (J 30 p.m.), St. George's (2 p.m.). St. Mary's (2.30 p.xr.)' 
Middlesex (1,30 p.m.), Westminster (2 p.m.), Chelsea' (2 pm) 
Samaritan (Gynaecological, by Physicians, 2 p.m.), Solio-simare 
' c ><y Orthopedic (4 P.M.), Gt. Northern Central (2.30 KM.), 
West London (2 30 P.M.), London Throat (9.30 a.m.). Royal Free 
SLlMg&AS *'“■>• 0h " d "»- ««- Ormond-strect (3 

TUESDAY (Hth).— London (2 p.m.), fit. Bartholomew’s (1.30 p w ) St. 
Thomas s (3.30 p.m.), Guy's (1.30 P.M.), Middlesex (1.30 p.m.). West - 
( L p '£'>- West London <2.30 p.m.), University Coll“ge 
/O 70 %I ' ' , S (( ® el > r K es (1 P.M.), St. Mary's (1 P.M.), St. Mark s 
tQ3n '/'(A C S nc<,r pm), Metropolitan (2.30 p.m.), Loudon Throat 
(9.30 a.m.) Samaritan (9.30 a.m. and 2.30 p.m.), Throat, Golden- 
square (9.30 a m.), Soho square (2 p.m.), Chelsea (2 p.m.), Central 

!? > ? d u I1 n T mh at i * n ' 1 om ar (2 Children, Gt. Ormond-street 

(2 P.M , Ophthalmic, 2.15 p.m.), Tottenham (2.30 p.m.). 

WEDNESDAY ilSthi.—St. Bartholomew’s (1.30p w.) UniversitvCotleire 
;2 p.m.) Royal Free (2 p.m.). Middle** (L30 p.m ” ChS-ing Cras! 
(3 p.m.), St. Thomass (2 p.m.), London (2 r.M.), Kinir's Colleire 
(2 P M.), St. Georges (Ophthalmic, 1 p.m.), St. Mary a (2 pji*) 
National Orthopedic 110 a.m.), St. Peter's (2 p.m." Samaritan 
<9.30 a.m. and 2 30 p.m.) Gt. Northern Central (230 p.m.), West¬ 
minster (2 P.M.), Metropolitan (2.30 P.M.), London Throat (9 30 "w ) 
Cancer (2 p m.). Throat Golden-square (9.30 a.m.), Guy's , 130 tZt 
Ro>aI Ear (2 PM.), Royal Orthopaedic (3 p.m.), Children Gt 
(9 3 ° A M '’ Denta1, 2 Tottenham (Ophthalmic] 

THURSDAY (16th\— St. Bartholomew's (1.30 p.m.), St Thomas's 
(3.39 p.m ) University College (2 p.m.), Charing Cross (3 p.m St 
Georges (1 p.m ) London (2 p.m.), King's College (2p.m.). Middlesex 
(1.30 P.M.). bt. Mary s (2.30 p.m.). Soho-squaro (2 p.m.), North-West 
JUmdon 2 P.M ), Gt. Northern Central (Gynecological, 2.3*) p.m.\ 
Metropolitan (2.30 p.m.). London Throat (9.30 a m. ). Samaritan 
(9.30 a.m. and 2.30 p.m.), Throat, Golden-square (9.30 a.iL), Guy's 
(1.301 p.m,), Royal Orthoprrdic (9 a.m.), Royal Ear (2 p.m / Children 
Gt. Ormond-street (2.30 p.m,), Tottenham (Gynaecological,’ 2.30 p.m.)’ 


/ 


LECTURES, ADDRESSES, DEMONSTRATIONS, &c. 

MEDICAL GRADUATES’ COLLEGE AND POLYCLINIC, 22. 
Chenies-street, W.C. 

Monday. — 4 p.m.. Dr. H. G. Adamson: Clinique (Skin). 

5.15 p.m. , Lecture : Mr. A. Carleas:—Some Internal Derange¬ 
ments of the Knee-joint. 

Tuesday.—4 p.m.. Dr. O. O. Hawthorne: Clinique (Medical). 

5.15 p.m., Lecture:—Dr. T. C. Stevens: The Diagnosis and 
Treatment of Acute Abdominal Conditions originating in the 
Genital OrganB. 

Wednesday.— 4 p.m., Mr. P. Daniel : Clinique (Surgical). 

5.15 p.m.. LectureDr. C. Mercier: Functional Disease and 
its Treatment. 

Thursday.—4 p.m., Mr. Hutchinson: Clinique (Surgical). 

5.15 p.m., Lecture :—Sir Alraroth Wright: borne Points in 
connexion with Therapeutic Inoculation. 

Friday.— 4 p.m., Mr. B. Harman : Clinique (Eye). 
POST-GRADUATE COLLEGE, West London Hospital, Hammersmith 
road. VV. 

Monday.— 12 noon: Lecture;—Dr. Low: Pathological. 2 p.m., 
Medical and Surgical Clinics. X Rays. Mr. Dunn : Diseases 
of tho Eye. 2.30 p.m.. Operations. 5 p.m., Lecture:—Dr. 
Saunders : Clinical, with cases. 

Tuesday.— 10 a.m., Dr. Moullin : Gynecological Operations. 
12 noon: Lecture:—Dr. Pritchard: Medical. 2 p.m., .Medical 
and Surgical Clinics. X Rays. l)r. Ball: Diseases of the 
Throat, Nose, and Ear. 2.30 p.m.. Operations. Dr. Abraham: 
Diseases of the Skin. 5 p.m., Lecture :—Dr. Low : Filariasis. 
Wednesday.— 10 a.m., Dr. Ball : Diseases of the Nose, Throat, and 
Ear. Dr. Saunders : Diseases of Children. 2 p.m.. Medical and 
Surgical Clinics. Dr. K. Scott: Diseases of the Eye. X Rays. 
2.30 p.m., Operations. 5p.m., Lecture:—Dr. Beddard: Practical 
Medicine. 

Thursday.— 12 noon, Lecture:—Dr. Pritchard: Medical. 2 p.m.. 
Medical and Surgical Clinics. X Rays. Mr. Dunn : Diseases 
of the Eye. 2.30 p.m.. Operations. 5 p.m., Lecture:—Mr. 
Baldwin: Practical Surgery. 

Friday. —10 a.m., Dr. M. Moullin : Gynaecological Operations. 

2 P.M., Medical and Surgical Clinics. X Raya. Dr. Ball: 
Diseases of the Throat, Nose, aud Ear. 2.30 p.m.. Operations. 
I)r. Abraham : Diseases of the Skin. 5 p.m., Lecture:—Dr. K. 
Scott: The Prescribing of Spectacles. 

Saturday.—10 a.m., Dr. Ball: Diseases of the Throat. Nose, and 
Ear. 2 p.m., Medical and Surgical Clinics. X Rays. Dr. K* 
Scott: Diseases of the Eye. 2.30 p.m., Operations. 



The Lancet,] 


DIARY.—EDITORIAL NOTIOES.—MANAGER’S NOTICES, 


[Jan. 11, 1908. 141 


NORTH-BAST LONDON POST-GRADUATE COLLEGE, Prince of 
Wales’s General Hospital, Tottenham, N. 

Monday.— Cliniquea:— 10 a.m., Surgical Out-patient (Mr. H- 
Evans). 2.30 p.m., Medical Out-patient (Dr. T. R. Whipham): 
Throat, Nose, and Ear (Mr. H. W. Carson); X Ray (Dr. A. H. 
Pirie). 4.30 p.m., Medical In-patient (Dr. A. J. Whiting). 

Tuesday.— Clinique:—10.30 a.m.. Medical Ont-patfent (Dr. A. G. 
Auld). 2.30 p.m.. Surgical Operations (Mr. Carson). Cliniques: — 
Surgical Out-patient (Mr. Edmunds); Gynecological (Dr. A. E. 
Giles). 4.30 p.m.. Lecture:—Dr. M. Leslie: Dropsy, its Sig¬ 
nificance and Treatment. 

Wednesday.— Cliniques: — 2.30 pm.. Medical Out-patient (Dr. 
Whipham); Dermatological (Dr. G. N. Meachen); Ophthalmo- 
logical (Mr. R. P. Crooks). 

Thursday.—2.30 p.m., Gynecological Operations. (Dr. Giles). 
Cliniques:—Medical Out-patient (Dr. Whiting); Surgical Out¬ 
patient (Mr. Carson); X Ray (Dr. Pirie). 3 p.m.. Medical 
In-patient (Dr. G. P. Chappel). 4,30 p m.. Lecture-Demonstra¬ 
tion:—Dr. G. N. Meachen: Selected Skin Cases. 

Friday.— 10 a.m., Clinique:—Surgical Out-patient (Mr. H. Evans). 
2.30 p.m., Surgical Operations (Mr. Edmunds). Cliniques: — 
Medical Out patient (Dr. Auld); Eye (Mr. Brooks). 3 p.m., 
Medical In-patient (Dr. M. Leslie). 

LONDON SCHOOL OF CLINICAL MEDICINE, Dreadnought 
Hospital, Greenwich. 

Wednesday.— 2.15 p.m., Dr. F. ITaylor: Medicine. 2.30 p.m., 
Operations. 3.30 p.m., Mr. Cargill; Ophthalmology. Out¬ 
patient Demonstrations :—10 a.m., Surgical and Medical, 
11 a.m., Eye. 

Thursday.— 2.15 P.M., Dr. G. Rankin : Medicine. 2.30 p.m., Opera¬ 
tions. 3.15 p.m., Sir W. Bennett : Surgery. 4 p.m., Mr. M. 
Davidson : Radiography. Out-patient, Demonstrations 
10 a.m., Surgical and Medical. 12 noon, Ear and Throat. 

Friday.— 2.15 p.m.. Dr. R. Bradford: Medicine. 2.30 p.m.. 
Operations. 3.15 P.M., Mr. McGavin: Surgery. Out-patient 
Demonstrations:—10 a.m., Surgical and Medical. 12 noon. 
Skin. 

Saturday. —2.30 p.m., Operations. Out-patient Demonstrations ;— 
10 a.m., Surgical and Medical. 11 a.m., Eye. 

GREAT NORTHERN CENTRAL HOSPITAL, HoIIoway-road, N. 

Friday —Lecture:—Dr. C. H. Wilcox -. Exophthalmic Goitre. 

ROYAL INSTITUTION OF GREAT BRITAIN, Albemarle street, 
Piccadilly, W. 

Tukspay. —3 p.m. , Dr. A. A. Gray : The Internal Ear of Different 
Animals. 

Friday.— 9 p.m., Prof. T. E. Thorpe: The Centenary of Davy’s 
Discovery of the Metals of the Alkalis. 

NATIONAL HOSPITAL FOR THE PARALYSED AND EPILEPTIC, 
t^ueen-square, Bloomsbury, W.C. 

Tuesday.— 3.30 p.m.. Lecture:—Dr. Beevor: Arterial Supply to 
the Human Brain, with Demonstration* of Injected Specimens. 

Friday.— 3.30 p.m., Lecture:—Dr. Beevor: Hemiplegia. 

HOSPITAL FOR SICK CHILDREN, Great Ormond-street. W.C. 

Thursday.—4 p.m.. Lecture:— Mr. W. W. Jamca: Importance of 
the Care of the Teeth iu Childhood. 

ST. JOHN’S HOSPITAL FOR DISEASES OF THE SKIN, 
Leicester-square, W.C. 

Thursday.— 8 p.m.. Lecture:—Dr. M. Dockrell : Bullous and 
Vesicular Eruptions: V., Herpes ; VI., Zo6ter; VII., Dermatitis 
Herpetiformis. 


EDITORIAL NOTICES. 

It is most important that communications relating to the 
Editorial business of The Lancet should be addressed 
exclusively “To the Editor,” and not in any case to any 
gentleman who may be supposed to be connected with the 
Editorial staff. It is urgently necessary that attention should 
be given to this notice. _ 

It is especially requested that early intelligence of local events 
having a medical interest , or which it is desirable to bring 
under the notice of the profession, may be sent direct to 
this office. 

Lectures, original articles, and reports should be written on 
one side, of the paper only, and when accompanied 

BY BLOCKS IT 13 REQUESTED THAT THE NAME OF THE 
AUTHOR, AND IP POSSIBLE OP THE ARTICLE, SHOULD 
BE WRITTEX ON THE BLOCKS TO FACILITATE IDENTI¬ 
FICATION. 

Letters, whether intended for insertion or for private informa¬ 
tion, must be authenticated by the names and addresses of 
their writers—not necessarily for publication, 
cannot prescribe or recommend practitioners. 

Local papers containing reports or turns paragraphs should be 
marked and addressed “ To the Sub-Editor." 

Letters relating to the publication, sale and advertising 
departments of The Lancet should be addressed "To the 
Manager." 

We cannot undertake to return MSS. not used. 


MANAGER’S NOTICES. 

THE INDEX TO THE LANCET. 

The Index and Title-page to Vol. II. of 1907, which was 
completed with the issue of Dec. 28tb, were given in 
The Lancet of Jan. 4th, 1908. 

VOLUMES AND CASES. 

Volumes for the second half of the year 1907 are now 
ready. Bound in cloth, gilt lettered, price 18s., carriage 
extra. 

Cases for binding the half year's numbers are also ready. 
Cloth, gilt lettered, price 2»., by post Is. 3d. 

To be obtained on application to the Manager, accompanied 
by remittance. _ 

TO SUBSCRIBERS. 

Will Subscribers please note that only those subscriptions 
which are sent direct to the Proprietors of The Lancet at 
their Offices, 423, Strand, London, W.C., are dealt with by 
them I Subscriptions paid to London or to local newsagents 
(with none of whom have the Proprietors any connexion what¬ 
ever) do not reach The Lancet Offices, and consequently 
inquiries concerning missing copies, &c., should be sent to 
the Agent to whom the subscription is paid, and not to 
The Lancet Offices. 

Subscribers, by sending their snbscriptions direct to 
The Lancet Offices, will insure regularity in the despatch 
of their Journals and an earlier delivery than the majority 
of Agents are able to effect. 

The Colonial and Foreign Edition (printed on thin 
paper) is published in time to catch the weekly Friday mails 
to all parts of the world. 

The rates of subscriptions, post free, either from 
The Lancet Offices or from Agents, are :— 

For vbb Unit™ Kingdom. 1 To the Colonies aki> Abroad. 

One Year . £1 12 6 i One Year . . £1 14 8 

Six Months. 0 16 3 1 Six Months. 0 17 4 

Three Mouths . 0 8 2 | Three Months . 0 8 8 

Subscriptions (which may commence at any time) are 
payable in advance. Cheques and Post Office Orflers (crossed 
“London and Westminster Bank, Westminster Branch”) 
should be made payable to the Manager, Mr. Charles Good, 
The Lancet Offices, 423, Strand, London, W.C. 


TO COLONIAL AND FOREIGN SUBSCRIBERS. 

Subscribers abroad ark particularly requested 
TO note the rates of subscriptions given above. It 

has come to the knowledge of the Manager that in some 
cases higher rates are being charged, on the plea that the 
heavy weight of The Lancet necessitates additional 
postage above the ordinary rate allowed for in the terms of 
subscriptions. Any demand for increased rates, on this or on 
any other ground, should be resisted. The Proprietors of 
The Lancf.t have for many years paid, and continue to pay, 
the whole of the heavy cost of postage on overweight foreign 
issues -, and Agents are authorised to collect, and generally 
do so collect, from the Proprietors the cost of such extra 
postage. 

The Manager will be pleased to forward copies direct from 
the Offices to places abroad at the above rates, whatever be 
the weight of any of the copies so supplied. Address— 
The Manager, The Lancet Offices, 423, Strand, 
London, England. 


METEOROLOGICAL READINGS. 

(Taken daily at 8 JO a.m. by Steward's Instruments.) 

The Lancet office. Jan. 9th, 1908. 


Date. 

Barometer 
reduced to 
Sea Level 
and 32° F. 

Direc¬ 

tion 

of 

Wind. 

Rain¬ 

fall. 

Solar 

Radio 

in 

Vaeno. 

Maxi 

mum 

Temp. 

Shade. 

Min. 

Temp. 

Wot 

Bulb. 


Remark*. 

Jan. 

3 

30 28 

N.E. 


49 

34 

25 


26 

Fine 


4 

30 25 

N.E. 


48 

39 

25 


29 

Fine 


5 

30-33 

N.W. 


30 

30 

26 


26 

Foggy 


6 

3012 

8.W. 


bO 

50 

23 

39 

39 

Overcast 


7 

29 63 

8.W. 

001 

52 

hi 

3y 

48 

48 

Overcast 


8 

28 93 

N.W. 

0-95 

44 

44 

34 

37 

37 

Raining 


9 

29 62 

N. 

016 

37 

36 

35 

34 

36 

Overcast 


During the week marked copies of the following newspapers 
have been received:— Hertfordshire Mercury, Westminster Gazette, 
Tottenham and Edmonton Weekly Herald, West Sussex Gazette, 
Daily Dispatch ( Manchester ), Montreal Gazette (Canada), Dublin 
Daily Express, Canterbury Times, Dublin Keening Telegraph, 
Dundee. Advertiser, Liverpool Daily Post and Mercury. Oxford 
Review, Daily News, Rath Herald, Yorkshire Observer, Wimbledon 
Gazette, Broad Arrow, etc. 















142 The Lancet,] 


ACKNOWLEDGMENTS OF LETTERS, ETC., RECEIVED, 


[Jan. 11, 1908. 


Communications, Letters, &c., have been 
received from— 


A. —Messrs. Aked and Aked, Lond.; 
Ardath Tobacco Co., Lond., 
Manager of ; Aston Manor Edu¬ 
cation Committee. Secretary of; 
Apothecaries’ Hall of Ireland, 
Dublin, Secretary of; Messrs. 

C. Ash, Sons, and Co., Lond.; 
All India Hospital Assistants 
Association, Bangalore City, 
Secretary of; Mr. H. H. A very - 
Jones, Birkenhead ; The Animals’ 
Friend, Editor of; "A Student.” 

B. —Mr. J. P. Berridge. Malvern; 
Rev. J. O. Bevan, Chlllenden-, 
Barnsley Hall Asylum, Br^ms- 
grove. Medical Superintendent 
of; Sir John Broadbent, Bart., 
Lond.; Bootle Corporation, Clerk 
to the; Messrs. Burroughs Well¬ 
come and Co., Lond.; Dr. 

A. T. Brand, Driffield; Mr. 
F. A. Brocklmus, Lond.; Mr. 
Moni Mohan Bos, Balrampur; 
Mr. B. Baker, Birmingham; 
Bury Infirmary, Secretary of ; 
Messrs. J. B. Brooks and Co., 
Birmingham ; Messrs. J. Beal 
and Son, Brighton; Brecon and 
Radnor Asylum, Talgarth. Clerk 
to the; Messrs. A. Burbidge and 
Co., Lond.; Berry Wood Asylum, 
Northampton, Clerk to the; 
Mr. C. Bircball, Liverpool; 
Messrs. Bedford and Oo., Lond.; 
Mr. S. H. Benson. Lond.; Messrs. 
Baker Bros.. Lond.; Monsieur E. 
Bougault, Paris; Dr. T. If. Brad¬ 
shaw, Liverpool; Mr. T. B. 
Barratt, Lond.; Dr. R. M. 
Buchanan. Glasgow. 

O. —Dr. S. G. Corner, Coggeshall; 
Carnarvonshire, &c., Inhrmary, 
Bangor, Secretary of; Messrs. 
Cornish Bros, and Co., Birming¬ 
ham ; Dr. K. J. Collie, Lond.; 
Messrs. Collyer and Davis, Lond.; 
Mr. Frederick W. Colllngwood, 
Lond.; Miss Channer, Lond.; 
Cheltenham Corporation, Clerk 
to the; Dr. J. Burton Cleland, 
Perth. 

D.—Dr. A. F. Dixon, Dublin; 
Dr. Clement Dukes, Rugby; 
Devon and Cornwall Sanatorium 
for Consumptives, Hon. Secre¬ 
tary of; Major C. Donovan, 

I. M.S., Nungumbakam, India; 
Messrs. Down Bros., Lond.; 
Dr. G. G. Davidson, Lond.; 
Disgusted. 

B. —Equipoise Couch Co., Ashford ; 
Messrs. Evans, Sons, Leseher 
and Webb, Lond.; Mr. F. Eve, 
Lond. 

P. —Dr. R. H. Fox, Lond.; Mr. H. 
Frowde, Lond.; ** Fens tan ton,’ 
Streatham Hill, Medical Super¬ 
intendent of; Mr. John R. Fryar, 
Canterbury; Dr. Hamilton S. 
Faber, Marseilles; Dr. F. R. 
Falrbank, Dorking. 

Q. -Mr. II. J. Gater, Crayford; 
Dr. H. J. Godlee, Whitchurch; 
Mr. Clement A. Graham, Loud.; 
'* Guernsey Gossip ” 

H.—Dr. A. R. Hird, Dublin; 
Mr. R. D. Handcock, Lond.; 
Heatley Patent Coramode Bed 
Co., Edinburgh; H. H. T.; Hull 
Royal Infirmary, Secretary of; 
Messrs. Hirschfeld Bros., Lond.; 
Professor J. B. Hetiier, Leeds; 
Mr. E. C. Hort, Lond ; Dr. K. H. 
Humphris, Ilkley in-Wharfedale; 
Hospital for Women and Chil¬ 
dren, Leeds, Secretary of; 
Hygienic Co., Lond.; Mr. L. G. 
Hill, Lond. 

L—Messrs. Isaacs and Co., Lond.; 
Messrs. Ingram and Rovle, Lond. 

J. —Sir Alfred Jones, Liverpool; 
Mr. G. M. Jones, Alton; J. F.; 

J. K. F.; J. L. B.: J. R. H.; Mr. 

E. B. Jones, Lond. 

K. —Mr. S. Karger, Berlin; Messrs. 

R. A. Knight and Co., Lond.; 
Kent County Asylum, Maid¬ 
stone, Clerk to the; Mr. Kiindig, 
Geneva. 


L. —Mr. John M. Lyons, Edin¬ 
burgh ; Mr. V. Langston, Lond.; 
Messrs. H. Langston and Co., 
Lond.; L. I. W.; Leeds Public 

j Dispensary, Secretary of ; London 
and Paris Exchange, Managing 
Director of; Mr. L. J. Levi, 
Lond.; Messrs. Luzac and Co., 
Lond.; Dr. Frederick Langmead, 
Lond. 

M. — Mr. A. E. Moore, Paignton; 
Midwives Association, Manches¬ 
ter, Secretaries of; Sir Charles 
R. McGregor, Bart., Lond.; 
Marmite Food Extract Co., 
Lond., Managing Director of; 
Dr. A. E. May land, Glasgow; 
Mr. K. V. G. Menon, Malabar. 
India; Mr. J. Melvin, Partick; 
Messrs. Mackie and Co., War¬ 
rington ; Messrs. Mather and 
Crowther, Lond.; Messrs. E. E. 
Martin and Co., Lond.; Messrs. 
May, Roberts and Co., Lond.; 
Monkwearmouth, &c., Hospital, 

j Sunderland, Secretary of; Dr. J. 

1 Miller, Glasgow ; Mr. E. J. R. 
MacMahon, Cheltenham. 

N. — Rev. D. Nickerson, Harling 
ton; Dr. J. B. Nias, Lond.; 
Nurse James, Milford House; 
Mr. J. C. Needes, Lond.; Mr. 
H. Needes, Lond. 

O. —Baron de Oliveira, Lond. 

P. —Dr. J. King Patrick, Glasgow; 

| Poplar Guardians, Clerk to the; 

Messrs. C. Pool and Co., Lond.; 
P. S. Syndicate. Lond., Secre¬ 
tary of; Dr. Pollard, Lond.; 
Dr. F. S. Pitt-Taylor, Rock 
Ferry; Messrs. Peacock and 
Hadley, Lond.; Messrs. Perreaux 
and Co., Lond; Messrs. Poulides 
a d Co.. Lond.: Mr. G. A. Par- 
i kinson, Lond.; Mr. C. F. Parsons, 
Lond.; Dr. M. S. Paterson, 
Frimley. 

R.—Mr. Henry Bundle, Southeea; 
Mr. F. W. Forbes Ross, Lond.; 
Dr. W. Ford Robertson, Edin¬ 
burgh ; Royal Mail Steam Packet 
Co., Lond., Secretary of; Messrs. 
Rea veil Bros, and Co., Almvick; 
Mr. H. P. Rees. Lond.; Royal 
Iustitute of Public Health, 
Lond.; Dr. G. B. Richmond, 
Lond.; Dr. A. Reyn, Copen¬ 
hagen ; Messrs. Reynolds and 
Branson, Leeds. 

, B.—Dr. F. E. Shipway, Lond.; 

Dr. Agnes B. Sloan, Gujrat, 

1 India; Dr. W. Stewart, Hirst; 

Mr. A. Stenhouee, Glasgow; 
j Society Anonyme des Uaux 
Miii'-rales, K\ ian. Manager of ; 
Seltzogene Patent Charges Co.. 
St. Helen’s; Messrs. Tweed 
Stephen and Co, Skegness ; 
Mr. R. B. Sargeant, Lond.; 
Somerset County Council, We8- 
ton-super Mare, Secretary of; 
Scholastic, Clerical, &c.. Associa¬ 
tion, Lond ; Star Engineering 
Co., Wolverhampton; Messrs. 
Savory and Moore, Lond.; Messrs. 
Scott and Bowne, Lond.; Mr. 
G. F. Stone, Bristol. 

T.—Dr. F. M. Turner, Lond.; 
Mr. A. Trewby, Lond.; Mr. 
James Turle. Bury St.Bdmund's ; 
Tiverton Infirmary, Hon. Secre¬ 
tary of; Dr. P. Thompson, 
Lond.; Dr. James Taylor, Lond. 

V. — Messrs. Virgil, Boys, and Co., 
Lond.; Messrs. J. *W. Vickers 
and Co., Lond.; Virogen, Lond., 
Secretary of. 

W. — Dr. J. K. Watson, West By¬ 
fleet; Messrs. A. Wulfing and 
Co, Lond.; Messrs. Werner, 
Pfleiderer, and Perkins, Peter¬ 
borough, Managing Director of; 
Mr. Faulder White, Coventry; 
Mr.J. Galloway Woir, M.P.,Lond.; 
Messrs. H. Wilson and Son, 
Lond.; Miss C. Wilkinson, 
Bournemouth. 

Y.-Dr. K. A. Yeld, Lond. 


Letters, each with enclosure, are also 
acknowledged from— 

A,— Dr. T. Dyke Adand, Lond.; I Parsons, Lond.; Aberystwyth 
Messrs. Allen and Hanburys, Infirmary, Secretary of; A. A.; 
Lond.; Messrs. Ashton and | Mr. Oliver Ackey, Khartoum; 


Messrs. S. J. Aldridge and Co., 
Lond.; Army and Navy Male 
Nurses’ Co-operation, Lond., 
Secretary of; Apollinaris Co., 
Lond. 

B.—Sir T. Lauder Brtinton, Lond.; 
Mr. F. J. Brcakell. Preston; 
Mr. G. F. Tracy Beale, Fowey; 
Mr. J. Bland-Sutton, Lond.; 
Dr. J. C. Boyd, Lifford; Benger’s 
Food, Manchester, Secretary of; 
Messrs. Bradshaw, Brown, and 
Co., Lond.; Bayer Co., Lond.; 
Dr. Hubert Biss, Lond.; Dr. 
T. II. Boyd, Richmond, Australia; 
Mr. P. B. Bushncll, Hove; 
Mr. J. C. Beckitt, Leigh ; Mr. 
A. A. Bradbume, Southport; 
Mr. A. J. Bulger, Wolverhamp¬ 
ton ; Dr. J. Barras. Go van; Miss 
M. Bohm, Croydon; Bradford 
Guardians, Clerk to the; Mr. W. 
Bubb, Cheltenham. 

0.—Mr. J. Cropper, Chepstow; 
Dr. R. A. Campbell, Gloucester; 
Mr. B. M. Coo mar, Calcutta; 
Mr. H. A. Collins, Croydon; 
Messrs. J. W. Cooko and Co., 
Lond.; Calcutta Medical Club, 
India, Hon. Secretary of ;C. H. O.; 
Dr. A. H. Copeman, Brighton ; 
Messrs. Crossley and Co., Lond.; 
Mr. J. W. Culmer, Epsom 
Mr. K. P. Court. Horsmonden ; 
Canada, Office of tile High Com¬ 
missioner, Lond., Secretary of; 
Sir T. F. Chavasse, Birmingham ; 
Mr. Z. A. Campbell, lx>nd.; 
Mr. G. C. Cope. Lond.; Messrs. 
T. Christy and Co., Lond.; 
Messrs. Clarke, Son, and Platt, 
Lond.; C. F. F; C. W. T.; 
Dr. L. Crossley. Benenden; 
Mr. F. W. Clarke, Chorlton-cum- 
Ilardy; C. W. M. ; C W. 

D.— Dr. D. L. Davies, Wisbech; 
Messrs. Davis and Go., Kpping; 
Dr. W. Duff, Wishaw; Messrs. 
J. Defries and Son. Lond.; 
Mr. W. C. Dickson, Kingskers- 
well; Dr. H. Davies, Lond.; 
Mr. G. J. Dowse, Lond.; Messrs. 
W. Duff and Co., Lond.; Derby¬ 
shire Royal Infirmary, Secretary 
of; Dr. L. Durno, Lond.; D. F.; 
Messrs. Dowie and Marshall, 
Lond. 

B. - Dr. H. Ebbinghaus, Dortmund; 
Mr. H. Kccles, Bishop's Stort- 
ford; K. C. IE. W. D.; E. B.B.; 
Electrical, Irlams o’-th’-Height; 
E. R. I. 

F.— Dr. J. K. Frost, Hereford; 
Dr. G. W. Fitzgerald, Man¬ 
chester ; F. L. K. ; Messrs. 
Festersen and Co., Basic; 
Mr. A. L. Flemming, Clifton. 

Q.—Dr. G. F. S. Genge, Wilton; 
Dr. G. C. Garratt , Chichester; 
Mr. H. M W. Gray, Aberdeen; 
Messrs. Grindlay and Co., Lond.; 
Messrs. W. and A. Gilbey, Lond.; 
StafT-Surgeon H. W. Gordon- 
Green, R.N., Sheerness; Mr. B. C. 
Ghosh, Midnapore, India; G. D.; 
Mr. J. Griffiths, Cambridge; 
General Apothecaries Co , Lond., 
Secretary of; Miss Gardner, 
Paioswick; Messrs. R. W. Greeff 
and Co., Lond. 

H. —Mr. J. B. Hall, Bradford; 
Mrs. Spencer Howard, Lond.; 
Mr. H. Hilliard, Lond.; II. S.; 
Colonel E. A. W. Hall. Lond.; 
Mr. P. E. Hoyland, Rotherham; 
Mr. G. G. Hamilton, Liverpool; 
Holloway Sanatorium, Virginia 
Water, Clerk to the; Messrs. 
Hanna and Neale. Dublin; 
Mr. F. Hinde, Sawbridgeworth; 
Dr. R. A. Hayes, Dublin ; Mr. 
W. A. Higgs, Castle Combe; 
Fleet-Surgeon W. K. Home, R.N., 
Portsmouth; Mr. F. A. Hep- 
worth, Dewsbury; Sir C. 
Holman, Lond.; H. A. C., 
Thornton Heath; Dr. C. H. 
Harvey, Savanna-Ia-Mar; Mr. E. 
Haag,'Lucerne; Haydock Lodge, 
Newton-le Willows. 

I. —Dr. A. C. Ingle, Cambridge; 
International Plasmon, Lond. 

J. —Dr. J. D. Jenkins, Ystrad; 
J. H.: Mr. H. W. James. Barrow; 
Dr. J. H. Jones, Standford 
Dingley; J. A. C.; J. B. S.; J. M.; 
Mr. B. B. Jones, Aberystwyth; 
Mr. L. J. Jarvis. Lond. 

K. —Dr. F. H. Keith, Glasgow; 
Mr. J. H. Keys, Plymouth; 


Messrs. C. Knight and Co., Lond.; 
Dr. A. Brown Kelly, Glasgow; 
Mr. W. Kirkby, Maesteg. 

L. —Mr. H. K. Lewis, Lond.; 

Dr. H. O. Lecky. Brighton; 
Mr. S. H. Lucas. Nelson, New 
Zealand; Mr. A. Leckie, Lond.; 
Mr. 0. Lund, Newcastle-ou- 
Tyne; Dr. A. P. Luff, Lond.; 
Mr. S. C. Lawrence, Edmonton; 
Mr. S. G. Loogworth, Melton; 
Mr. C. B. Lockwood, Lond.; 
Messrs. Lindsay, Howe, and Go., 
Edinburgh; Mr. W. W. Linney, 
West Croydon; L. J. W. 

M. —Dr. W. H. Millar, Lond.; 

Messrs. Mitchell and Co., Lond.; 
Mr. J. Murray, Lond.; Captain 
J H. Murray, I.M.S., Port 
Blair; Dr. Reginald Miller, Lond.; 
Mr. G. F. W. Meadows. Otley; 
Dr. F. C. Madden, Cairo; Dr. 

C. B. P. Mitchell, Malvern; 
Dr. It. H. Morison. Toorak ; 
Dr. Felix Meyer, Melbourne; 
Mr. J. M. Mangan, Ennis; 
Mr. B. J. Mayne, Carn Brea; 
Dr. J. M. Morris, Neath; Mr. 
J. E May, Lond.; M. M. M.; 
Mr. T. B. Marshall, Birmingham ; 
Dr. P. Matthews, Barras ford; 
Mr. G. B. McKoan, Ledbury; 
Dr. McC. 

N. —Mr. J. B. Neal, Lond.; 

Messrs. Nicolay and Co., Lond.; 
Dr. R. G. Northwanger, New- 
castle-on-Tyne; Mrs. N.; Norfolk| 

1 and Norwich Hospital, Sec. of. 

O. —Dr. S. J. Orrnerod, Leather- 
head; Dr. H. O’Neill, Belfast; 
Dr. J. M. O'Meara, Holbeach. 

P. —Dr. J. J. Pringle, Lond.; 

Dr. A. M. Pullock, Indwe, Cape 
Colony; Peterborough Infirmary, 
Secretary of; Mr. 4. W. Power, 
Lond.; Miss B. L. Person, Lond.; 
Mr. J. E. Platt, Manchester; 
Dr. A B. Pies, Sitoebonilo, Java; * 
Mr. P. Phillips. Davos Plat/.; 
Dr. J. A. W. Pereira, Exeter; 
Messrs. Parke, Davis, and Co., 
Lond.; Dr. H. A. Perkins, Tun¬ 
bridge Wells. 

R.— Dr. J. W. Rob, Weybridge ; 
Dr. G. Ranking, Lond.; Dr. 

J. M. Handle, Ru&n Minor; 
Mr. P. H. Ross, Nairobi, British 
East Africa: Dr. A. Miguel 
y Komon, Valladolid, Spain; 
Dr. G. J. Robertson, Oldham; 
Messrs. Richardson and Co., 
Lond.; Mr. T. Rose, Lond.; Mr. 
P. Kuat, Marseilles. 

8,—Dr. F. F. Schacht, Lend.; 
Mrs. Stallybrass, New Brighton ; 
Mr. J. C. Sale, Skegness; Dr. 
A. M. Smith, Oakland. U.S.A.; 
Messrs. G. Street and Co., Lond.; 
Dr. B. Schloesser, Nice; Major 

C. G. Spencer, R.A.M.C., Kew 
Gardens-, Dr. A. Somerville, 

1 Leek; Dr. S. P. Sanchez-Barco, 
Alcoba^a, Portugal; Mr. R. H. 
Jocelyn Swan, Lond.; Messrs. 
Spiers and Pond, Lond.; Dr. L. 
i Sam bon, Lond.; Mr. D. Stewart, 

, Glasgow; Dr. W. H. Sturge, 
Hoddesdon; Stockport Corpora¬ 
tion, Treasurer to the; Messrs. 
Speyer and Peters, Berlin ; Dr. 
E. Smyth, Lond. 

T.— Dr. J. L. Timmins, Lond.; 
Mr. W. Trotter, Lond.; Miss 
Alice Taylor, Worcester; Mr. J. 
Thin, Edinburgh. 

V. — Dr. Anthony Vost, Alva ; 
Dr. J. F. de Villiers. Vrede, 
Orange River Colony; V. S. 

W. — Dr. A. F. Wilson, Lond.; 
Mr. J. R. Woodcock, Bacton; 
Dr. V. Wanostrocht, Kingston 
Hill; Surgeon L. Warren, K.N., 
Portsmouth; Messrs. Winkworth 
and Co., Lond.; Wolverhampton 
General Hospital, Secretary of; 
Mr. W. Webster. King’s Lynn; 
Dr. W. H. O. Woods, Swansea; 
Mr. Owen Williams, Burry Port ; 
W. N. H.; Western Australia, 
Lond., Agent-General for ; Miss 
W. ; Mr. J. H. Wolfe, Lond.; 
Dr. O. K. Williamson, Lond.; 
Warneford Hospital, Learning- 
ton. Secretary of; Messrs. 
J. K. Wilson and Co., Glasgow; 
Mr F. H. Wagstaffe, Croydon; 
Dr. F. G. Wallace, Lond.; Mr. J. 
Wanamaker Paris; Mr. T. F. 
Wyse, Dalkey; Mr. J. J. Wadde- 
low, Whittiesea. 






THE LANCET, January 18, 1908. 


% Clinical lecture 

ON 

ERYTHRiEMIA 

(POLYCYTH7EMIA WITH CYANOSIS, MALADIE DE 
VAQUEZ). 

Delivered in the Radcliffe Infirmary , Oxford , on You. 28th, 
1907, 

By WILLIAM OSLER, M.D., F.R.S., 

REOrCS PROFESSOR OF MKDICIFE, DXIV1 RSITX OF OXFORD. 


Gentlemen, —It is interesting to follow the stages in the 
recognition of a new disease. Very rarely does it happen that 
at all points the description is so complete as at once to gain 
universal acceptance. Albuminous urine and its association 
with dropsy had been noted before Bright studied the changes 
in the kidneys and drew with a master hand the picture of 
the disease which we now know so well. Complete as was 
Addison’s monograph it took a good many years before we 
recognised fully the relation of the suprarenal bodies to the 
disease that now bears his name. The original description 
of simultaneous disease of lymph glands and spleen by the 
distinguished old Quaker physician, Hodgkin, had not 
attracted any more attention than had his equally remark¬ 
able contribution on insufficiency of the aortic valves (which 
antedated by several years Corrigan’s account), until Wilks, 
the “ grand old man ” to day of British medicine, drew 
attention to the condition. And so it was with myxeedema, 
-which was well known for years in England before our 
continental brethren recognised its existence. First a case 
here and there is reported as something unusual; in a year 
or two someone collects them and emphasises the clinical 
features and perhaps names the disease. Then in rapid suc¬ 
cession new cases are reported and we are surprised to find 
that it is by no means uncommon. This has been the history 
of a very remarkable malady of which the patient before you 
is the subject. 

In 1892 Vaquez, a Paris physician, well known for his 
researches on the pathology of the blood, described a condi¬ 
tion of hyperglobulism with cyanosis, which he believed to be 
due to an over-activity of the blood-forming organs. Then 
in 1899 Cabot of Boston reported a case and a second in the 
-following year, and McKeen another Boston oase. In report¬ 
ing a fifth case Saundby and Russell seem to have been the 
•first to realise that the condition was a “definite clinical 
entity and one which was new to medical science.” In 1901 
I had become greatly interested in the question, having 
under observation a case of chronic cyanosis with a very 
high blood count. Then in quick succession I saw two 
other cases and these formed the basis of a paper 1 in which 
I brought forward the available evidence in favour of the 
view that we bad to deal here with a new disease. In the 
following year I returned to the question and was able to 
summarise 17 cases. 2 Within the past three years the litera¬ 
ture on the subject has grown apace. From almost every 
country cases have been reported. The Index Medicus for 
1906 has 12 references to papers, while in the numbers 
for this year to date there are 17. Papers of gTeat value 
have been published by Turk of Vienna, Weintraud of Wies¬ 
baden, Bence of Budapest, Senator of Berlin, Parkes Weber, 
Robert Hutchison, Watson and Saundby in this country, 
and by Engelback and Brown and by Howard Anders in the 
United States. There are now at least 70 cases on record, 
which indicates that we are dealing with a fairly common 
affection and one which, like myxeedema, only requires to 
be known to be recognised. 

The patient before you illustrates in a typical way the 
features of the disease. -*We are much indebted to Dr. E. 
Morton, of Woodstock, who brought her in and to Dr. W. P. 
Richardson of Blisworth, Northampton, who has arranged 
for her to return for a more careful study. A married 
woman, aged 54 years, with five children, she has had all 
her life exceedingly good health. For the past three years 
Bhe has not been so well, suffering with pains in the hands 
and feet, which a medical man whom she consulted called 
neuritis. She has been able to attend to her work, but of late 
years has lost somewhat in strength. She has not been short 


1 American Journal of the Medical Sciences, 1903. 

2 Brit. Med. Jour., Jan. 16th, 1904. 

Ho. 4403. 


of breath and she has not had headaches. About a year ago 
she noticed that the abdomen was swollen. For some time 
Bhe has known that her face has changed in colour. It is 
darker and in the cold becomes intensely blue. The hands 
and feet, too, have become blue, particularly the feet and 
legs after she has been walking about, and they are at times 
painful. Altogether, the history presents very few points of 
moment and the condition has come on insidiously in a very 
healthy woman. When admitted the cyanosis was extremely 
marked and the house physician. Dr. J. W. S. Macfie, an old 
pupil of Dr. G. A. Gibson of Edinburgh, and who naturally 
knows all about cyanosis, immediately made a blood count 
and had the diagnosis of the new disease ready for us. 

The patient’s appearance at once attracts attention. The 
face has a dusky hue and the lips a purple tint; she rests 
quietly without dyspnoea and with the head low. Over the 
cheeks and nose there are numerous small distended venules. 
The conjunctiva; are not suffused ; the tongue is of a deep, 
purplish-red colour. The hands and feet are very much 
cyanosed, though not so deeply as they were on admission. 
She tells us that after very slight exposure to cold they 
become livid. One remarkable circumstance is the degree 
of vaso-motor instability. If the hand of a healthy person is 
held down for a little while there is a slight and perceptible 
change in colour, but it does not become actually cyanosed 
unless, perhaps, in cold weather. Usually, however, a 
marked difference in colour is noticed and when held up 
above the head the skin gradually becomes pale again. You 
can see the change, for instance, in a normal hand in a 
very few seconds. When this patient holds the hand down 
within 30 seconds the veins become turgid and full and the 
skin of a deep-blue colour ; held up the blood rapidly 
leaves the hand and it becomes pale. The effect of posture 
is still more striking in the feet. If she sits on the edge of 
the bed for a few minutes the legs, as high as the knees, 
become purple. One can almost see the blood drop into 
them. When she returns to bed and the leg is held up the 
blood very quickly runs out and the skin becomes pale. Over 
the general surface of the body there is a dusky tint which is 
best seen by pressing the hand firmly upon the skin of the 
abdomen or the back. The ansemic impression remains for 
some seconds and is very slowly obliterated. Another feature 
of interest about the skin—when a series of lines are drawn 
with a sharp edge the usual reaction is hypenemic (which 
from its intensity in some conditions of the nervous system 
has been called the taohe cerihrale), the result of a vaso¬ 
dilator action. But here just the opposite takes place. 
Along the line of irritation there is a vaso-constrictor action 
in the Bmall arterioles and the lines stand out as bands of 
ansemia, in this instance of unusual width, fully four milli¬ 
metres on each side of the line. 3 

The second feature of importance relates to the abdomen, 
the skin of which is relaxed and scarred, and to the left of 
the umbilicus there is a marked prominence. On palpation 
this is easily made out to be a greatly enlarged spleen ; 
the edge is just at the navel but to the left it extends 
fully four fingers’ breadth below this level. Into the 
left flank the edge may be readily traced, where it is 
two fingers’ breadth above the anterior superior spine of 
the ilium. A notch is readily palpable and when grasped in 
the two hands the whole organ is freely moveable. The flat¬ 
ness on percussion extends as high as the eighth rib. The 
liver is not enlarged and there is nothing else of any moment 
in the abdomen. Except for the cyanosis and the dilatation of 
the superficial veins there is nothing of special moment in 
the circulatory system. The apex of the heart is tilted into 
the fourth interspace, but the organ is not enlarged. The 
sounds are clear at the apex and base and there is no special 
accentuation of the aortic second sound. The pulse is 96 and 
the blood pressure is 118. The superficial arteries are just 
palpable. There are numerous petechias scattered over the skin 
of the legs. The examination of the lungs is negative. There 
is no emphysema. The third point of special interest is in the 
examination of the blood, which flows in a large drop from 
finger or ear when pricked, and is sensibly richer in colour 
than normal and the drop is unusually viscid. A number of 
counts have been made which show the red blood corpuscles 


3 This “white line." one of the most interestlnK msnifestations of 
what S. Solis-Coben calls vaso-motor ataxia, is met with: (1) in_many 
normal persons; (2) in hysteria and neurasthenia; and (3) in conditions 
of cutaneous irritations when dermatographia may be produced, it 
may come out and persist as a white line; transient h y per re mi a may 
precede it, active hyperwmia may follow it, or occasionally factitious 
urticaria. Recent French writers have suggested it* association with 
adrenal insufficiency. 

C 


144 The Lancet,] 


PROFESSOR WILLIAM OSLER: ERYTHREMIA. 


[Jan. 18, 1908. 


to range from 9,200,000 to 9,710,000 per cubic millimetre ; 
the leucocytes are about 24,000 per cubic millimetre and the 
haemoglobin from 130 to 160. The red blood corpuscles look 
normal ; the average diameter is 7 1 5 microns. There are a 
few poikilocytes. The most striking feature is the presence 
of a number of nucleated red blood corpnscles of all forms. 

A differential count of the leucocytes show polymorphs 73 • 6 
percent., lymphocytes 18 per cent., large mononuclear forms 
3 '6, and coarsely granular eosinophiles 4 • 8 per cent. 

Dr. G. Mann has estimated for me the specific gravity of 
the blood which is 1'0755; the normal average is 1‘0777. 
He has also very kindly made a comparative estimate with 
the hematocrit of the ratio of plasma and corpuscles, which 
was the following :— 

Patient. Normal person for control. 

Ited cells.. ... 76*5 | lied cells . 48'5 

White cells . 4-85 White cells . 3'0 

Plasma . 1S*67 , Plasma . 48 '5 

Dr. G. Mann estimated that the patient bad fully 58 per cent, 
more red blood corpuscles than the normal individual. 
Miss Mabel Fitzgerald has estimated on several occasions the 
alveolar CO a by Haldane’s method and it was found to range 
from 4'13 to 4'61, just at the lower limit of normal. The 
urine looks normal. Dr. W. Ramsden of the physiological 
laboratory has made a careful study of it with the view of 
determining the presence of an excess or abnormality of the 
pigments. The specific gravity is 1016. A small quantity of 
albumin is present. There is no sugar, the pigments normal 
and cot in excess ; urea was 18 grammes for the 1000 cubic 
centimetres ; the chlorides 5 • 8 grammes. 

You must not expect to see in every case the triad of 
symptoms so well marked as in this patient. I think you 
will agree with me that we have here a condition which doeB 
cot conform to any known disease and I am in full accord 
with those who regard it as a hitherto unrecognised affection 
of the blood-making organs. We may now discuss the 
features in greater detail. 

The eytmotu, the signal symptom, which at once calls 
attention to the condition, has been present in a great 
majority of the cases. And yet it is accidental and at any 
time can be made to disappear. 1 Keep this patient for an hour 
or even less at a temperature above 80° and the cyanosis will 
change to a vivid red. The first case I saw presented 
remarkable alterations in this respect. In the hot summer 
days he was “ red as a rose” and looked bursting with blood 
and in the winter he became as blue as indigo. The colour 
of the skin in health depends on two circumstances—the 
degree of fulness of the peripheral vessels and rate of the 
circulation in them. There may be general pallor and 
apparent anosmia with a normal blood count. These pseudo- 
amemias are most interesting and deceptive. Only the other 
day I saw a young girl who at once attracted attention by 
her colour, or rather by an entire absence of colour, but when 
I remarked upon it she answered, “ Oh, I never worry about 
that, I was born pale.” The symptoms did cot suggest 
anaemia, but I was not prepared to have a report from Dr. 
A. G. Gibson that she had more than 5,000,000 of red 
blood corpuscles to the cubic millimetre. It is a matter of 
local distribution. Just the opposite condition may be 
present—the colour may be good with pronounced anaemia. 
The old writers recognised a ohloroiU rubra. A few years 
ago there was admitted to Ward E of the Johns Hopkins 
Hospital a well-built, healthy looking man, complaining of 
shortness of breath and palpitation of the heart. His colour 
was high and due, as could be seen with a lens, to fulness 
of the small venules of the skin. Even the skin of the body 
looked reddish. To our astonishment the count was 
2,000,000 of red blood corpuscles per cubic millimetre. 
We called the case anmmia rubra. It was not until the 
count sank below 1,200,000 per cubic millimetre that the 
features of anaemia became evident. 

In individuals, and indeed in nations, there are remarkable 
differences in the degree of fulness of the cutaneous vessels. 
The out-of-door life and the damp cold, plus sometimes the 
plethora-producing beer and the vaso-dilator influence of 
spirits, tend to make the exposed skin of the Englishman 
much more vascular than in his American or colonial 
relatives. Chillblain, so common in this country, is one 
expression of this extreme local congestion under the 
influence of cold. A state of permanent turgescence of the 


* When this patient was shown at the Clinical Section of the Koval 
Society of Medicine as the room got hot and doubtless in part due to 
the excitement her colour changed and the skin loot the cyanotic hue. 


capillaries and small veins of the hands and face may be 
entirely local—the feet may not be involved—and is usually 
of no moment, save in women who worry over the appear¬ 
ance and appeal to us—in vain, I fear—for help. I saw one 
rare sequel of this chronic engorgement of the vessels of the 
bands—viz., clubbing of the fingers. The man had had for 
20 years or more a red face and red beefy-looking hands—in 
the winter always blue and cold. There was no heart lesion. 
He had noticed the change in the shape of the terminal 
joints for five or six years. 

The other circumstance upon which the colour of the skin 
depends is the rate of blood flow. If now I rub vigorously 
this patient’s left hand, or place it in warm water, the 
activity of the circulation in the skin is increased, as can be 
seen at once by the rapidity with which an area of pressure 
ansemia is filled up. And with the increased rapidity of 
blood flow the colour changes from a reddish-purple to a 
bright red. In the one the blood is arterial, in the other 
venous; the change in colour is due to a rapidly produced 
change in the rate with which the blood passes through the 
capillaries of the skin. Normally the current is so rapid 
that the tint of the skin is arterial. Cyanosis results when¬ 
ever the capillaries are full and the current is slow. The 
faqtors must be combined. Conditions in which the stream 
in force and volume sinks to a minimum may be associated 
with pallor, not with cyanosis. I had once a unique expe¬ 
rience. I remember it well, as the patient was one of the 
first to apply after the opening of the Johns Hopkins Hos¬ 
pital. She had Raynaud’s disease and held up her right 
hand, the fingers of which presented a remarkable appear¬ 
ance. The little one was normal, the ring inger was as 
white and as cold as marble, the middle finger was deeply 
cyanosed (local asphyxia), while the index finger was as 
“red as a rose.” There was probably just as much 
blood in the index as in the middle finger, but In the 
one the arterial sluices were wide open, the capillaries 
distended, and the stress rapid, while in the other the 
arteries were contracted, the capillaries full, and the stream 
slow. In the dead-white ring finger there was probably more 
than contraction of the arteries and slowness of the stream— 
an angio-spasm involving all the smaller vessels, arterioles, 
capillaries, and venules. In the patient before us there may 
be two accessory factors favouring slowness of flow in the 
terminal vessels. The observations of Farkes Weber, Haldane, 
and others have shown that the whole volume of blood is 
greatly increased. In one case Haldane estimated the total 
amount to be more than double the normal. With this 
the specific gravity is higher than normal. But another 
element, the viscosity, is still more important and this has 
been shown by many observers to be greatly increased. It 
may be readily seen with the drop as it flows, for example ; 
it takes an unusually long time to spread under a covered 
glass. It would, of course, be in the capillaries that this 
increased viscosity would be effective. 

There is one other factor in inducing cyanosis upon which 
Saundby, very rightly, lays great stress—namely, the 
dilatation of the venules and the loss of tonicity in the 
peripheral veins. In this patient the cyanosis in the legs is 
a question altogether of gravity. Dependent they are blue, 
held up they become pale. As she is recumbent in bed they 
are of a dusky purplish red. We must not forget, however, 
that cyanosis is not altogether a question of stasis and 
capillary engorgement. The peculiar colour is a corpuscular 
affair depending upon the haemoglobin whether oxidised or 
reduced. There are remarkable forms of cyanosis in which 
the colour of the skin is altogether due to changes in the 
haemoglobin : the methasmoglobinsemia due to the taking 
of the coal-tar products, the enterogenous cyanosis which has 
been studied and reported by the Dutch physicians (Stokvis and 
Talma) and by Samuel West and Wood Clarke in this country, 
and the form reported by Gibson and Douglas in which coIod 
bacilli were isolated from the blood. WeBt and Clarke give 
an analysis of all the recorded cases of this idiopathic 
cyanosis, both met- and sulph-hsemoglobinsemia. It has been 
called enterogenous on the view that the change is due to 
the action of substances absorbed from the bowels. The 
tint of skin and mucous membranes of both toxic and entero¬ 
genous forms differs from that of ordinary cyanosis and may 
be recognised at a glance, as it is rather an ashen-grey 
lividity, suggesting a light type of argyria. A popular 
American headache remedy introduced of late years into 
this country is responsible for many cases, and on several 
occasions I have put the question point-blank, “ Have you 
been taking- 1" There is a certain characteristic colour 





The Lancet,] 


PROFESSOR WILLIAM OSLER: ERYTHRiEMIA. 


[Jan. 18, 1908. 145 


of the polycythaemic cyanosis which is referred to by Cabot 
and one or two other observers—a sort of red Indian hue 
which is most marked in circumstances when the arterial 
is just beginning to obscure the venous tint. And one more 
point may be mentioned; as with all conditions it which 
there is persistent hypermmia of the skin pigmentation may 
occur; this was very marked in a case of Stockton and 
Lyon. There have been cases reported in which the pains 
In the hands and legs with the extreme congestion have 
suggested the erythromelaigia of Weir Mitchell—the red, 
painful neuralgia. In Joseph Collins’s case this was a very 
marked feature and the patient complained a good deal of 
pains in the hands and feet, but in the few cases of erythro- 
melalgia I have seen only one extremity was attacked, and 
it was, as it name indicates, a red erythema, not influenced 
by gravity to any extent. The extreme grade of local 
asphyxia may suggest Raynaud's disease, and this has been 
the diagnosis in a case which Dr. W. S. Thayer very kindly 
showed me. 

For the recognition of the disease a blood count is 
necessary, not simply a blood examination, as in the cases of 
leukaemia. The essential feature, the polycythemia, the 
erythremia, can be determined only by counting the number 
of red blood corpuscles in a cubic millimetre. A true 
polysemia, a plethora vera, is present. Haldane estimated 
that a patient of Paikes Weber had nearly double the normal 
amount of blood and post mortem the oases have shown a 
state of great fulness and engorgement of the internal 
vessels. This is another point of analogy with leuksemia, in 
which also there may be an extraordinary increase in the 
total volume of blood. The counts have been very remark¬ 
able—this patient has nearly double the normal. Cabot has 
reported 12,000,000 per cubic millimetre, and in a case of 
Kuster the count was 13,600,000 per cubic millimetre. The 
question has been raised whether it is possible to pack this 
number of red bleed corpuscles into a cubic millimetre. Dr. G. 
Mann, who has interested himself in this point, tells me that 
it would be possible to put 13'9 millions of red corpuscles 
into this space, so that the maximum recorded count is within 
this limit. You might suppose that in every condition of 
local engorgement with cyanosis the blood count would be 
high, but this is not the case. In a case of alcoholic 
neuritis with legs just as purple as those of this woman, in 
Raynaud’s disease, in the skin of a “ Bardolphian ” facies 
bursting with blood, the number of red blood corpuscles per 
cubic millimetre may be normal. 

The enlargement of the ipleen is variable. It rarely 
reaches the size fern in this patient. Cases have been 
reported in which the edge of the organ has reached the 
crest of the ilium. It may precede the occurrence of the 
cyanosis and it may not have been noticed during life but 
have been found post mortem. It has been present in a 
large proportion of all the cases. 

Many additional features have been noticed. This patient 
presents very few symptoms, only pains in the hands and 
feet and a Blight loss of vigour. Headache has been a 
common complaint and a distressing sense of fulness with 
occasional attacks of vertigo. One of my cases had recurring 
attacks of nausea and vomiting. Constipation is a very 
common symptom. High blood pressure is the rule and it is 
remarkable considering the great increase in the volume of 
blood that it is not increased In the present case. 8clercsis 
of the superficial arteries and a trace of albumin in the urine 
have been frequently noted. In the’ first case I studied this 
combination of albuminuria, high blood pressure, and arterio¬ 
sclerosis had suggested a diagnosis of Bright’s disease. 
Attacks of bronchitis and of asthma have been described. 
In Case 1 of my series during the winter season piping rdleB 
were constantly present in the bronchial tubes. Haemorrhages 
have occurred in a number of instances, sometimes petechial, 
as on the skin of this patient, sometimes from tbe mucous 
membranes—haemoptysis, hrematemesis, or bmmaturia. Death 
from cerebral haemorrhage has occurred in several instances. 

We scarcely know enough to discuss intelligently the patho¬ 
logy of this interesting affection but there have been five or 
six post-mortem examinations within the past 18 months 
which throw some light upon the condition. Theoretically, 
polyglobulism may be due to a diminished destruction of the 
red blood corpuscles, to an excessive loss of plasma, and to an 
increased production of red cells. A relative polycytbmmia 
is by no means rare and occurs in many clinical conditions 
associated with loss of fluids. It rarely reaches the high 
grade seen in these cases. Weintraud suggests that the poly¬ 
globulism of this disease is due to retarded destruction but 


there are no clinical or anatomical facts in support of this 
view ; nor, on the other hand, is there any evidence of 
increased haemolysis in the deposition of pigment in organs, 
such as occurs in hmmachromatosis, or in changes in the 
proportion of the urinary pigments. A true erythrsemia 
follows a residence at high altitudes and is present in con¬ 
genital heart cases, in both probably an adaptive process, 
more corpuscles being required to carry on the O a metabolism. 
The studies on the bone marrow by Miller and others have 
shown it to be in a state of active hyperplasia in congenital 
heart cases. Recently Ambard and Fiessinger 5 have 
reported a case of congenital cyanosis with poljcytfluemia ini 
which there was the most intense proliferation of the bone! 
marrow. 

In this splenic polycythsemia there have been at least six 
post-mortem examinations—all with practically the same ana¬ 
tomical changes—a plethora vera ; intense hyperplasia of the 
bone marrow, a myelomatosis rubra ; and enlargement of the 
spleen, with histological changes indicative of chronic passive 
congestion, a uniform hyperplasia of all its elements. It 
may be that the spleen participates actively in the process, 
as the histological studies do not indicate that it is an 
enlargement due to the accumulation of the products of 
haemolysis. Neither spleen nor lymph glands ever lose their 
power of making red blood corpuscles, though in normal 
states in the adult they hand the function over to tbe bone 
marrow. But even with an undoubted evidence of myeloma¬ 
tosis we are not nearer the essence of the diseat e—the 
why —the cause of the mysterious flooding of tbe 
body markets with the products of its red-blood 
factories. From a score of causes the output may at any 
time be doubled, either by working overtime or by setting 
in motion all the blood-making machinery. After a 
btemorrhage tbe little discs are turned out in countless 
billions and if from any cause, as in high altitudes, or in 
congenital heart disease, there is trouble in the lung- 
exchange to barter tbe C0 3 for the O a , an extra supply of 
corpuscles is soon forthcoming to make up the defect. 
Nothing is more certain—in the microcosm as in tbe 
macrocosm, given a demand and there is soon a. 
Bupply. But here is a condition in which, so far as 
we know, there is an over-supply without any corresponding 
demand and the same riddle confronts us as in leukmmia and 
several other diseases of which over-production of a normal 
tissue or element is the essence. Tbe interesting suggestion 
has been made by Koiiinyi and Bence that the disease is doe 
to a lessened power of the red blood corpuscles to absorb 
oxygen. Given a bsemoglobin of poor quality, incapable of’ 
combining normally with O. a greater number of erythrocyte* 
would have to be manufactured to meet the usual demands of 
the system. With this, too, they regard the increased viscosity 
of the blood as an important element in producing the 
cyanosis. Saundby has brought forward the view that there 
is such a state of capillary dilatation with slowing of the 
blood current that each little boatlet of blood cannot dis¬ 
charge its proper cargo, and to make up for this failure more 
are put into circulation, the antithesis of the condition 
existing at high altitudes when as each little boatlet cannot 
get a sufficient cargo of O, in the space of time it remains 
in the lung capillaries, three are sent out to do the work for 
which two usually suffice. The remarkable combination of 
symptoms is one which lends itself to theoretical considera¬ 
tions. We have not yet got to the heart of the mystery of 
leuksemia, and in this remarkable disease is added another to 
the many interesting problems relating to the physiology and 
pathology of the red blood corpuscles. 

A word about the name, always a difficulty in connexion 
with a new disease. The choice lies between an eponymic, 
an anatomical, or a symptomatic name. The one suggested 
by Parkes Weber—tplenomegalic polycythsemia—has been 
adopted in this country. In France it has been called 
maladie de Vaquez, or Vaquez-Osler, and in the United 
States some of my friends have been kind enough to asso¬ 
ciate my name with it. But the priority of description rests 
with Vaquez and if a name is to be associated with the 
disease it should be that of our distinguished French) 
colleague. Among other names which have been suggested 
are polycythsemia rubra and erythrocythsemia megalosplenica. 
In many ways the name erythi aemia, suggested by Turk of 
Vienna, seems to be tbe most appropriate. It is short 
and it designates the most striking and the most constant 
peculiarity ; it has the great advantage of an analogy with 


5 Arch, de Med. Experiment. Mare., 1907. 




146 The Lancet,] DR. T. R. BRADSHAW : TROPICAL ABSCESS OF THE LIVER. 


[Jan. 18,1908. 


leukaemia, and both affections are associated with states of 
morbid activity in the bone marrow. 

We know as yet very little about the treatment of the 
disease. As a long experience with leukaemia has demon¬ 
strated, we have nothing at our disposal which controls the 
morbid processes in the bone marrow. Two or three 
measnres have been carried ont which have given relief. 
When there are fnlness of the head and vertigo repeated 
bleedings have been tried with great relief. Inhalations of 
oxygen have been need and cases have been reported in 
which the cyanosis has been relieved and the number of red 
blood corpuscles greatly diminished. We Bhall ask to have 
this given a thorough trial and Dr. Sankey has agreed to 
apply the x rays over the spleen, which seems to have been 
helpful in some instances of enlargement of the organ. 6 


% Clinical Jcdnrc 

ox 

TROPICAL ABSCESS OF THE 
LIVER. 

Delivered at the Liverpool Royal Infirmary on Dec. 3rd, 1907, 

By T. R. BRADSHAW, B.A., M.D. Dcb., 
F.R.C.P. Lond., 

PHYSICIAN TO THK INFIRMARY; LECTURER ON CLINICAL MEDICINE AT 
THE UNIVERSITY OF LIVERPOOL. 


Gentlemen, —Suppuration within the liver or closely 
adjacent to the organ occurs in association with various 
morbid conditions and presents great diversity in its clinical 
aspects. In general pyaemia, wherever the source of infection 
may be, multiple abscesses may form in the liver as well as 
in other parts of the body; if the source of infection is 
located within the collecting area of the portal vein the 
abscesses will first appear in the liver and will probably be 
confined to that organ, constituting portal pyaemia or 
suppurative pylephlebitis. Again, a very similar condition 
may arise from a septic focus, however established, in the 
gall-bladder or the larger bile passages, the infection 
spreading along the smaller bile-ducts and giving rise to 
suppurative cholangitis, a condition indistinguishable 
clinically from suppurative pylephlebitis. Abscesses such 
as these are the class most likely to occur in persons who 
have never visited tropical or subtropical countries. The 
symptoms to which they give rise are mostly those of 
profound toxaemia, the liver is but slightly or not at all 
enlarged, and the signs of the local condition may be 
equivocal or altogether wanting. Hence the disease of the 
liver is difficult—it may be impossible—to diagnose with 
any certainty. At the same time a correct diagnosis, if 
it could be made, would be of little practical value, 
since the abscesses, being numerous, are not amen¬ 
able to surgical interference. Again, suppuration may 
take place in the walls of a hydatid cyst in the liver and 
occasionally a collection of pus is found between the upper 
surface of the liver and the diaphragm (subphrenic abscess), 
of which the origin is somewhat obscure. Finally, there is 
the so-called “tropical abscess,” which forms the subject of 
our present consideration. 

The most noticeable features of tropical abscess, as dis¬ 
tinguished from other forms of suppuration in the liver, are 
that it is most often a single abscess, that it generally 
attains a large size and so gives indications of its presence, 
that it is not as a rule associated with general pyaemia, and 
is not dependent on any antecedent coarse disease of the 
liver. This type of abscess is rarely found except in persons 
who have lived in tropical or subtropical countries and it 
affects Europeans more often than natives. The exact 
causes which determine its formation are not thoroughly 
understood. Habitual overfeeding and indulgence in alcohol 
are generally—no doubt justly—credited with a considerable 
share in its production, and many authorities hold that 
malaria is one of the factors in its etiology. It must be 

6 For a month this patient has had the oxygen inhalations daily and 
the x-r»y treatment. She has gained several pounds in weight and 
is feeling very much stronger. The oxygen inhalations have had no 
influence on the cyanosiB, nor is there any change in the polycyth.-vmia. 
The spleen is somewhat reduced but the cyanosis this morning 
<Jan. 1st) is very marked. 


remembered, however, that malaria is of such common 
occurrence in tropical countries that it might be expected 
to be found in the subjects of tropical abscess without 
there beyig any causal relation between the two, and also 
that the organisms of malaria, as far as is known, never 
excite suppuration. The cause which overshadows all others 
by its frequency is the occurrence of dysentery. The 
importance of dysentery in the production of tropical 
abscess was strongly insisted on by Hurchison, and at the 
present day some pathologists go so far as to regard suppura¬ 
tive hepatitis as practically dysentery located in the liver. 
In this connexion it should be borne in mind that at least 
two forms of dysentery are now recognised—amoebic 
dysentery, which arises solely in tropical or subtropical 
countries, and bacterial dysentery associated with the 
presence of micro-organisms, of which Shiga's bacillus may 
be taken as the type. Abscess of the liver is rarely seen 
in the dysentery of temperate regions, even when, as in 
arduous campaigns and other times of stress and privation, 
dysentery occurs with great severity. Whether bacillary 
dysentery in tropical regions can give rise to abscess, or 
whether, as some maintain, the amoebic variety alone can 
do so, is a question which is still tvbjudice. It is, however, 
admitted that while the contents of a large number of liver 
abscesses are sterile as regards bacilli the majority of 
abscesses associated with amcebic dysentery do actually 
contain amoebae. 

The possibility of the successful treatment of tropical 
abBcess by surgery depending on its being single or at most 
double, the prognosis in any given case will largely depend 
on the proportion of cases in which single abscesses occur. 
This is, however, not easy to ascertain with any degree 
of certainty. Post-mortem statistics are not available for 
the purpose, as they will, of course, show an excess of 
multiple, that is, incurable, cases. The average of various 
statistics indicates that the abscess is single in 70 per cent., 
double in 10 per cent., and multiple in 20 per cent. 

In this country single abscess of the liver is met with 
almost solely in persons who have lived in tropical countries 
and who have suffered from dysentery or at least diarrhoea. 
The symptoms are often indefinite, comprising chiefly weak¬ 
ness and lassitude, loss of flesh, a sallow muddy complexion, 
and sensations of chilliness or actual rigors which are likely 
to be attributed by the patient to malaria. Pain in the 
right shoulder is a time-honoured symptom of abscess in 
the upper part of the right lobe and is explained by radiation 
along a small branch of the phrenic nerve which com¬ 
municates with the nerve to the subclavius muscle. If in a 
patient with a history and symptoms such as these physical 
examination reveals the existence of enlargement of the liver 
the presence of abscess may, as a rule, be diagnosed with 
sufficient probability to justify the performance of an 
exploratory operation. Enlargement of the liver in an 
upward direction is especially significant as it hardly ever 
occurs except in abscess, but it is not always easy to 
recognise, as I shall point out later. Enlargement in a 
downward direction is generally recognised without diffi¬ 
culty, but in the case which I am now going to relate, 
though it was very great, it was completely masked by 
ascites, a most unusual complication of abscess of the liver. 

The patient, a man, aged 28 years, was admitted to my 
ward at the Liverpool Royal Infirmary on Nov. 21st, 1907. 
He had joined the army in 1899, had served in the Boer war, 
and afterwards had been with his regiment in India. Four 
years previously to being admitted to the infirmary he had had 
a severe attack of dysentery which had lasted between six and 
eight weeks and he had had another attack at a date not 
specified. He had also had several attacks of ague. He had 
contracted syphilis three years ago and was treated for it. 
He said that he used to drink about six pints of beer a day 
while in India but denied taking spirits. He came to 
England with his regiment in March, 1907 ; two months later 
he was invalided from the army on account of malaria, and 
had never been really well since. About the end of June he 
took a plaoe as barman. He denied that he was in any way 
intemperate but he had to relinquish the work after a month 
owing to illness. At that time be had sharp shooting pains 
in the right hypochondriac region and six weeks later he 
noticed that the abdomen was distended. Early in October 
he consulted a medical man, who, apparently suspecting 
abscess of the liver, made an exploratory puncture in the 
back, but only found blood. Three weeks before admission 
he bad been tapped in the abdomen in the middle line (the 
mark of the puncture was still visible in the hypogastric 



The Lancet,] 


DR. T. R. BRADSHAW: TROPICAL ABSCESS OF THE LIVER. [Jan. 18, 1908. 147 


region) and, as he said, about a quart of dark fluid had been 
removed. Since then he had kept to his bed. 

On admission the patient looked very ill, his complexion 
was sallow, the pupils were widely dilated, the temperature 
did not rise above 96° F., and the pulse was 120. The 
abdomen was greatly distended with fluid, the walls being 
tightly stretched; there was anasarca of the legs ; the 
superficial veins over the upper part of the abdomen and the 
front of the chest were engorged, and there was some 
dyspnoea. The abdominal distension pointed to the liver as 
the seat of disease but it made an examination of the organ 
impossible. The need for relief was clearly urgent, so I 
resolved to perform paracentesis abdominis immediately so as 
to remove the tension and at the same time to enable a 
physical examination of the abdomen to be made. A medium¬ 
sized trocar and cannula was inserted between the umbilicus 
and the pubes and 176 ounces of fluid, which was deeply 
and uniformly red from the presence of blood, were with¬ 
drawn. After this the liver was easily felt. It was 
enormously enlarged and very hard to the touch. In the 
semi-recumbent posture its lower edge reached down to the 
iliac crest; its upper limit I did not ascertain exactly as I 
did not want to disturb the patient more than was necessary, 
but percussion in the right mammillary line showed that the 
upper limit of dulness was at the fourth intercostal space. 
The spleen was also distinctly felt. 

We now had to consider what was the nature of the 
enlargement of the liver. Four possibilities presented them¬ 
selves : 1. Cirrhosis of the liver with enlargement of the 
organ. Cirrhosis is generally the obvious diagnosis in a patient 
with ascites, especially where there is a history of indulgence 
in alcohol. Certain points, however, were strongly against it. 
The general appearance of illness and toxremia were too 
profound ; there was an entire absence of jaundice; the en¬ 
largement of the liver was far too great and it took place in 
an upward direction ; the presence of blood in the fluid was 
against cirrhosis, and so to some extent was the patient's 
age. 2. Tropical abscess. In favour of this there was the 
clear history of dysentery and of recent febrile attacks, the 
profound toxsemia and illness, and the evidence of enlarge¬ 
ment of the liver in an upward direction. On the other 
hand, the ascites, which was so striking a feature, I had 
never met with in abscess of the liver. Further, its occur¬ 
rence is not mentioned by Professor W. Osier in his text¬ 
book nor by Dr. Andrew Davidson in his article on Tropical 
Abscess of the Liver in Allbutt and Rolleston’s ' ‘ System 
of Medicine.” Dr. Rolleston observes: “Marked ascites 
is an extremely rare accompaniment of hepatic abscess.” 1 
3. Malignant disease of the liver presented itself as 
a possibility. The chief points in its favour were 
the blood-stained ascitic fluid and the hardness of the 
liver. 4. The possibility of hydatid disease was con¬ 
sidered but was dismissed. The ascites was as much 
against hydatid disease as against abscess ; the ab¬ 
sence of a localised tumour and the existence of pro¬ 
found toxaemia were also against it. Reviewing all the 
circumstances, I formed the opinion that the case was 
one either of tropical abscess or of malignant disease of the 
liver with a strong leaning to the former. Mr. G. G. 
Hamilton kindly saw the case with me without delay, but we 
agreed that after the tapping no further operative inter¬ 
ference was desirable that day. The patient was ordered 
some brandy and a carminative mixture containing aromatic 
spirit of ammonia and tincture of cardamoms. On the 
next morning we found that he had had a better night 
and he said that he felt better and had experienced distinct 
relief from the tapping. I was now able to examine the 
back and I found that the upper level of hepatic dulness had 
the characteristic arched form, the highest point being in 
the mid-axillary line at about the level of the sixth rib, while 
behind it sloped downwards to about the ninth. In the 
mammary region coarse pleural friction was heard. I now 
felt confident that 1 had to do with an abscess of the liver 
and requested Mr. Hamilton to operate. To confirm the 
diagnosis still further he proposed examination with the 
Roentgen rays and the shadow on the fluorescent screen 
bore out in a striking manner the conclusions arrived at on 
other grounds. The right cupola of the diaphragm was seen 
to be projecting up into the chest like a dome and quite 
motionless, while the left half lay about two inches lower 
down and moved freely with respiration. 

Mr. Hamilton proceeded to evacuate the abscess. The 


1 Diseases of the Liver, p. 140. 


patient was anaesthetised and a vertical incision about three 
inches long was made in the front of the abdomen a little to 
the right of the middle line and reaching upwards to the 
costal arch. The liver, much enlarged, came into view at 
once. On the anterior surface pus could be seen pointing 
under the capsule. After careful packing to prevent the 
escape of pus into the peritoneum a thick special liver abscess 
trocar and cannula was inserted at this spot and 66 ounces 
of chocolate-coloured pus flowed away. The cannula, with 
a tube attached, was left in ritu. For the first 24 honrs the 
abscess continued to drain and the patient seemed to be 
doing well, but he sank and died 48 hours after the 
operation. 

At the post-mortem examination it was found that the 
main abscess had drained well, but there was a second 
abscess located in the Spigelian lobe, which was distended 
to the size of an orange. There was no thrombosis in the 
portal vein or its branches and the ascites was apparently 
due to pressure on the portal vein by the Spigelian lobe and 
some enlarged, but not suppurating, glands in the transverse 
fissure. The blood in the ascitic fluid was probably due to 
rupture of small blood-vessels in the capsule of the liver. 
There were several uncicatrised ulcers in the colon. The 
spleen was enlarged, indurated, and pigmented, the result of 
repeated attacks of malaria. 

The failure to save this patient by operation was, no doubt, 
inevitable, owing to the existence of a second abscess which 
could not have been ascertained during life. To search for 
a second abscess during the operation in every case would 
involve an amount of manipulative disturbance which would 
materially add to the danger, and in this case, even if it bad 
been found and opened, it is unlikely that the patient would 
have recovered. 

While the diagnosis of abscess of the liver may often be 
made without great difficulty there are cases which present 
very puzzling features which may mislead the observer unless 
he is on his gnard against them. An important point to bear 
in mind is that a normal temperature may be present for 
days together in patients with abscess of the liver. I have 
known an experienced surgeon very unwilling to operate on 
a case of abscess of the liver because no pyrexia had been 
noticed during several days in which the patient had been 
under observation. The operation proved the correctness of 
the diagnosis. In my experience the chief difficulty in the 
diagnosis of abscess of the liver has arisen from its 
simulating disease of the right lung or pleura or from its 
being complicated with actual effusion into the pleura. 
Infective processes immediately below the diaphragm readily 
spread to the pleura by means of the lymphatics. In the 
case we have been considering pleural friction was a 
prominent sign; in other cases pleuritis goes on to 
effusion which masks the characteristic arch of the upper 
border of the liver which we have seen is a valuable 
sign of abscess. If at the same time the liver is 
enlarged downwards and is palpable in the abdomen 
we are in danger of concluding that it is merely 
displaced by the pressure of the fluid in the thorax. 
Cases of this kind may be very puzzling both to the physician 
who has to diagnose and to the surgeon who has to operate 
on them. A few years ago a Chinaman was admitted to my 
ward with signs of eflnsion in the right pleura. I made an 
exploratory puncture in the eighth or ninth intercostal 
space behind and drew off several ounces of pas. I requested 
one of my surgical colleagues to open the pleura, which was 
done, but to his surprise only serous fluid was found in that 
cavity. Further investigation showed that the pus which I 
had struck upon was really in the liver. Owing to the 
diaphragm being pushed up the lower part of the pleura had 
become merely a potential cavity, which my trocar and 
cannula had traversed without tapping it and had pierced the 
prominent diaphragm and entered the underlying abscess. I 
was thus misled to the extent that I believed that I had to 
do simply with an empyema, whereas there was in reality a 
serous effusion in the pleura and also an abscess in the liver. 

Before concluding I will briefly relate the case of a young 
woman who had never been out of England but who 
developed a single abscess of the liver hardly distinguishable 
from the tropical variety, and in whom the physical signs 
pointed to a lesion in the thorax. 

In May, 1906, I was asked by Dr. John Davies of Kirkdale 
to see a young woman, aged 18 years, who was suffering from 
severe abdominal symptoms. She had peritonitis, with 
abdominal distension, and effusion in the peritoneum. The 
case seemed to be almost hopeless but she gradually 






Thb Lancet,] MR. J. F. DOBSON & DR. J. K. JAMIESON : EXCISION OF THE C/F.CUM, ETC. [Jan. 18, 1908. 


Results. 

Liquid Vnconcentrated. 


Time. 

1 hour. 

i 4 hour. | 

1 hour. 

2 hours. 

Anthrax spores . \ 

i + 

1 + 

+ 

+ 

Staphylococcus pyogenes i 
aureus. ) 1 

+ 

+ 

+ poor 

-4- slight 

Streptococcus pyogenes ... 

0 

0 

0 

0 

Controls . ! 

+ 

+ 

1 

+ 

+ 


Lit/uUl Reduced to Hal/ its Bulk . 


Time. 

i i hour. 

! 4 hour. 

1 1 hour. 

2 hours. 

Anthrax spores . 

+ 

+ 

+ 

0 

Staphylococcus pyogenes i 
aureus. \ 

9 

0 

0 

0 

Streptococcus pyogenes ... 

0 

0 

0 

0 

Controls ... . 

+ 

+ 

+ 

+ 

Liquid Reduced to Quarter Bulk. 


Time. 

i hour. | 

t 4 hour. 

1 hour. 

2 hours. 

Anthrax spores . i 

1 j 

+ 

+ 

0 

0 

Staphylococcus pyogenes \ , 

aureus.. ... / ; 

0 ! 

0 

0 

! 

0 

Streptococcus pyogenes ... | 

: 0 i 

i 0 

0 ! 

0 


Bat while the substance of the catgut is thus not only 
aseptic but powerfully antiseptic, its dry surface is liable to 
contamination by contact with septic material, and it is 
essential that before being used it should be washed with 
some trustworthy germicidal liquid. 

My practice has been to put the catgut, like the instru¬ 
ments, in 1 to 20 solution of carbolic acid about a quarter 
of an hour before the operation is begun. Any of the catgut 
that remains unused upon the reel may be afterwards 
kept in a similar solution for any length of time without 
disadvantage. 

The essential precaution of purifying the surface of the 
catgut is, I fear, sometimes overlooked, the result being 
occasional suppuration attributed to defect in the ligature, 
while it is really the fault of the surgeon. 


EXCISION OF THE C/ECUM AND ASCEND¬ 
ING COLON WITH THE CORRE¬ 
SPONDING LYMPHATIC AREA. 

By J. F. DOBSON, M.8. Lond., F.R.C.S. Eng., 

ASSISTANT SURGEON' TO THE GENERAL INFIRMARY AT LEEDS AND 
LECTURER ON CLINICAL SURGERY IN THE UNIVERSITY 
OF LEEDS i 

AND 

J. K. JAMIESON, M.B , O.M. Edin., 

DEMONSTRATOR OF ANATOMY IN THE UNIVERSITY OF LEEDS. 


In The Lancet of April 27th, 1907, p. 1137, will be found 
a paper by us on the Lymphatic System of the Ascending 
Colon, Csecum, and Appendix, based on the examination of 
30 specimens injected by the method of Gerota. In this 
paper we described an operation for malignant disease of the 
csecum or ascending colon which was designed to remove in 
one piece the csecum and ascending colon containing the 
growth, with the terminal portion of the ileum, the hepatic 
flexure, all the lymphatic glands receiving lymphatic vessels 
directly from the region of the growth, and the intervening 
tissues containing these vessels. By this operation the 
whole of the ileo-colic chain of Iymphatio glands is extir¬ 
pated, including the gland lying on the duodenum at the 
origin of the ileo-colic artery, which we found to be the 
highest gland receiving these direct vessels. At that time 
no opportunity of carrying oat this method on the living had 
presented itself, but recently one of us has performed the 


li*. 

operation on two occasions, once for carcinoma of „ the 
ascending colon and once for a tuberculous tumour of the 
ciecum. It seems desirable to report these cases, as the 
operation appears to have advantages over the more usual 
methods of removing growths in these situations. 

Case 1. Carcinoma of the atoending colon. —The patient, 
a man, aged 47 years, was admitted into the Leeds General 
Infirmary on Sept 17th, 1907, under the care of Dr. W. H. 
Maxwell Telling. The history given was as follows. He 
had enjoyed good health until a year ago when he began to 
suffer from pain in the epigastrium. This pain was noticed 
from time to time and in February, 1907, he had a severe 
attack accompanied by vomiting ; at the same time the 
abdomen was said to be swollen and he was troubled with 
flatulence. He bad bad no vomiting since this attack in 
February ; there had been neither constipation noi diarr! oea 
and no blood had been seen in the stools. He noticed a 
swelling in the abdomen in March and thought it had 
increased in size lately ; he lost weight considerably np to 
February but not since. The patient was extremely amende ; 
the pulse was feeble. There was a mass in the right loin 
which could easily be felt on bimanual palpation ; it was 
hard and nodular, rather tender and slightly moveable ; the 
abdomen was not distended and there was no visible 
peristalsis. There were no enlargement of the liver and 
no ascites. The urine contained organisms bnt no pns or 
albumin. 

Operation. —This was performed on Sept. 30th and the 
following description of it is taken from the notes written by 
Mr. L. R. Braithwaite, the resident surgical officer, who 
assisted. Ad incision Beven inches long was made in the 
right linea semilunaris, the tnmonr in the ascending colon 
was defined, and the small intestine was packed off to the 
left side of the abdomen. The duodenum aDd the ileo-colio 
vessels were then defined, the overlying peritoneum was 
divided, and a fairly large uppermost gland of the ileo-colic 
chain was pushed downwards. The artery and vein were 
then clamped and divided, the ligature being applied about 
half an inch from the superior mesenteric artery. At this 
stage clamps were applied to the transverse colon close to the 
hepatic flexure and to the ileum about six inches from the 
ileo-csecal valve. The peritoneum on the outer side of tbe 
ascending colon was then divided and tbe whole mass, 
ascending colon, ctecum and terminal portion of the ileum, 
was thrown over to the left, the peritoneum, ileo-colic vessels 
and chain of glands being stripped np to tbe duodenum ; the 
ureter was seen and avoided and some vessels were tied. The 
meso-colon was then divided from the duodenum to the 
selected point on the colon, some branches of the middle 
colic artery being tied. In the same way the peritoneum of 
the anterior layer of the mesentery was divided down to the 
ileum and also the posterior layer, and the terminal branch of 
the mesenteric artery was secured. The whole mass was now 
easily withdrawn from the abdomen and the colon and ileum 
were divided between clamps ; both ends were closed by 
celluloid thread continuous suture, three layers in tbe colon 
and two in the ileum. Lateral anastomosis between the two 
portions of gut was now effected, thus drawing up the 
mesentery and covering in the denuded area on the posterior 
abdominal wall. A small tubular drain was inserted through 
a stab wound in the loin and the anterior wound was closed 
in the usual way. 

The patient made an excellent recovery from the opera¬ 
tion ; there was some distension of the abdomen with 
vomiting on the second day but this ceased after the bowels 
had acted. The tube gave exit to a certain amount of dis¬ 
charge and a small sinus remained which did not completely 
close for a few weeks. At tbe present time the patient is 
very well; he has gained 2 stones in weight and his ansemia 
is much better. 

In this case the csecum was placed at a high level and the 
ascending colon was contracted by the growth, so that the 
tumour lay comparatively close to the duodenum. 

On examining tbe specimen, almost the whole of the 
ascending colon was found to be Infiltrated with growth, in 
parts an inch thick. The mucous membrane over the growth 
was ulcerated. The hepatic flexure was not invaded. The 
ileum was slightly hypertrophied ; the crecum was distended 
with thin fsecal material and its walls were slightly thickened ; 
the ileo-colic opening was smaller than usual. The appendix 
was normal in appearance. The ileo-colio chain of glands lay 
close to the ascending colon ; many of its members were 
enlarged, the highest (duodenal) gland being of tbe size of a 
bean. The right juxta-colic glands were enlarged and 
c2 










150 The Lancet,] MR J. F. DOBSON & DR J. K. JAMIESON: EXCISION OF THE C^CUM, ETC. [Jan. 18, 1908. 


adherent to the growth. There was no infiltration of the 
parietal peritoneum on either side of the gut. On micro¬ 
scopical examination the growth was found to be a columnar - 
celled carcinoma. There was no evidence of disease in any of 
the glands of the main ileo-colic chain examined. One of 
the juxta-colic glands examined was found to be completely 
infiltrated with growth. 



Diagrammatic representation of parts removed. 

Case 2. Tuberculous disease of the ccccurn .—The patient, a 
man, aged 48 years, was admitted into the Leeds General 
Iofirmary on Sept. 9th, 1907, under the care of Dr. T. 
Courton. He was well until six months ago when he began 
to suffer from indigestion and flatulence. Shortly afterwards 
he felt a small lump on the right side of the abdomen ; this 
had gradually increased in size. He had also noticed a 
banana shaped swelling to the inner side of this lump which 
appeared at intervals and caused intense pain; this swelling 
lasted about two minutes and then subsided with a gurgling 
noise. He felt sick during the attack and vomited sometimes, 
usually about an hour after a meal. He had had diarrhoea 
during the last week but constipation was the rule ; blood 
had not been noticed in the stools. He had lost weight 
lately. On examining the abdomen a mass was to be felt in 
the right iliac fossa of about the size of an egg ; it had 
a nodular surface, could be moved slightly towards the 
umbilicus, and was very tender. Occasionally the banana- 
shaped swelling described by the patient appeared below 
and to the inner side of the mass; this was evidently a 
hypertrophied loop of ileum. There were no evidence of 
ascites and no enlargement of the liver. The general 
condition of the patient was fairly good ; the chest was 
appirently normal, the urine was normal, and there were no 
ealarged glands. The patient was blind. A diagnosis of 
carcinoma of the csecum was made. 

A similar operation (which took place on Sept. 18th) was 
performed in this case as in the first one. The ileo-colic 
chain of glands was extensively diseased, the uppermost 
gland lyiDg in front of the duodenum being very large 
Above this gland, around the trunk of the superior mesen¬ 
teric artery, were several glands which were quite small and 
appeared healthy ; they were not interfered with, but the 
uppermost gland of the ileo colic chain was pushed down¬ 
wards and removed with the rest of the chain. There was 
some rather troublesome haemorrhage at this stage of the 
operation. On bringing the ileum and colon together to 
effect the anastomosis there was a good deal of tension on 


the colon, its walls were very fragile, and the gut tore across 
beyond the suture line ; the torn portion was removed and 
the gut was re*sutured. A transverse incision was then made 
through the right rectus muscle and the colon was again 
clamped. Further traction, however, developed other slight 
tears : these were closed with suture and it was decided to 
implant the end of the ilenm into the sigmoid flexure. This 
was done with some little difficulty owing to the shortness 
of the meso sigmoid. The ureter was not seen at any stage 
of the operation. 

With the exception of slight suppuration in the abdominal 
wound the patient made an excellent recovery from the 
operation. Seen on Nov. 14th he was in excellent health, 
the bowels acting naturally. He had gained a stone in 
weight since the operation. 

On external examination this specimen presented a 
peculiar appearance, as the caecum had contracted so 
that the ileum and colon formed an almost even curve. 
On incision the caecal wall was hard and three-quarters 
of an inch thick. The induration extended half-way up 
the ascending colon. The ileo-colic orifice was very 
small owing to the great thickening of the flaps of the 
valve. The mucous membrane of the csecnm and lower part 
of the colon was shaggy and fungoid. The anterior ileo-colic 
glands were enlarged and behind the ileo-colic junction there 
was a hard mass composed of enlarged posterior ileo-colic 
glands and the appendix, matted together with indurated 
subperitoneal tissue. Several glands in both upper and 
lower groups of the main ileo-colic chain were enlarged and 
fleshy ; others were small and apparently healthy ; the highest 
gland (duodenal) was of the sizs of a grape and on section 
was soft except at the lower part where it was hard and 
fibrous. No suspicion was felt that the growth was other than 
malignant until microscopical sections had been made. It 
was then found that the mass in the wall of the ceecum was 
tuberculous. Sections of the highest (duodenal) gland were 
cut and it was also found to be affected with tubercle ; one 
of the smaller glands lying below this diseased gland was 
examined and found to be healthy. It is evident that, as 
one would expect from the arrangement of the afferent lym¬ 
phatic vessels, the absence of disease in the lower glands of 
the chain is no warrant for assuming that the highest gland 
is also unaffected. The error in diagnosis made in this case 
was fortunately immaterial; it is evident, from the details 
given above, that anything short of the complete removal of 
the ileo-colic chain of glands would have been insufficient. 

We may refer to the paper previously quoted for the details 
of the anatomy of the lymphatics of the caecum and ascend¬ 
ing colon and for the reasons why this operation is, from 
the anatomical standpoint, the ideal one to perform in cases 
of carcinoma and no doubt also in tuberculous disease. 
Practically it presents no especial difficulties, and it baa 
many advantages over the usual methods apart altogether 
from the removal of the “lymphatic area.’’ The blood- 
supply of the portion of intestine to be removed is effectually 
controlled and the risk of contamination of the field of 
operation is minimised by deferring the division of the gut 
until towards the end of the operation. The removal of 
several inches of the ileum enables the small intestine to be 
brought up to the colon with ease and allows of a satisfactory 
anastomosis being performed. Further experience and the 
detailed examination of many specimens removed by this 
method will perhaps enable us to judge whether this 
extensive removal of glands, justified on anatomical grounds, 
is necessary for pathological reasons. 

It is, we believe, correct to say that no similar operation 
has been previously described. F. S. Bird 1 described an 
operation, consisting of the removal of the caicum and 
ascending colon with the lower glands of the ileo-colic 
chain, for malignant disease, and Hartmann 9 removes these 
glands in tuberculous disease of the ca»;um. The essential 
point in the operation which we devised is the removal of the 
whole of the ileo-colic chain of glands en masse with the 
growth. 

It seems immaterial whether the mass be detached from 
the abdominal wall from above downwards or from below 
upwards. But it certainly seems an advantage to secure the 
ileo-colic artery and to isolate the uppermost gland of the 
ileo-colic chain as the fir».t step in the operation. In these 
two cases the right colic artery arose from the ileo colic 
artery and did not therefore reqaire a separate ligature. In 
a certain proportion of cases it will be found to arise 

1 Tub Lancet. Feb. 17th, 1906, p. 440. 

2 Revue de Chirurgie, vol. xxxv., p. 170, 1907. 



This Lancet,] DR. DUDLEY W. BUXTON: LEGAL RESPONSIBILITY AND ANESTHETICS. [JaN. 18, 1908. 151 


from the Bnperior mesenteric artery and will then require 
ligature. 

It will be noted that the term “ lymphatic area,” as used 
in this paper, includes all the primary lymphatic glands 
receiving direct vessels from the ciecum and ascending colon, 
the lymphatic vessels, and the tissues in which these vessels 
lie. If the term “lymphatic area 'is to come into common 
use in describing surgical operations it seems desirable that 
it Bhould bear the interpretation here given to it. This will 
mean that its use will be very restricted ; there are very few 
organs which possess a “lymphatic area" capable of removal 
by the surgeon. It is misleading to describe as the 
“ excision of an organ and its lymphatic area,” an operation 
which includes merely the removal of a few of the nearest 
lymphatic glands. 


LEGAL RESPONSIBILITY AND 
ANAESTHETICS. 

By DUDLEY W. BUXTON, M.D., B.S. Lond,, 
M.R.C.P. Lond., 

COXSVI.TISO AX.ESTHKTIST TO THE XATIOXAL HOSPITAL FOR THE 
PARALYSED AXD EPILEPTIC, QUEER'S SQUARE; AX.FSTHET1ST 
IX UXIVERS1TY COLLEGE HOSPITAL; AND SEHIOR 
AN.tSTHETIBT TO THE DF.MTAL HOSPITAL 
OF LOSDOX. 


The responsibility which everyone feels, or should expe¬ 
rience, when called upon to administer an anaesthetic to a 
patient is in part a moral one and in part a legal one. The 
moral obligation is to do the best that can be done for the 
patient according to the lights of the administrator. Such 
an obligation is involved in every act of a medical practi¬ 
tioner In his dealings with bis patient. In the case of the 
administration of an anaesthetic, however, two issues at least 
are placed before the anaesthetist. He has not only to select 
and to administer the anaesthetic in the best way for the 
patient, thereby insuring his complete insensibility and 
recovery with a minimum of ill-effects but also it is in¬ 
cumbent upon him to provide for the convenience of the 
operating surgeon so that he may carry out his procedure 
under the most favourable conditions. 

There is, however, an overriding responsibility which the 
law cow recognises in the administration of anaesthetics. 
This legal responsibility constitutes the subject of the present 
paper. It attaches obligations upon the anaesthetist: (1) as 
regards his patient; (2) as regards the operator; and further 
imposes obligations (3) upon the operator when he selects 
or directs the nse of the anaesthetic. Upon some of these 
points the law is tolerably clear but upon others no definite 
pronouncements have been made. 

The anaesthetist undertakes the use of what are potent 
agents for good or evil. Their employment necessitates a 
certain amount of skill, knowledge, and experience. In the 
eyes of the law these are assumed to be in the possession of 
any duly qualified medical practitioner. Should, however, an 
ansestbetio be deliberately given by a qualified practitioner 
in such a way as to jeopardise the patient's life through want 
of skill or experience, an action for mal praxis would lie as 
against the anaesthetist. Such actions, although cot common, 
have been brought against various persons. Notably a dentist 
in Paris was severely dealt with for undertaking to ad¬ 
minister an anaesthetic without possessing a legal status in 
his calling which entitled him to carry out such a proceeding. 
In more than one instance a death under an ansestbetio has 
led to an action for malpraxis and has placed the administrator 
in a terrible position. How far the anesthetist is responsible 
for accidents occurring under anaesthesia and connected with 
the operation, or the patient’s struggles during delirium pro¬ 
duced by the inhalation, has not been at present fully dealt 
with in the law courts. In dental operations, for example, 
the dropping of a tooth into the windpipe would no doubt 
fall within the domain of the operator, but when the dentist 
does not possess a medical diploma the measures necessary 
to meet the impending asphyxia would devolve upon the 
anaesthetist. He would in this case make himself responsible, 
at all events in part, for the ultimate result. Indeed, it is 
probable that in most cases, if not in all, the responsibility 
in dental operations is shared by the dentist and anaesthetist 
in so far as the operation is concerned. Un the other band, 
the dangers of the anaesthesia lie solely within the sphere of 
the anaesthetist. 


The relation of anaesthetist to surgeon is a peculiar one. 
The former may be called in as an expert and the whole 
responsibility of the anaesthesia thrown upon him. In such 
a case he decides upon what ansestbetio to give and what 
method to employ and accepts the burden of the patient’s 
safety until the latter has recovered from the at aesthetic. 
In such a position he (the anaesthetist) may have to decide 
whether the operator is (1) a properly, i.e., legally, 
qualified person; and (2) whether the operation per¬ 
formed is a legal one. When an anaesthetist ad¬ 
ministers an anaesthetic to the patient of a person whose 
name is not on the Medical Register or Dental Register 
he becomes guilty of the offence of “covering,” and so 
becomes liable to pains and penalties as ordained by 
law. 

The General Medical Council’s decision has established 
the illegality of a medical practitioner administering an 
anaesthetic to assist an unqualified person, be the latter 
quasi surgeon, dentist, bonesetter, or what not. It is not 
clear, however, in what light the Council regards the kindred 
practice of a fully qualified medical man allowing an un¬ 
qualified person to give an anesthetic while he operates. It 
seems tolerably clear that what was formerly a common 
enough practice—viz., a surgeon making use of a dresser, a 
nurse, or even a domestic servant to “keep the anesthetic 
going"—would legally fall under the category of “covering” 
and so expose the coverer to a reprimand or worse from the 
General Medical Council. Some time since a death under 
chloroform occurred when the master of a workhouse was 
attempting to give the anesthetic. I believe the occur¬ 
rence, although severely animadverted upon by the profes¬ 
sional press, was not brought officially before headquarters. 
In midwifery the custom of committing the chloroform to 
the hands of a well-trained nurse has been recognised for so 
long that no one appears to regard it as an act of covering. 
Although technically it is undoubtedly this, it remains to be 
seen whether a nsage adopted by the most eminent of 
accoucheurs would meet with any reproof from even the 
most punctilious observer of the code of medical ethics. At 
the same time it must be remembered that if anything were 
to go wrong the position into which the medical man might 
be placed would be an unpleasant one. No attempt would, 
however, in all probability be made to enforce penalties in 
certain cases. If, for example, in an emergency one medical 
practitioner found himself far away from help, he would 
be justified, it appears to the writer, in committing the 
anaesthetic to an assistant even if he was an unqualified 
person. He would in this case have the onus thrown 
upon him of proving that the step he adopted was 
forced upon him by the exigencies of the occasion. A 
death under chloroform occurred at one of the provincial 
hospitals some year or so back and the press reprobated the 
surgeon in charge of the case for allowing a staff nurse, a 
woman, to give the chloroform. In this case there was, I 
believe, no question at all about there being no medical aid 
available. The gentleman criticised was extremely angry 
and wrote to the journal in which the strictures upon his 
conduct appeared, Btating that not only was the nurse in 
question the usual administrator of chloroform at the hos¬ 
pital, but that he, the surgeon, personally, would sooner be 
anaesthetised by her than by anyone else." As an expression 
of personal feeling this is interesting but it does not alter 
the law. No doubt whoever allowed the nurse to give the 
chloroform was responsible for the act of covering thereby 
perpetrated. 

A more difficult question arises out of the relation between 
surgeon and anaesthetist when the latter is a junior house 
surgeon or qualified dresser. The operator often says that he 
will take the responsibility and desires the ansesthetist to 
adopt some measures which the latter regards as dangerous 
or unnecessary. In the case of an expert the same difficulty 
may arise in the selection of the anaesthetic. The expert 
either thicks the disagreement sufficient for him to retire from 
the case or yields, possibly after consultation with the 
surgeon, or the latter surrenders his view. 

The Burgeon who calls in an anaesthetist to his assistance 
naturally considers that the patient is his and that he there¬ 
fore may insist upon a particular anaesthetic being given. 
If the anaesthetist feels he cannot Bafely adopt his suggestion 
he can always make way for someone else, but when the 
anaesthetist is specially called in by the patient or the 
general practitioner on the same basis as the operator his 
position is a wholly different one from that just discussed. 
In this latter case it is to he assumed that special value is 




152 The Lancet,] DR. PARKES WEBER: ARTERITIS OBLITERANS OF LOWER EXTREMITY, ETC. [Jan. 18, 1908. 

— 1 - ■- ■ — — 


attached to his judgment and in the event of an; difference of 
opinion arising it must be referred to those most interested, 
the patient and bis friends, of course through the interven¬ 
tion of their personal medical adviser. Such cases have 
arisen, but, as a rule, tact and mutual confidence between 
the operator and the anesthetist render some compromise 
possible. In the event of any serious accident arising in 
such cases it is extremely difficult to define the legal re¬ 
sponsibility as regards surgeon and anesthetist. If the latter 
takes the position of an assistant and obeys the dictation 
of the surgeon the latter would seem to be the responsible 
person, but inasmuch as any qualified medical practitioner 
must be responsible qvd his licence to practise for his actions 
towards his patients or those committed to his charge, he 
could not, I opine, plead that he had no responsibility in the 
case. Either he was competent to conduct the administra¬ 
tion of the anaesthetic, in which case he accepts personal, 
indeed sole, responsibility in it; or, if incompetent and without 
direction by another, he would have to show that his incom¬ 
petence was not the immediate cause of the disaster. In 
either case the position is a most delicate one. The dresser 
or house surgeon coming as assistant to the operator takes 
his directions from his chief ; it is extremely difficult to 
determine what responsibility rests upon such assistant. 
Indeed, the issue might be raised as to whether so responsible 
a position as that occupied by the ansesthetist, involving, as 
it does, risk to life, can justifiably be relegated to anyone 
who is not able to accept full responsibility. It must, how¬ 
ever, be remembered in this connexion that in some hos¬ 
pitals a senior dresser is deputed to give anaesthetics, 
but in this case there is usually an officer present who 
directs and is, in fact, responsible for the conduct of the 
anaesthesia. 

The patient and his friends practically in all cases regard 
the surgeon as responsible for the operation in all its details, 
and this responsibility the surgeon in most cases is willing to 
accept. The conduct of the aniesthesia, although sufficiently 
important in itself, ranks as a part only of the operative 
procedure, and both the public and the profession regard it as 
ultimately the concern of the surgeon. It is he who usually 
calls in an ansesthetist for his aid and if anything goes amisB 
takes his part in seeing that proper measures are adopted 
for warding off a fatal accident. It is, however, worthy of 
remark that, at all events In dealing with hospital cases, 
coroners as a rule subpoana the anaesthetist and not the 
surgeon, even in cases in which the immediate cause of 
death was one more directly connected with the operation 
-or general condition of the patient than with the anaesthetic ; 
for example, in such cases as those in which regurgitation 
of stercoraceons material leads to its aspiration into the air- 
passages under an anaesthetic. Hence it would appear that 
although the surgeon must be regarded as the principal, yet 
when the anaesthetist actually undertakes his part of the 
proceedings he makes himself responsible for the safety of 
the patient. It becomes his duty to warn the surgeon of 
impending danger from shock or other cause and generally 
to see to the well-being of the person committed to his 
charge. 

When an ansesthetist is called upon to give an anaesthetic 
to a patient and he learns beforehand that the operation 
about to be performed is of an illegal kind or has anything 
about it which renders it in his view of doubtful legality, he 
would become an accomplice were he to still conduct the 
administration. In this case the issue is clear enough. If, 
•however, he comes to the case in ignorance of the nature of 
'the operation, it is extremely difficult for him to determine 
what course to pursue should his suspicions be aroused 
during the progress of the operation. It is clearly no legal 
duty of his to attempt to follow the steps of the operation 
any more than it is for him to advance his opinion as to 
whether what has to be done is being done properly. In 
these circumstances his legal position appears to be that he 
must be able to show his bona fidet and his ignorance of 
the patient and of the reasons for the operation, if the 
circumstances surrounding the case make him an unwitting 
accomplice. Io this connexion comes that class of cases in 
which the patient after an operation strives to show that 
the surgeon has done more than he obtained leave to do, 
the patient being as a result permanently damaged. Here, 
unless the ansesthetist has made himself a party to any 
compact between the patient and the surgeon, he cannot 
share the latter's responsibility as regards the operation and 
its sequelse. 

Mortlmer-Btreet, W. 


ARTERITIS OBLITERANS OF THE LOWER 
EXTREMITY WITH INTERMITTENT 
CLAUDICATION (“ANGINA 
CRURIS ”). 

By F. PARKES WEBER, MD. Cantab., F.R.C.P. Lond., 

PHYSICIAN TO THE GERMAN HOSPITAL, LONDON, AND TO THE 
MOL'NT VERSON HOSPITAL FSB CHEST DISEASES, HAMPSTEAD. 


The patient, a Russian Jew, aged 42 years, 1 seems fairly 
well nourished but complains of cramp-like pains in the 
inner part of the sole of the left foot (muscles of the instep) 
or in the calf of the left leg, which always attack him after 
he has walked for three or four minutes and oblige him to 
rest a few minutes before going on. No pulsation can be felt 
in the left dorsalis pedis artery nor in the tibialis postica 
artery behind the internal malleolus, though both these 
arteries ' 1 can be felt beating in the right limb The pulsa¬ 
tion of the femoral artery is normal in both groins. When 
the patient is examined lying in bed scarcely any difference 
between the two feet can be observed, but when the legs are 
allowed to hang over the side of the bed the distal portion 
of the left foot (unlike the right foot) becomes red and con¬ 
gested-looking, especially the fourth and filth toes. If the 
patient then forcibly flexes and extends the ankle-joint 
a few times the skin of the foot in less than a minute 
loses its congested look and becomes blanched and alabaster¬ 
like. If muscular exertion (by walking) is continued 
for three or four minutes the patient commences to limp 
and has to rest on account of cramp-like pains in 
the muscles of the instep or the calf. If examined at that 
time the foot appears pale but not so white as it does after 
only a few movements. The blanching of the foot can be 
to some extent lessened by making the patient inhale amyl 
nitrite but vaso-dilator drugs (trinitrine and amyl nitrite) 
fail to bring back pulsation to the left dorsalis pedis and 
tibialis postica arteries, although they distinctly increase 
the pulsation in these vessels on the sound side (right 
foot). There is no ansssthasla and the electrical reactions 
are normal and equal on the two Bides. A Rootgen-ray 
photograph of the two feet shows that the bones of the 
little toe give less shadow 3 In the left foot than in the right. 
There is no evidence of any disease elsewhere in the body. 
The radial arteries feel normal. The pulse is about 84. of 
moderate size and fair pressure. The brachial blood pressure 
(estimated by the Riva-Rocci apparatus * with a broad band) 
is 135 millimetres of mercury in each arm. A blood count 
gives 4,175,000 red cells and 9000 white cells in the cubic 
millimetre of blood, and the hiemoglobin value is 90 per 
cent, of the normal (by Haldane's method). Microscopical 
examination of the blood films shows nothing abnormal. The 
urine is free from albumin and sugar. The knee-jerks and 
plantar reflexes on both sides are natural. The pupils are 
equal and react naturally to light. Ophthalmoscopic 
examination giveB no evidence of disease. On the patient's 
admission to the German Hospital (AugUBt 8th, 1907) there 
was ulceration on the little toe of the left foot, but the ulcer 
has since then slowly healed np. 

The treatment in hospital has consisted in rest in bed (at 
first), the application on alternate days to the affected ex¬ 
tremity of local hot-air baths 5 and Professor Bier's light 
ligature method of producing passive congestion, sub¬ 
cutaneous injections of fibrolysin (altogether 47 Merck's 


1 The case was shown at the Clinical Section of the Royal Society of 
Medicine on Dec. 13t h, 1907. 

2 The tibialis postica artery cannot invariably be felt beating in the 
patient’s right limb. The pulsation of this artery is. as is well known, 
often very difficult to feel in quite healthy persons with firmly-set, 
well-covered ankles. The same difficulty occurs with the pulsation of 
the popliteal artery, which in this patient can be felt on neither 
side. 

8 The Rflntgen rays have shown that a certain amount of bone- 
absorption or decalcification undoubtedly sometimes occurs in parta 
affected by Raynaud's symptom complex or arterial ischaemia of any 
kind. 

* Owing to the absence of pulsation in the affected foot the blood 
pressure in the lower extremities could not be compared by the Rlva- 
Rocci method. Unfortunately, I was unable to employ plethysinograph 
methods. 

5 In a case of commencing slight arterio sclerotic gangrene (a man, 
aged 59 years) under treatment by local hot water baths W. Rdpke 
(Munchener Medicinische Wochenschrlft, 1907, No. 14, p. 666) had the 
satisfaction of observing return of pulsation in the dorsalis pedis and 
tibialis postica arteries of the affected extremity; the returning 
pulsation was at first only Intermittently, but afterwards permanently, 
present. 




The Lancet,] DR. PARKES WEBER: ARTERITIS OBLITERANS OF LOWER EXTREMITY, ETC. [Jan. 18,1908. 153 


ampollie have been used), medium doses of iodipin by the 
mouth, dermatol powder for the ulcer, and wrapping up of 
the foot. Recently the patient had been given Levico 
water. By all this treatment it is very difficult to 
know whether much good has been done. The patient cer¬ 
tainly thinks he feels better and has gained weight, and the 
ulcer on the toe has healed up, but the cramp-like pains 
(already referred to) on walking persist. The affection 
commenced gradually about five years ago with pain in the 
sole of the foot on walking. Various methods of treatment 
have been tried, including electrical baths at the London 
Hospital (which certainly seemed to do good) under Dr. 

E. R Morton and treatment at a thermal water health resort. 
He has been more or less threatened with local gangrene but 
so far has escaped with two attacks of slight ulceration on 
the little toe and one on the great toe. The ulceration in 
such cases is very indolent and slow in healing and may be 
termed “ischaemic ulceration”; by “ischaemic” it is meant 
to imply not that the blood in the affected part is actually 
-deficient in quantity but that the rate and pressure of the 
supply are insufficient. 

It is necessary to explain that the patient suffers from two 
distinct kinds of pain : (1) the cramp-like muscular pains of 
intermittent claudication (“angina cruris”), as already 
mentioned ; and (2) a local pain and tenderness in the 
affected toes which have sometimes kept him awake at night, 
especially when there was ulceration. Sometimes there is 
also a third kind of pain apparently connected with the 
ankle-joint. The patient has previously enjoyed good health 
with the exception of an attack of “scrofulous” abscesses 
(some connected with bone disease) in Russia when be was 
four years old. The scars resulting from these abscesses are 
still very noticeable on examining the patient. There is no 
history of any venereal disease. He has always been moderate 
in the use of alcohol and likewise in the use of tea and 
coffee. He has been accustomed to smoke rather freely. The 
case is a typical one of the class of obliterative arteritis, 
which often leads to gangrene of extremities and occurs in 
men in the prime of life, especially in poor Jews from Russia 
who have been accustomed to smoke cigarettes rather freely 
Within the last few years I have had the opportunity of 
teeing (partly owing to the courtesy of various oolleagues) 
ten cases in male Jews of the East-End of London between 
30 and 52 years of age, some of them employed in cigarette 
factories, where they could obtain cigarettes without paying 
for them. Syphilis apparently plays no part in the etiology. 
The really essential cause of the arterial disease in these 
cases still, however, remains unknown. It is possible that in 
these cases for some reason (insufficient exercise, imperfect 
diet, or too much cold) during the growing period of life the 
blood-vessels, especially those of the lower extremities, do 
not develop in proportion to the growth of the rest of the 
body. If this were the case it would be natural that during 
adult life the hypoplasic vessels should be specially liable to 
disease. 

Cases in which amputation has had to be performed 
have been described by Dr. E. Michels and myself in 
1903, 9 and in the Transactions of the Pathological 
Society of London. 7 Striking cases have been brought 
before the Clinical Society of London or published in 
English medical literature by Mr. A. Pearce Gould, 8 the 
late Dr. W. B. Hadden, 11 Mr. W. G Spencer, 10 and others. 
The pathology of the affection has been thoroughly studied 
and discussed by several writers on the continent, including 

F. von Winiwarter," C Sternberg, 111 A. A. Wwedensky, 1 * 
W. von Zoege-Manteuffel," Bunge, 15 P. Wolff, 11 and 0. 


6 Brit. Med. Jour., 8ept. 12th. 1903, p. 566. 

7 1905, vol. Ivl., p. 223. 

8 Pearce Gould: Tramactlons of the Clinical Society of London, 
vol. xvii.. p. 95, and vol. xxlv., p. 134; and The LxxcEr, March 15th. 
1902. p. 717. 

8 W. B. Hadden : Transactions of the Clinical Society of London, 
vol. xvll., p. 105 

10 IV. G. Spencer: Ibid., vol. xxxl., p.89. 

11 F. von Winiwarter: " LTeber eine eigenthiimllclie Form von 
Endarteritis und Bndnphlebitis mit Gangrau des Fusses," Archiv fur 
KtioiacheChirurgie. Berlin. 1879. vol. xxiii., p. 2o2. In C Fried lander's 
original paper on Arteritis Obliterans, Centralbl&tt iurdie Medlcinischen 
Wissenschaften. Jan. 22nd, 1876. the process of obliterative arteritis was 
discussed with no special reference to the present class of cases 
17 C. Sternberg. Wiener Kllntscbe Wocheriscbrift, 1895, Nos. 37 and 39 

7 ^A. A. Wwedensky ; Archiv tiir Kliuiache Chirurgie. 1898, vol. Lvii., 

17 Zoege-Manteuffel: Ibid.. 1891, vol. xlii., p. 569; and Deutsche 
Zeitschrift filr Chirurgie. 1898. vol. xlvil., p. 461. 

11 Bunge : Archiv fiir Kllnlschc Chirurgie, 1901, vol. 1x111., p. 467. 

1,1 P. Wulff: Deutsche Zeitschrift ftlr Chirurgie, 1901, vol. Ivl if., 


von Wartburg, 17 and the relation of the vascular changes to 
the phenomena of Charcot's “intermittent claudication of 
extremities ” has been repeatedly considered by W. Erb 18 of 
Heidelberg and many others. I suspect that the cases 
described by Dr. H. Batty Shaw under the heading “ Erythro- 
melalgia ” in a past volume of the Transactions of the Patho¬ 
logical Society of Loudon 18 were really examples of a 
similar arteritis obliterans. At the recent meeting of the 
Association of Physicians of Great Britain and Ireland 
(London, 1907) Dr. E. S. Reynolds of Manchester described 
some typical cases of intermittent claudication of extremities 
from the clinical point of view. No operative interference 
had been necessary in bis cases. 

Gangrene may sometimes, as in the case jost described, be 
delayed for years. In a man now 44 years of age (like¬ 
wise of the Hebrew race) with arteritis obliterans in the 
right lower extremity the affection has remained at least 
two years to my knowledge without gettiog worse. Curiously 
enough, some of the cases with the most decided "inter¬ 
mittent claudication ” seem to escape gangrene longest, as 
if, as Erb maintains, there were a decided nervous element 
in those cases in addition to the arterial obstruction. 
Similarly, with angina pectoris, it is often not the patients 
with the best marked attacks who die first. It must not be 
forgotten that “ intermittent claudication of extremities ” 
may be due to other kinds of arterial obstruction (such as 
that connected with an aneurysm) besides the so-called 
“idiopathic arteritis obliterans” which I have been 
discussing. On the other hand, this idiopathic arteritis 
obliterans of extremities does not invariably give rise to the 
typical phenomena of intermittent claudication. Thus, in 
the case of a Russian Jew, aged 52 years, whom I have 
recently seen, the complaint has been of pain in the instep 
or in the big toe of the right foot which commenced about two 
years ago but there has been no real intermittent claudication 
on walking. Yet pulsation in the dorsalis pedis artery is 
quite abseot on the right side, though easily felt on the left 
side. In that patient, however, pulsation in the tibialis 
postica artery of the affected extremity can be felt. 

Intermittent claudication of extremities (“intermittent 
limping,” “dysbasia intermittens" of Erb, 30 dyskinesia 
intermittens,”“dyspragia intermittens" 33 ) was <ie«cribed 
by H. Bouley 33 (1831) in horses, by Charcot 31 (1858) in 
men, and afterwards by many other writers.. Great analogy 
between the phenomena of arterial obstruction in the leg and 
the phenomena of angina pectoris has been insisted on by 
Allan BnrnB 35 (1809), Sir Benjamin Collins Brodie 30 (1846), 
Potain 37 (1870), and notably by Hnchard. 38 Some authors 


17 O. von Wartburg : Beltriige zur Kliuischen Chirurgie, 1902, 
vol. xxxv., pp. 656-670. 

1'Vide W. Erb, “Ueber das intermittlerende Hinken,” Deutsche 
Zeitschrift filr Nervenhellkunde, Leipzig, 1898 vol. xiii., p. 1. and Krb's 
later writings on the subject, including “Ueber Dyslmia Angiosklero- 
rotica (l-termittierendes Hlnken)," Miincbener Medicinische Wocben- 
schrlft, 1934, vol. xxi , p 905; "Ziir Kasuistik der Intermittierenden 
Angiosklerotii'chen Bewegungsstdrungen (Dysbaale Dyskinesie) des 
Menschen,” Deutsche Zeitschrift fiir Nervenhe Ikundo, Leipzig. 1905, 
vol. xxix., p. 465; and Ein weiterer Fall von Angiosklerotischer 
Bewegungsstorung des Armen, ibid . 1906, vol. xxx., p. 20i. 

19 1903, vol. liv., p. 168. 

20 The term suggested by Erb (in 1898) was “dysbasia intonnittens 
angiosclerotic*. ” 

91 Owing to the affection not being necessarily confined to the lower 
extremities but sometimes affecting the arms the term “ Dyskinesia in¬ 
termix tens angiosclerotica” was regarded as preferable by U. Determann, 
Deutsche Zeitschrift ftir Nervenneilkunde, 1905, vol xxix., p. 152. 
Amongst more recent papers see alsoOehier, “ Ueb«*reinen Bemerkens- 
wer'en Fall von Dyskinesia Intermittens Braehiorum.” Deutsches 
Archiv fiir Kliniscbe Medicln, Leipzig. 1907, vol. xcli., p. 154. 

2 - Tbe term “Dyspragia intermittens angiosolero .ioa" was intro¬ 
duced by N. Ortner in reference to analogous disorders in the Intes¬ 
tines and abdominal viscera. See N. Ortner, • Zur Klinlk der 
Angiosklerose der Dannarterien (Dyspragia intermittens angio¬ 
sclerotica intestinalis),” Volkmann’s Sammung Klinischer Vortrfige, 
Leipzig 1903 No 347. For such disorders of the abdominal viscera the 
term ‘angina abdominis" has been used by F. Perutz, Miinchener 
Mediciniache Wocbensehrift 907, No 22. p. 1' 75. 

23 H. Boulev : Archives Generates de Mrdecine, Paris, 1831, vol. xxvil., 
p. 425. Bouley first introduced the term “claudication inter- 
mittente.” 

24 Charcot: Comptea Rendus de la Soci£t4 de Biologie, Paris, 1858, 
vol. v., p. 225. 

23 Allan Burns: Observations on some of the most Frequent and 
Important Diseases of the Heart. Edinburgh, 1809 Professor Osier, 
in his well-known Lectures on Angina Pectorla, New York Medical 
Journal, Oct 31st, 1896, p. 572) specially drew attention to this priority 
of Burns. 

20 Brodie: Lectures on Pathology and Surgery, London. 1846, p. 360. 

27 According to Hueliard. M&dadies du Occur, second edition, Paris, 
1893, p 517 and p. 608. Potain spoke of angina pectoris as “painful 
intermittent claudication of t he heart.” 

98 Huchard: Ibid. 





154 The Lancet,] DR. F. LANGMEAD : A NOTE ON CERTAIN PUPILLARY SIGNS IN CHOREA. [J„N. 18,1908. 


(G. L. Walton and W. E. Paul) 38 even speak of intermittent 
claudication of the lower extremity as “angina cruris.” 
“Angina cruris,” like “ angina pectoris," occurs much more 
frequently in men than in women. The interest of the 
present case lies chiefly in the remarkable spastic con¬ 
traction of the minute cutaneous blood-vessels of the 
foot which precedes the muscular cramp-like pains (angina 
cruris). For this reason the case might almost be 
described as one of “angina cruris (or rather angina 
pedis) vaso-motoria.” It presents in this respect a striking 
analogy to the form of angina pectoris described by 
Nothnagel 30 (1867) as “angina pectoris vaso-motoria,” in 
which the painful phenomena of angina pectoris were pre¬ 
ceded by contraction of cutaneous blood-vessels. Nothnagel 
in his cases thought that the whole symptom-complex was 
of vaso-motor origin and that there was no organic disease 
present, but by necropsies on two cases of angina pectoris 
with very decided vaso-motor symptoms Hans Curschmann 31 
proved the presence of sclerotic changes in one of the 
coronary arteries. Just as there are cases of angina 
pectoris (“ pseudo-angina ”) without organic disease of the 
coronary arteries, so according to Oppenheim and Hans 
Curschmann 33 there are probably also cases (though rare) of 
intermittent claudication of extremities without organic 
arterial disease—a “dysbasia intermittens angiospastica ” in 
contradistinction to '' dysbasia intermittens artei iosclerotica.” 
So also A. Westphal 33 has recently described the case of a 
woman, aged 43 years, suffering from recurrent attacks of a 
vaso-motor neurosis, during which temporary absence of 
pulsation in the dorsalis pedis artery was noted. 33 

The congested condition of the foot in the present case 
and in similar cases (best marked, of course, with the limb 
in the dependent position) is, I believe, of “conservative” 
nature, and it may be explained as an automatic attempt to 
compensate (for the arterial obstruction) by dilatation of 
capillaries and venules—that is to say, it may be explained as 
an automatic attempt to favour collateral circulation as far 
as possible, and to make up for deficiency of the arterial 
supply by increase of the total quantity of blood in the 
affected part. 3 ' 

Harley-street, IV. _ 


A NOTE ON CERTAIN PUPILLARY SIGNS 
IN CHOREA. 

By FREDERICK LANGMEAD, M.D. Lond., 
M.R.C.P. Lond., 

PHYSICIAN TO OUT-PATIENTS, PADDINGTON GREEN CHILDREN’S HOS¬ 
PITAL; MEDICAL REGISTRAR, 8T. -MARY S HOSPITAL. 


Little attention has apparently hitherto been paid to the 
changes in the movements of the iris muscles which are 
frequently to be seen in chorea. Most of the text-books 
confine themselves to the statement that the pupils are 
usually dilated, a few mention that inequality of the pupils 
has been described and that the smaller pupil is said to be 
on the side of the body which is more affected by pseudo¬ 
voluntary movements. For some years, during the routine 
examination of choreic children, I have observed and been in 


Walton and Paul: Boston Medical and Surgical Journal, April 3rd, 
1902. d. 351. 

8° Nothnagel: Deutsches Archiv fiir Klinisohe Medicln, Leipzig, 
1867, vol. ill., p 309. 

Hans Curschmann: “ Ueber Vasomotorische Krampfzustftnde bei 
echter Angina Pectoris,” Deutsche Medicinische Wochenechrift, 1906, 
vol. xxxii., p. 1527. See also E. Schmoil, "Ueber Motorische, 
Sensoriscbe und Vasomotorische Symptome verursacht durch Koronar- 
sklerose und sonstige Krkrankungen der Llnkseitigen Herzhalfte," 
Miinchener Medicinische WochenBchrift, 1907, No 41, p. 2027. 

** Hans Curschman: " Untersuchungen iiber das Functionelle 
Verhaltender Gefiiese bei Trophischen und Vasomotorischen Neurosen,’’ 
Miinchener Medicinische WochenBchrift, 1907, No. 51, p. 2519. 

A Westphal: " Ueber Hysterische Pseudotetanie rnitEigenartlgen 
Vasomotorischen Stdrungen,” Berliner Klinische WochenBchrift, 1907, 
No. 49, p. 1567. 

** Organic vascular changes may follow recurrent angiospasm, as 
noted in some cases of very chronic Raynaud's disease, but in some of 
these cases it must be remembered that there may be a syphilitic 
element present (especially congenital syphilis). 

35 Cf. F. P. Weber: " Sequel of a Case of Trophic Disorder of the 
Feet,” British Journal of Dermatology, 1902, vol. xlv., p. 392. In 
ordinary haemorrhagic infarctions of the luDg from embolisms we have, 
I believe, a striking Instance of automatic attempts (though ineffectual 
ones) to compensate for arterial obstruction by extreme dilatation of 
capillaries and venules. On the other hand, "local syncope" due to 
temporary angio-spaBtic conditions (such as those readily excited in 
some persons by the application of cold) may, as is well knowm, be 
followed by reactionary hyperemia when the vascular spasm ceases. 
Local congestion may, therefore, either accompany or alternate with 
arterial obstruction. 


the habit of noting other pupillary phenomena, a descrip¬ 
tion of which it is the object of this paper to give. 

1. Hippus. —The first is hippos. In many children who 
are more than slightly affected by the ordinary sthenic type 
of chorea the movements of the iris are extraordinarily wide 
and rapid. This is readily explained by the jerky move¬ 
ments of the eyeballs and the consequent quick and frequent 
variations in the amount of light which reaches the retime, 
and also the suddenly altering accommodation for the many 
objects which in turn are included in the visual field. This 
necessarily renders the detection of rhythmical oscillatory 
movements of the iris no easy matter, but during intervals of 
quiet these movements, which constitute hippus, are some¬ 
times noticeable. 

2. Peculiarities of movement of accommodation. —That 
the contraction of the pupils to accommodation may be 
extremely rapid and sudden has already been mentioned, but 
it will frequently be seen also, that the reaction is asynchron¬ 
ous on the two Hides, one pupil contracting, while the other 
remains temporarily dilated. This is especially marked when 
the pupils are unequal, the larger usually reacting more 
slowly. 

3. Contraction. —Contraction of the pupils both to accom¬ 

modation and to light is usually ill-sustained, and here again 
the affection may be unequal, so that when both are con¬ 
tracted one will sometimes be seen, as it were, to tire out 
and dilate whilst the other remains small. _ 

4. Varying inequality of the pupils. —It may be noticed 
in some cases that one pupil remains persistently smaller 
than the other during the complete examination. This may 
continue for several weeks and only be replaced by the 
normal equality when the child has recovered or, on the 
other hand, when next seen the pupils may be equal or that 
which was formerly the larger may now be the smaller. 

5. Eccentric pupils. —Eccentricity of the pupils may 
occasionally be present and may become better marked 
when the pupil is contracted and less obvious when dilated. 

As far as 1 have been able to judge, it wonld appear that 
these phenomena are by no means uncommon and bear no 
relation to any particular form of chorea. The pupil is no 
more often or obviously affected on the side on which there 
is greater movement, or paralysis, than on the other. Mere 
inequality of the pupils is of little significance, for it is 
commonly fonnd among children, but I have not found the 
hippus, the altered accommodation, or the eccentricity of 
the pupils, in any other general condition, except articular 
or cardiac rheumatism. This is of si ght interest from the 
point of view of the common etiology of rheumatism and 
chorea. 

Oxfoid-terrace, W._ 


A CASE OF IMPERFECT DEVELOPMENT: 
ACRANIA. 

By ALEXANDER YULE, M.D. Aberd. 

On August 20th, 1906, I was called upon at 7.30 f.m. to 
visit a married woman, 27 years of age, who had been in 
labour since 2 p.m. of the same day. The pains were now 
constant and severe, with little, if any, intermission. The 
abdomen was of much greater size than is usual at such 
times and very tense. The child could not be distinctly felt 
through the abdominal walls. The membranes presented 
at a short distance from the external outlet but neither 
the os uteri nor the presenting part could be made out. 
The membranes meanwhile continued to descend slowly. 
Between 12 and 1 A.M. on August 21st the membranes 
ruptured with copious gushing of liquor amnii. I then 
introduced my hand into the vagina and found the cavity of 
the pelvis unoccupied but sufficiently extended to have 
received the head of a child at the concluding period of 
labour. I thereupon carried my hand upwards and reached 
a fairly well dilated os uteri immediately above the brim of 
the pelvis. The presentation could not be understood and 
appeared to be a ronnded hardness, in conjunction with what 
suggested the idea of a small collection of bones. It was 
clear that delivery had to be attempted. The obstructions 
accordingly were put to one side, the hand was introduced 
into the uterus, a foot was seized, and delivery was speedily 
effected by version. For some time after this liquor amnii 
kept pouring away, saturating the bed and dripping through 
to the floor. 

With regard to the aspect and conformation of the child. 


Thk Lancet,] MR. WALTON : BONE CAVITIES TREATED BY STOPPING WITH PARAFFIN. ;[JAN. 18,1908. 1 £5 


the accompanying illustration taken from the “Cjclopsediaof 
Obstetrics” by Charles Clay, M.D., and published at Man¬ 
chester in 1858, gives a better idea of the appearances pre¬ 
sented than any verbal description could convey. The illus¬ 
tration is a precise representation of what was seen so far as 
shoulders and face went. The presentation is hereby also 
explained and the improbability of the child passing through 
the os uteri unaided, the shoulders and what represented the 



bead being between them and filling up the dilatation of 
the os uteri with the foetus beyond its circumference and 
within the uterus. 

Hitherto her labours have been natural and she has three 
children. In most cases of defective development of this 
kind labour has been premature and the foetus dead. When 
the foetus is dead and premature it may be assumed that the 
superabundant liquor amnii described by observers in such 
cases would aid delivery by the free downward rush, accom¬ 
panied by pains. Expulsion also would be facilitated by the 
circumstance of the yielding nature and quality of being 
easily moulded and compressed of that which is dead and 
decomposing in contradistinction to that which is alive. In 
the present case there was no descent of the child on account 
of malposition. Had Nature been left to her unaided efforts 
there i6 reason to believe that the liquor amnii would have 
drained entirely away and that the foetus would have 
remained in the firm embrace of the contracted uterus, 
with ineffective attempts at expulsion. 

The foetus was a full-term male and as far as outward in¬ 
spection went complete, with the exception notified. On 
birth it lived for a few minutes—the eyes moving and 
rolling, muscular movements passing over the body and 
limbs. Subsequently rigor mortis was well marked, and the 
length of the child was over 17 inches. The mother said 
that she had been frightened about the supposed time of her 
conception but 1 do not consider that this bad anything to 
do with what is here described. The subsequent course of 
her recovery was uneventful. 

Guildford. _ 


SOME CASES OF BONE CAVITIES 
TREATED BY STOPPING WITH 
PARAFFIN. 

By ALBERT J. WALTON. FRC.S.Exg., L.R.C.P. Lonu., 
t BSc., 

.ASSISTANT DIRECTOR, PATHOLOGICAL INSTITUTE ; LATE HOUSE SURGEON, 
LONDON HOSPITAL; LATE SENIOR HOUSE SURGEON AND REGISTRAR, 
SCHOOL OF TROPICAL MEDICINE, ROYAL ALBERT DOCKS. 


Up to a few years ago the treatment of chronic abscess of 
bone and chronic osteomyelitis was in a very unsatisfactory 
state ; the condition was treated by palliative means for a6 
long as possible, during which time the cavity increased in 
size until it reached the surface. It was then opened, 
scraped, plugged with gauze, and gradually filled from 
below. Now, as the newly-formed granulation tissue had 
to be converted in sequence into fibrous tissue, osteoid tissue, 
and finally true bone this process took a long time to com 
plete, a cavity of the size of a hen’s egg usually remaining open 
for about four months and then resulting in a scar, which 
was depressed and adherent to the underlying bone and very 
liable to break down. To overcome the loDg convalescent 
period many attempts have been made to fill the bone cavity 
with various substances, the wound is then sewn up, and 


having healed by primary union the substance in the cavity 
is gradually absorbed and replaced by bone, but as the wound 
is quite healed the patient is able to go about his usual work 
and is independent of the changes going on in the bone 
beneath the surface. 

In the evolution of the present methods the following 
materials have been used as stopping : —1. Blood clot. This 
did well for small cavities provided they were made perfectly 
aseptic but in larger spaces it is liable to break down. 

2 Strands of catgut were placed in the cavity in the hope 
that the blood would clot more firmly around them. This 
was not found in practice adequately to fulfil its object. 

3. Pieces of sterilised 6poDge. These wej e not absorbed and 
hence did not carry out the main object of their use. 

4. Pieces of decalcified bone. With these the crevices could 
not be filled, which seems to be one of the essentials of 
success, and in the majority of cases their use was followed 
by failure. 5. Plaster-of-Paris. This could be well sterilised, 
but it took a long time to set firm, was not absorbed at all, 
and in most cases led to such irritation that it was ultimately 
discharged, leaving the cavity to be filled up from below, 
with the presence of an open wound. 6 The method intro¬ 
duced by Mikulicz of filling up the cavity with a mixture of 
iodoform and paraffin. This, wi,h modification f, is the method 
now generally in use. Moorhof uses a mixture of iodoform, 
60 parts, spermaceti and oil of sesame of each 40 parts, this 
mixture being chosen, first, because of its antiseptic 
properties and secondly, because it is said to be more easily 
absorbed than paraffin. In 1905 he had recorded 195 cases 
of different sorts without a single failure. Cases treated in 
a similar manner have been recorded in this country by 
Seymour Jones and Corner. 1 The cavity is scraped out, 
sterilised, and dried carefully so that the mixture may come 
into contact with every part of the wall ; it is then filled 
with the mixture and alter this has set firm the soft parts 
are sewn over it. 

In the first of the three following cases such a method was 
tried but without success. On considering this case and 
several others of similar failure attempted by various 
surgeons it appeared to me that certain modifications might 
be applied which would decrease the likelihood of failure, 
and on putting them into practice, as in the last two cases, I 
found the method was completely successful. Tfce notes of 
the cases are as follows. 

Case 1.—The patient, a youth aged 18 years, was 
admitted to the Londoo Hospital on May 6 h, 1907. Six 
months before admission an abscess had formed in the right 
ankle. One month later the abscess was opened at an 
infirmary where he had been since with sinuses still dis¬ 
charging. He was then sent to the London Hospital for 
further treatment. On admission there was a sinus one inch, 
above the right external malleolus, which ran in for one inch 
leading to the bare end of the tibia ; over the lower end of 
the anterior surface of the right tibia was a scar three inches 
long, with a sinus at the upper end leading to bare bone. 
The tibia was much thickened beneath the scar ; two inches 
above its upper extremity was another 6inus leading to bare 
bone. A radiograph showed much thickening, with irregular 
formation of new bone around the lower end of the tibia ; in 
the centre of this could be seen a sequestrum about two 
inches in length with an irregular outline. 

At the operation an incision was made over the scar and 
the outer wall of the involuernm was removed ; the 
sequestrum was loosened by chiselling and removed; the 
sinuses were scraped and the cavity was plugged with sterile 
gauze strips. The wound was replugged daily until the 
tenth day. On this day an anaesthetic was read ministered, 
the cavity was scraped out, and the bleediDg was stopped as 
far as possible with pressure by gauze plugging. The peri¬ 
osteum was reflected but was found to be very thick, 
cartilaginous, and inelastic, so that it could not be drawn 
across the cavity. Attempts were then made to dry the 
cavity with a modification of Moorhol’s apparatus, air 
being parsed through tubes containing formalin and calcium 
chloride to dry the air. It was, however, fouud impossible 
to get the walls perfectly dry. The cavity was then filled 
with Moorhof’s mixture, this being poured in at a tempera¬ 
ture of 114° F., at which it is a liquid. It did not harden 
well or quickly in the cavity. The periosteum was sewn 
across with P*genstecher thread as far as possible and the 
skin was united with silkworm gut. On the day after the 
operation the patient’s temperature rose to 102° and a bright 


1 St. Thomas's Hospital Reports, vol. xxxil., p. 433. 




1 56 The Lancet,] MB. WALTON: BONE CAVITIES TREATED BY STOPPING WITH PARAFFIN. [Jan. 18,1908. 





The Lancbt,] MR. F. W. ALEXANDER : ELECTROLYTICALLY PRODUCED FLUIDS, ETC. [Jan. 18, 1908. 157 


liad apparently greatly decreased. Radiographs taken at 
regular intervals showed gradual absorption of the paraffin 
and replacement by bone. Radiographs showing this 
absorption were submitted for publication, but were not 
capable of reproduction. 

Here, then, are two cases varying greatly in their clinical 
character, one due apparently to a very attenuated staphylo¬ 
coccus and the other probably tuberculous, both of which 
reacted well to this form of treatment, the active disease 
being cut short and the convalescent period being greatly 
shortened from that of even the most satisfactory cases 
•where methods of opening, scraping, and draining are 
employed, being in these cases two weeks as compared with 
from two to four months by the other method, and the final 
results seem to be remarkably good. Apparently not only 
is the paraffin slowly absorbed and replaced by new bone, 
but a large amount of the inflammatory new bone deposited 
around the shaft is also absorbed as soon as the irritant 
material has been removed. 

To secure good results the following points seem to be 
necessary. First, the wound should be carefully protected 
by gauze from contamination with the material in the abscess 
cavity or the irritant substances used to sterilise and to dry 
the cavity. Secondly, the operation should be completed 
in one Btage so that good apposition of the edges of the 
periosteum and skin may be insured. This does not in any 
way seem to prevent the sterilisation of the cavity, the only 
argument in favour of doing it in two stages. Thirdly, 
paraffin of a melting point of 120° F. should be used to fill 
the cavity. Many cases have now been recorded by Stephen 
1’aget where its use subcutaneously has been followed by 
success and one case where it was used to fill up a frontal 
sinus, the cavity in the bone being packed with it. 3 It sets 
more firmly than Moorhof's mixture and can be sterilised 
more readily and has no local or general toxic characters, 
whilst the argument used against it that it is not absorbed 
does not from these cases seem to be correct. 

For permission to publish these cases I am much indebted 
to Mr. C. W. Mansell Moullin, under whose care the patients 
were. 

.London Hospital, E. 


ELECTROLYTICALLY PRODUCED FLUIDS 
CONTAINING HYPOCHLORITES, 
THEIR MANUFACTURE, AND THE 
RATIONALE AND CHEMISTRY 
OF THE PROCESS FOR 
SECURING STABILITY. 

By FREDERICK W. ALEXANDER. L.R C.P. Emu., 
M.R.C.S. Eng., D.P.H, 

MEDICAL OFFICER OF HEALTH OF THE METBOI'OLITAZV UOEOUGK 
OF POPLAR. 


In the metropolitan borough of Poplar the Hermite 
process of making an electrolytic disinfecting fluid has been 
in operation for a period of nearly two years. The fluid has 
been made throughout at an average strength of from 4 Z to 
4'8 grammes or more of available chlorine per litre and 
by appropriate treatment has been rendered exceedingly 
stable, thereby enabling it practically to maintain an un¬ 
diminished strength for months, and even extending to 
years, as samples taken and kept since the installation 
of the plant prove. Owing to the evanescence of the 
chlorine great difficulty was experienced at first in ren¬ 
dering the fluid stable. I was occasioned much anxiety, 
as the process that I had recommended and which 
had been adopted by my council was not giving the satis¬ 
factory results that I had anticipated and had been led to 
hope for. I had been assured, and in turn had assured my 
council, before adopting the process, that the fluid could be 
rendered quite stable by the addition of certain chemicals. 
In September, 1905, I had given to me a note relative to the 
bases formerly used to render stable the fluid made by the 
Hermite process—namely, lime and caustic soda. Neither 
of the processes was adopted. I had ascertained that by 
merely adding a solution of caustic soda to the fluid it would 
roduce stability, but such I found on experiment would not 
ring about the desired effect, for fluid made at 4 • 8 grammes 

t Brit. Med. Jour., August, 1905. 


of available chlorine per litre began to degenerate imme¬ 
diately it left the electrolysers and in a very few hours 
only gave a test of 2 0 grammes of available chlorine 
per litre and continued to diminish in strength. Then, 
after the addition of cauBtic Boda, the carboy was 
necessarily shaken for some minutes, but shaking a 
carboy of 150 pounds weight by hand was, of course, a 
most difficult operation. Better results, however, were 
certainly obtained by half filling the carboy. It was 
observed that upon the addition of caustic soda to the 
electrolytic fluid a white precipitate was formed which 
immediately fell to the bottom of the carboy. The pre¬ 
cipitate was, of course, hydroxide of magnesium and the 
shaking of the carboy caused this insoluble and not easily 
diffusible compound to be distributed throughout the fluid 
and to give it a milky appearance, and it was found that the 
more milky in appearance the fluid became the more stable 
was the fluid rendered. The white precipitate ultimately 
settled at the bottom of the carboy and the fluid became 
quite clear. Having arrived at this point, and in order to 
secure the desired full amount of chlorine in the fluid from 
the moment it leaves the electrolysers, arrangements were 
made to drop the solution of caustic soda into the carboys and 
to stir whilst they were being filled, and by another simple 
mechanical arrangement the hydroxide of magnesium and 
the electrolytic fluid were mixed well together by stirring 
the mixture in the carboys immediately after the process of 
filling. For my present purpose I need not further describe 
this arrangement and the apparatus for mixing. Careful 
thought and experiments have explained to me the rationale 
of this process and my explanation will possibly throw some 
light upon the whole process of the electrolytic production of 
hypochlorites. 

To understand the process of making the fluid stable one 
must first comprehend what is common knowledge respect¬ 
ing the electrical action within the electrolysers and to find 
out if there be any point which has been previously over¬ 
looked. I venture to say that my observations and experi¬ 
ments have demonstrated there it a point and this the 
crucial one, the discovery of which has teen most gratifying 
and which I consider well worth all the trouble I have taken 
in this direction. The Hermite process adopted at Poplar, 
which no doubt will give a key to all other processes, has 
been described as follows :— 

(а) When » solution of s mixture of magnesium chloride and sodium 
chloride is submitted to the action of an electric current of the proper 
strength in a special apparatus called an electrolyser, the magnesium 
chloride is decomposed by the electric current, as also is the water. 
Nascent chlorine and nascent oxygen or ozone are formed at the 
positive pole. These two bodieB immediately combine and iorm an 
oxygenated compound of chlorine, unstable,* but of great oxidising 
power. This chlorine compound is soluble in the liquid in which it is 
formed. The hydrogen Droduced by the decomposition of the water 
and the magnesium are*set free at the negative pole, the latter de¬ 
composing the water and producing magnesium hydrate, of which part 
combines with the chlorine compound set free, and the rest remains iu 
suspension in the tank. 

The Bodium chloride acts ss a conductor for the electric current. 

The solution of the chlorine compound obtained by t his method has 
only a slight smell of chlorine, it is nearly neutral. Its strengt h can be 
easily tested by the usual arsenious acid test.—Extract from a 
pamphlet upon Sanitation by Electricity—Ilermite System. 

Or again:— 

(б) The principle of this process is passing a current of electricity 
through sea water, or if sea water is not handy, a solution 
of magnesium and sodium chlorides; a portion of these chlorides 
is converted into hypochlorite, a substance which disinfects, 
deodorises, and bleaches similarly to the active ingredient of 
bleaching powder—calcium hypochlorite. The change from chloride 
to hypochlorite takes place almost entirely with the magnesium salt- 
yielding magnesium hypochlorite MgCIOV. It. is found, however, that, 
in the electrolysers and tanks a white dei>oait, takes place, consisting of 
magnesium oxide combined with water, viz., magnesium hydrate, 
showing that the magnesium hypochlorite haa decomposed, forming 
magnesium hydrate, which precipitates, leaving hvpochlorous acid in 
solution. The action may take place as follows: "lilg(C10) 2 + 211-0= 
MgtUOlo -f 2HC10. The amount oi oxidising power is expressed by tbe 
quantity of available chlorine in grammes per litre, the usual working 
strengths being from 0 5 to 1 0gramme per litre of solution.—From a 
paper read iieiore the British Association by J. Napier, F.C.S., F.I.O., 
borough and county analyst, Ipswich. 

Now is this chemical expression right? I venture to 
suggest that it is not, for the reason that the major portion 
of the white deposit in the electrolysers is an oxychloride of 
magnesium (MgCl(OCl)) and the formation and accumu¬ 
lation of this deposit is the bete noire of the process. I have 
explained in another place how difficulties of working tbe 
electrolysers on account of this formation of oxychloride of 
magnesium are at present surmounted. No doubt there is a 
limited quantity of hydroxide of magnesium in the deposit 
bit not much. I have caused an analysis to be made of the 




158 Thb Lanobt,] MR. F. W. ALEXANDER: ELECTROLYTICALLY PRODUCED FLUIDS, ETC. [Jan. 18. 1908. 


deposit NaCl is cot acted npon to an; extent, if any at all, 
bnt carries the current to the MgCl a , and there is formed, 
according to the above description (a), magnesium hypo¬ 
chlorite in solution and magnesium hydrate in suspension; 
and. according to description (i), bypochlorous acid in solu¬ 
tion and magnesium hydroxide in suspension ; but nothing 
is said in either instance about the deposit of oxychloride of 
magnesium. 

Now I venture to suggest, and I think it can be proved, 
that there are in the electrolysers in solution both hypo¬ 
chlorite of magnesium and hypochlorous acid. What really 
must occur during the electrolytic process is that hydroxide 
of magnesium is certainly formed at the negative pole and 
unstable compounds of oxygen and chlorine at the positive pole 
and the hydroxide of magnesium endeavours to combine with 
these unstable compounds of oxygen and chlorine. Some of it 
no doubt does do so, but a large portion, possibly half, for 
reasons which will be given further on, is prevented from 
doing so by the formation of the oxychloride of magnesium 
or there may not be sufficient hydroxide of magnesium 
formed to combine with all the unstable compounds of 
oxygen and chlorine, so that clearly what one has to do to 
render the fluid stable is either to assist the process by the 
addition of hydroxide of magnesium whilst the electrolysis 
is taking place or to complete the process afterwards by the 
addition of hydroxide of magnesium after the flnid has left 
the electrolysers or to combine both methods. It most be 
remembered that hypochlorite of magnesinm is stable for 
practical purposes when kept in non-actinic bottles and 
stoppered with paraffined corks or kept away from the light, 
but hypochlorous acid is very unstable even in the dark. 

In Poplar there is added and kept stirred within the fluid 
to be electrolysed a small quantity of hydroxide of magnesium 
the object of which is obvious—namely, to assist in picking 
op the unstable compounds of oxygen and chlorine formed at 
the positive pole. Now, if the heaped-up deposit in the 
electrolysers and which deposit lies closely against the 
positive pole were hydroxide of magnesium, where would be 
the necessity to add this compound ? It speaks for itself 
that the deposit is not hydroxide of magnesium but 
magnesium oxychloride. Now for a step further. When 
sodium hydroxide is added to the electrolysed solution the 
following change is said to take place :— 


^-OCi NaOH 

Mg MgC] 2 + 

"-OC1 NaOH 


^OH OC1 

= Mg + Mg (NaCl) 2 , 
'-OH OC1 


the magnesium sodium double salt being considerably more 
stable than the corresponding magnesium one. 

This may be so, but I venture to say that the double 
magnesium sodium salt is not formed and here I would call 
attention to the fact that the hydroxide of magnesium fails 
to the bottom as mentioned in the first part of this paper 
and the fluid will not remain stable unless it be rendered 
milky throughout, either by shaking or stirring, which in 
other words means that the hydroxide of magnesinm, which 
is extremely insoluble aud not diffusible, must, in order to 
fix the unstable and evanescent compounds of oxygen and 
chlorine—that is to say, to preserve tbe strength of the 
fluid—be brought into immediate and absolute contact with 
such compounds by making the fluid milky throughout, then 
the hydroxide of magnesium having done its work, the 
surplus sinks to the bottom of the carboy. In order to 
make hydroxide of magnesium soluble it requires 5000 parts 
of water at 15'5° and 36,000 parts at 100°. Will the 
addition and stirring of hydroxide of magnesium in the 
electrolytic fluid answer tbe same purpose ? Yes, certainly 
it will, and 1 find it will answer much better than 
the addition of sodium hydroxide for a reason I will 
presently state ; therefore, it cannot be that a magnesium 
sodium double salt is formed when magnesium hydroxide is 
added instead of the sodium hydroxide. Hydroxide of 
magnesinm has no action upon the already formed hypo¬ 
chlorite of magnesium, hence it must be the unstable com¬ 
pounds of chlorine and oxygen present in conjunction with 
the hydroxide of magnesium which effect the result afore¬ 
mentioned. To pursue the case further I have added and 
stirred into a filling carboy oxide of magnesium in place of 
hydroxide of magnesium and have rendered the fluid quite 
stable and obtained the same results, and in this instance no 
double magnesium sodium salt could have been formed, and 
oxide of magnesium will not act upon hypochlorite of 
magnesium. Carbonate of magnesium 1 have found up to 
the present not satisfactory as the unstable compounds of 


oxygen and chlorine in the strength of solution manufactured' 
will not displace carbonic acid. 

The following experiment which I have carried out is, no 
doubt, interesting and assists my contention. Electrolytic 
fluid was being made at 4'818 grammes of available chlorine 
per litre, i lb. carbonate of magnesium was placed into the 
specially constructed 15 gallon carboy, and the electrolytic 
fluid as it came direct from the electrolysers was allowed 
to run into tbe carboy and during the time of filling kept 
well stirred with the carbonate of magnesium, of course 
making a very milky fluid, and when this carboy was filled a 
final stir was given by means of the geared stirrer. Into 
another 15-gallon carboy £ lb. of oxide of magnesium was 
placed and a similar process as mentioned above in the case 
of the carbonate was carried out. In due course the fluids 
cleared themselves and sediment formed. Tbe electrolytic 
fluid, as mentioned above, was being made at 4 ■ 818 grammes 
of available chlorine per litre and within 24 hours the fluid 
with the carbonate of magnesium gave a test result of 2'741 
grammes of available chlorine per litre, but the one con¬ 
taining the oxide of magnesium remained at 4 ■ 818 grammes 
per litre. 

Fluid made at 4'818 grammes per litre and mixed with 
carbonate of magnesium— 

At expiration of 24 hours gave 2-741 grammes per litre. 


.. 48 ,, 

. 2 064 

.. 72 „ 

, 1'870 

„ 96 „ 

. 1-691 

„ 120 „ 

. 1-690 

.. 168 „ 

, 1-500 

„ 192 „ 

. 1-472 

.. 216 „ 

. 1-394 

„ 37 day* 

. 0-963 

* After continued testing* and exposure*. 


And fluid made with oxide of magnesium and made at 4'818 
grammes per litre— 

At expiration of 24 hours gave 4-818 grammes per litre. 


, 48 „ 


4*818 

. 72 „ 


4818 „ „ 

, 96 „ 


4 818 

, 120 „ 


4-818 

, 168 „ 


4 676 

, 192 „ 


4 676 

, 216 „ 


4 676 

, 37 day* 


4-416 

* After continued testing* and exposure*. 


This no doubt shows that there were 2-741 grammes of 
available chlorine per litre due to hypochlorite of magnesium 
and 2 • 077 grammes of available chlorine were due to hypo- 
chlorous acid or other unstable componndg of oxygen and 
chlorine. The fluid upon standing in the carboy in which 
the oxide of magnesium was stirred gave an alkaline reaction 
and tbe fluid upon standing in the carboy with carbonate of 
magnesium added gave a faintly acid reaction. This clearly 
proves that hypochlorons acid or the other unstable 
compounds of oxygen and chlorine are not strong enough in 
the strength of the manufactured solution to displace the 
carbonic acid from the carbonate of magnesium but readily 
combine with the oxide of magnesium and the fluid becomes 
also alkaline. The continued dropping in strength of the 
available chlorine in tbe carboy with the insoluble carbonate 
of magnesium Is undoubtedly due to the exceedingly unstable 
hypochlorous acid or other unstable compounds of oxygen 
and chlorine which lose some chlorine in the first state, the 
remainder being converted into hydrochloric acid which 
then slowly but steadily acts upon the hypochlorite of 
magnesium. 

It is obvious that the stable solutions of electrolytically 
made hypochlorite of magnesinm are preferable to those of 
sodium and potassium or even calcium, because for fixing 
purposes there would have to be used hydroxide of the 
metals of the alkalies which are extremely caustic, alkaline, 
and very soluble, and where varying strengths of electrolytic 
fluid containing the hypochlorites of sodium and potassium 
are produced one may add too much or too little of the 
hydroxides of the alkalies. Tbe hydroxide of the alkaline 
earth calcium may also be used as stated in the first portion 
of this article, but when the extremely insoluble hydroxide 
or oxide of magnesium is added and stirred in the manner 
described one can add and stir in any quantity but only the 
necessary amount will be absorbed. Besides, the alkalinity of 
the hydroxide of magnesium can only be observed by placing 















The Lancet,] 


ROYAL SOCIETY OF MEDICINE: SURGICAL SECTION 


[Jan. 18,1908. 159 


-a small portion in the moist state upon test paper which 
clearlj shows as well as its Insolubility that it is not a strong 
alkali. By very simple means the hydroxide or the oxide of 
magnesium can be added to the Said in the electrolyser and 
kept stirred in it immediately it has passed over the last 
weir, thereby securing the full amount of chlorine. I 
think it is common knowledge that metallic hypochlorites 
of the alkali metals and alkaline earths may be 
obtained in the pure state by neutralising hypochlorous 
acid with certain metallic hydroxides of the alkali metals 
and alkaline earth groups, but to obtain hypochlorite of 
magnesium by means of the hydroxide or oxide of magnesium 
even upon a small scale, to say nothing of the large quantity 
manufactured in Poplar, is not common experience and 
knowledge. 

I particularly desire, in conclusion, to state that through¬ 
out my experience in the production and improvement of the 
electrolytic disinfecting fluid I have had no desire to pose as 
a chemist. I have been much interested in the Hermite 
process since the publication of the report of “ The Lancet 
Commission ” in the year 1894, and since the plant has 
been working in Poplar for the last two years I have given 
close observation and continued attention to the process, in 
the course of which I have not hesitated to avail myself of 
the valued knowledge and experience in these matters of 
M. Hermite, the chemical knowledge of Dr. W. R. Hodgkinson 
of the Military Academy, Woolwiob, Dr. J. Gordon Parker 
of the Herald’s Institute, Bermondsey, and Mr. Albert E. 
Parkes, analyst for Stepney, to all of whom I am much 
indebted for the success achieved in the undertaking. 

Public Health Office, Bow-road, E. 


gtelrkaJ Sontties. 


ROYAL SOCIETY OF MEDICINE. 


SURGICAL SECTION. 

Subphrenic Abgcess. 

A MEETING of this section was held on Jan. 14th, 
Mr. J. Warrington Haward, the President, being in the 
chair. 

Mr H. L. Barnard read a paper on Some Surgical Aspects 
of Subphrenic Abscess. He discussed a series of 76 cases. 
After dealing fully with the anatomical subdivisions of 
subphrenic abscesses, he said that a right anterior 
intraperitoneal subphrenic abscess was situated between 
the upper surface of the right lobe of the liver 
below and the dome of the diaphragm above. In 
regard to the treatment of right anterior intraperitoneal 
subphrenic abscesses he said that in appendicitis when the 
infection was recent and the abscess was diffuse the right 
loin incision should be employed. In cases due to perforated 
.gastric and duodenal ulcers which presented in the epi¬ 
gastrium an anterior incision should first be made and when 
the perforation had been closed a counter-opening might be 
made in the loin. When the abscess had become well 
localised after ten or 14 days it wa6 better to drain it by the 
posterior transpleural or subpleural method, whether it pre¬ 
sented in the epigastrium or not, if the exploring needle 
could find pus in the lower intercostal spaces behind. The 
liver should be pressed up by an assistant so as to close the 
pleural space whilst the pleura was incised. Where the 
exploring needle failed to find pus behind and an 
epigastric swelling was present the anterior epigastric 
incision should be employed and the peritoneum opened 
as high up as possible in the subcostal angle. A 
right posterior intraperitoneal subphrenic abscess formed 
in the subhepatic pouch or the right renal fossa. It was 
a pyramidal space transversely disposed beneath the over¬ 
hanging margin of the liver. The abscess was bast 
drained by a loin incision as far back and high up as 
possible below the last rib. The index finger guided the 
drainage-tube transversely below the liver. Should the signs 
at the right baBe indicate the presence of pus under the 
dome of the diaphragm, the index finger should be inserted 
between the liver and the diaphragm, and a long tube passed 
up into the right anterior intraperitoneal subphrenic space. A 
left anterior intraperitoneal subphrenic abscess was also 
known as an anterior perigastric abscess or a perisplenic 


abscess. That fossa was bounded by the diaphragm above. 
In the acute and diffuse stage soon after perforation it was 
usual to open the abdomen in the middle line and to close the 
perforation. Practice then differed. The abdomen was some¬ 
times sponged out and closed altogether. In other instances 
a drainage-tube was passed into the pelvic fossa through 
a puncture above the pubes and the patient was sat 
up in Fowler’s position. Others drained from the anterior 
incision. He preferred to make a counter-opening in the left 
loin and to pass a tube up to the spleen and then adopted 
the Fowler position and the pelvic drain. When the abscess 
had become localised and pointed in the epigastrium it 
should be opened by a left epigastric incision as high up as 
possible in the costal angle. A large tube, irrigation, 
suction, and position were then usually enough to insure 
efficient drainage. Otherwise the abscess might be counter- 
opened by the posterior transpleural method, guided 
by a finger in the cavity. When the abscess had 
not extended forward to the front it was nevertheless well 
to explore it from the epigastrium and then to open 
it by the posterior transpleural method above the 
adhesions. The lateral subpleural method was suitable 
to some of these cases or a posterior or a loin incision 
might be made and a finger passed up through the 
adhesions to the spleen, after the general peritoneal cavity 
had been packed off. A left posterior intraperitoneal sub¬ 
phrenic abscess occurred in the small sac of the peritoneum. 
When the abscess pointed in front it should be cut 
into and drained, l’osterior perigastric abscesses should 
be explored from the front and drained from behind 
by a loin incision or the posterior transpleural route. 
The pouch between the Spigelian lobe and the spine was 
nearly inaccessible. A right extraperitoneal subphrenic 
abscess formed in the cellular space uetween the layere of 
the coronary and other peritoneal ligaments of the 
liver. When the absoess pointed in the epigastrium it 
should be opened there by an incision strictly in the 
middle line. In two of his cases he was able to reach 
the abscess without opening the peritoneum. With a large 
drainage-tube, irrigation, suction, and position counter¬ 
drainage was seldom necessary. If the abscess did 
not point in front it would probably be disposed of 
by puncture between the ribs behind over the area of dul- 
ness. The rule was then to use an exploring needle and 
to adopt the posterior transpleural method. Should the pus 
point in the right loin the abscess should be opened there 
and a tube be passed up into the subphrenic space. The left 
extraperitoneal subphrenic abscess formed in the cellular 
tissue in the left loin. A left loin incision over the swelling 
would sufficiently drain the pus away. He declared that 
it was clear that a promiscuous search for pus with an 
ineffective syringe was dangerous and deceptive, but the 
proper use of a good aspirating needle upon the operating 
table and under a full anaesthetic was the most certain 
means of diagnosis and it had never failed him. The 
only safe rule in thoracic operations was to follow the 
needle, and it was useless to make a large opening and 
admit air to the pleura, where the needle could demonstrate 
that no pus was present. Needling should never be aban¬ 
doned until it was certain that no pus was present, and it 
might be added that although the method was so free from 
risk when practised through the thoracic wall it was never 
safe to puncture abdominal swellings across the peri¬ 
toneum and through the abdominal wall because they 
afterwards leaked into the peritoneum. Of the 76 con¬ 
secutive cases which made up the series 40 lived and 
36 died, a mortality of 47 "4 per cent. 64 cases were 
operated upon of the series of 76 consecutive cases, and of 
these 24 died, making a mortality of 37 • 5 per cent. These 
operations were divided up as follows: 26 posterior opera¬ 
tions with seven deaths and four lateral operations with 
three deaths. Posterior operations were therefore more 
favourable. Of his own series of 21 consecutive cases 
submitted to operation, four died (19 per cent.); 15 of 
these operations were posterior with two deaths (13 3 per 
cent.), and nine were anterior with two deaths (22‘2 
per cent.). 

The President said that it would be interesting to know in 
what proportion of these cases of subphrenic abscess the base 
of the lungs was involved. 

Dr. F. de Havillanp Hall said that physicians were 
sometimes asked in cases where subphrenic abscess was 
suspected and there was a resonant area giving an amphoric 
sound whether the disease was above or below the diapt ragm. 





160 The Lancet,] 


BOYAL SOCIETY OF MEDICINE: CLINICAL SECTION. 


[Jan. 18, 1908. 


He described two cases of subphrenic abscess, in one of 
which the x rays were useful in diagnosing the condition. 
He emphasised the importance of an early diagnosis 
being made because otherwise if the cases were left they 
all died. 

Dr. Donald W. C. Hood said that he regarded fulminating 
pleuritis as an indication of trouble beneath the diaphragm. 
In eight cases of subphrenic abscess from gastric perforation 
the patients were admitted to hospital suffering from 
fulminating pleuritis without any symptom pointing to the 
stomach condition. 

After Dr. F. H. Hawkins (Beading) had related some 
interesting cases of subphrenic abscess, Dr. H. S. French 
inquired concerning pyrexia and leucocytosis. 

Mr. Barnard, in the course of his reply, said that in many 
of the cases of tubphrenic abscess the temperature ranged 
from 99° to 100° F. Leucocytosis was found in all of the 11 
cases in which it was looked for. The base of the lung was 
involved in 56 out of the 76 cases of abscess. In regard to 
diagnosing whether in any given case the seat of the disease 
was above or below the diaphragm he thought the best thing 
to do was to take into consideration the history of the onset 
of the malady which would afford the necessary clue. In 
one case in which he had tried the x rays they bad been 
of use. _ 


CLINICAL SECTION. 

Exhibition of Cates.—Status Lymphaticus. 

A meeting of this section was held on Jan. 10th, Sir 
Thomas Barlow, the President, being in the chair. 

Mr. R. G. Hanx showed a case of Polycythsemia with 
Enlarged Spleen without Cyanosis. The patient was a girl, 
aged 18 years, not very robust, but without symptoms apart 
from attacks of abdominal pain. She had two menstrual periods 
in her fifteenth year ; none since. The external genitals were 
infantile in character, there was no pnbic hair, and practically 
no mammary dei elopment. Her health had been better during 
the past year than during the preceding four years. She 
was growing and her weight was increasing. The spleen was 
considerably enlarged ; the surface was smooth and fairly 
even ; it was never tender or painful. There was no enlarge¬ 
ment of the liver. The heart was normal. There was no albu¬ 
min or sugar in the urine. She had never been cyanosed nor 
had she had jaundice. There was no history of hsemorrhages. 
Her blood was last examined by Dr. O. C. Giiiner on Dec. 30th, 
1907. The red cells numbered 6,200,000; they showed slight 
differences in size, otherwise they were normal. The white 
cells numbered 11,580 : polycuclears, 64 per cent.; lympho¬ 
cytes, 28 per cent.; large mononuclears, 6 1 2 per cent.; mast 
cells, 0 • 2 per cent. ; and eosinophiles, 0 8 per cent. The 
haemoglobin was 115 per cent, (Gaertner's apparatus) ; colour 
index, 0 915. The specific gravity was 1036 (Hammerschlag's 
method). Viscosity (water being 1) was 5 3. The osmotic 
pressure was measured in terms of NaCl by determining in 
what strength of NaCl haemolysis would not occur. In that 
way a 0'88 per cent. NaCl solution was found isotonic with 
the non-defibrinated blood. The hiemolysis was determined 
by centrifugalising the mixed blood and salt solution in 
Hamburger’s special pipette.— Dr. R. Hutchison suggested 
inherited syphilis as a cause in some of these cases and Dr. 
F. Parkes Weber commented on the difficulty of explaining 
the attacks of abdominal pain. 

Mr. J. P. Lockhart Mummery showed a case of Hemi- 
hypertrophy in a child. The patient was aged four and a 
half years. He was firBt seen in December, 1905, and had 
been under observation ever since. The parents and hiB 
brothers were healthy and there was no family history of 
congenital defects. All the measurements on the left side 
of the child’s body were larger than on the right side. The 
bones were larger and longer, the left eye was larger, and 
the left side of the tongue was larger. The child was, in 
fact, growing faster on the left side than on the right. As 
a result the child’s body was gradually assuming a curve, 
with the concavity to the right side. During the time the 
child had been under observation the condition had sensibly 
increased, otherwise the child was quite healthy and no 
abnormality or cause for the condition could be discovered. 
The right testicle was undescended and smaller than the 
left. 

Dr. Sidney P. Phillips showed a case of Multiple Telangi¬ 
ectases. The patient was a married woman, aged 56 years, 
subject to free bleeding from both nostrils since childhood ; 
since 1897 she had been bleeding at times from vascular 


patches on the tongue ; and in 1900 bleeding occurred from 
similar patches on the roof of the mouth ; in October, 1907, 
free epistaxis with bleeding from the toDgue and from small 
nsevus-looking spots on the lower lip occurred. The former 
bled occasionally when the teeth were cleaned. The father 
of the patient was subject to violent epistaxis and had some 
vascular elevations on the tongue which bled at times. The 
patieut’s sister died from haemorrhage of the gums. The 
patient had one child who had vascular elevations on the 
tongue but had bled from them only once. The patient had 
stigmata on the cheeks and scattered about the trunk small 
red spots of the size of a pin’s head, and several small elevated 
vascular patches on the lips and tongue which often bled. All 
the vascular patches hud shrunk considerably since she bad 
been in hospital for two months. 

Dr. F. Parkes Weber showed a case of Multiple 
Hereditary Developmental Angiomata (TelaDgiectaseB) of 
the Skin and Mucous Membranes, with Recurring Epistaxis, 
which was described in full in The Lancet of July 20tb, 
1907, p. 160. Similar cases had been recorded by Professor 
W. Osier and others. 1 —These last two cases were discussed 
by Dr. T. Colcott Fox, Mr. T. H. Openshaw, and Mr. M. S. 
Mayou. 

Mr. W. Sampson Handley showed a case of Excision of 
the Larynx and the Lower Half of the Pharynx for Malig¬ 
nant Growth of the Posterior Pharyngeal Wall in a woman, 
aged 44 years. Ten weekB ago a retro-laryngeal growth 
could be felt filling up the pharynx at its janction with the 
oesophagus. Bougies could not be passed and the patient 
was emaciated from inability to take food, even fluids being 
rejected. She was willing to undergo any risk for relief 
from her wretched condition. Ten days after a preliminary 
gastrostomy he excised the growth. A low tracheotomy was 
done and the whole of the larynx, the lower half of the 
pharynx, the uppermost portion of the oesophagus, and the 
left lobe of the thyroid were removed. One enlarged 
gland was found to the left of the pharynx. The 
upper ends of the trachea and oesophagus were closed 
by sutures. Her convalescence had been uninterrupted and 
on the second day she expressed herself as feeling better 
than before the operation. She had now, seven weeks after 
the operation, gained weight and improved in colour, and 
was very grateful for the relief obtained. Saliva passed 
into the stomach through a rubber funnel lyiDg behind the 
tongue, its narrow end emerging by a median fistula in the 
neck to be connected below with a rubber tube which passed 
into the stomach through the gastrostomy opening. Although 
no air passed through the mouth from the lungs the patient 
was able to speak in an intelligible whisper. At present food 
was given entirely by the gastrostomy opening, although 
the patient was able to swallow liquids in very small 
quantities. 

Dr. J. Graham Forbes showed a case of Congenital 
Absence of the Left Pectoral Muscles. The patient was aged 
45 years. With the exception of the clavicular attachment 
of the pectoralis major, which alone remained, the pectorales 
major and minor were absent on the left side. There was 
poor muscular development of the left arm and shoulder 
muscles but no paresis. 

Mr. A. E. Barker showed a case of Oerebro-spinal 
Meningitis complicating Otitis Media on which lumbar 
puncture had been performed. The patient was aged 31 
years and was shown to emphasise the point that lumbar 
puncture might be of remedial as well as of diagnostic value. 
The patient’s condition at the time the meningitis was found 
in the temporal region was almost hopeless, and when thick 
greenish turbid fluid was drawn off as well from the lumbar 
sac at tbe same time tbe prognosis was not improved. 
Continued drainage through the temporal wound and lumbar 
tapping of 20 cubic centimetres repeated about every two 
days at first was followed by steady improvement and 
ultimately convalescence. Fourteen tappings were made 
in all. 

Dr. Sidney Phillips read a paper on a case of Fatal 
Acute Illness in a child from “Status Lymphaticus.” He 
said that tbe patient was a boy, aged five and a half years, 
whose breathing began to be noisy and difficult on Oct. 12tb, 
1906 ; the breathlessness increased day by day and he was 
admitted into St. Mary's Hospital on Oct. 15th. Dr. Phillips 
saw him the same afternoon ; he was a well-developed, well- 
nourished boy, propped up in bed gasping for breath in great 


1 See especially Osier, (Quarterly Journal of Medicine, 1-07, vol. It* 
p. 53. 





The Lancet,] 


UNITED SERVICES MEDICAL SOCIETY. 


[Jan. 18,1908. 16! 


distress. The boy was too breathless to speak much but 
when he shrieked out, as he did at times in his extreme 
distress, the voice was quite clear. He had been sent into 
hospital for diphtheria but there were no signs of membrane 
anywhere. It was clear that the breathlessness was not dne 
to laryngeal or to pulmonary disease. All that could be done 
was to administer a little morphine which gave some 
temporary relief and he died during the night apparently 
from heart failure. The necropsy was made next day by Dr. 
B. H. 8pilsbury and nothing was found wrong in any organ 
of the body except an enlargement of the thymus gland 
and certain changes in the spleen and lymphatic glands. 
The case seemed to be an example of the affection at one 
time spoken of as “thymic asthma,” and more recently as 
"lymphatism” or the “status lymphaticun.” Similar cases 
had been recorded by Grawitz, 3 Jacobi, 3 and Dr. Crozier 
Griffith. 1 Each of these children had had convulsions, though 
not at the time of the fatal illness. Instances in which sudden 
death with dyspnccal attacks had been found associated with 
enlargement of the thymus and the lymphatic glands were 
so numerous that it had been concluded that there was more 
than mere coincidence. Death in these cases had been 
attributed to laryngo-spasm, but laryngismus stridulus did 
not kill off infants in this sudden way, and in none of the 
recorded cases was there any mention of the characteristic 
crowing breathing ; death, too, had appeared always to have 
resulted from cardiac failure. The theory of laryngo-spasm 
appeared to have been put forward in default of any better 
explanation at a time before the changes had been observed 
in the thymus and lymphatic glands. Death had been 
attributed to pressure upon the trachea by the enlarged 
thymus gland. Morfans s found the traphea flattened and 
its calibre narrowed in an infant aged two and a half months 
who died with an enlarged thymus gland. Koenig,” 
Perrucke, 7 and Siegle have each recorded a case in which after 
the enlarged thymus gland had been raised from over 
the trachea by operation the symptoms were relieved. 
Paltauf ’ advanced the theory that the enlargement of the 
thymus and lymphatic glands of the body were evidences of 
a constitutional state in which sudden cessation of the heart’s 
action might occur from very slight causes—among otherB 
administration of anaesthetics. This theory was supported 
by Escherich and it was suggested that the symptoms 
arose from a toxaemia the result of an over-secretion of the 
thymus gland; the affection had been called thymic 
asthma. More recently Blunder 9 had suggested that the 
toxic was not necessarily the thymus secretion but arose also 
from the lymphatic glands, being, in fact, a lympho- toxaemia. 
There was still much doubt on the subject and even if the 
affection were toxic it was open to question whether the 
lymphatic gland enlargement itself was not a result of some 
toxin possibly absorbed from the alimentary tract. In Dr. 
Phillips’s case, the boy being five years old was able to 
struggle against his breathlessness for some three days 
instead of succumbing at once, as was the case in young 
infants. During those three days his symptoms were 
certainly not due to laryngeal spasm and the necropsy 
showed they were not due to any pressure by the thymus 
gland. They seemed certainly more like toxic symptoms 
than anything else ; in fact, they were not unlike those some¬ 
times Been in what had been called uraamic asthma.—The 
paper was discussed by Dr. F. J. Poynton who described 
two cases, Dr. J. M. Bernstein, Dr. G. A. Sutherland, 
and Dr. A. E. Russell. _ 


LARYNGOLOGICAL SECTION. 

Exhibition of Cases and Specimens. 

A meeting of this section was held on Jan. 3rd, Dr. J. B. 
Ball, the President, beiDg in the chair. 

Mr. W. H. Kelson showed a case of Bleeding Polypus of 
the Nose in a woman, aged 20 years, who had suffered from 
epiataxis for four months. The polypus was attached to the 
floor of the nose just below the anterior end of the inferior 
turbinal. 

Dr. W. Jobson Horne showed a man, aged 43 years, with 


3 Deutsche Medicinische Woehenscbrift, 1888, vol. xiv., p. 429. 

» Transactions of the Association of the American Physicians, vol. 
vili., 1888. 

* Ibid., 1903. 

3 Society Medicale des Hdpltaux, 1894, p. 361. 

3 Centralblatt fur Chlrurgie, 1897, p. 605. 

3 Gazette Hebdomadsire de Modecine et de Chirurgle, 1889, p.695. 
a Wiener Kllnlsche Wochenschrift, No. 46,1889, and No. 9. 1698. 
s Transactions of the Association of American Physicians, 1903, p. 253. 


Thickening and Injection of the Right Half of the[ Epi¬ 
glottis, The disease had progressed recently and 'was now 
considered to be malignant. “ 

Dr. Herbert Tilley showed a case of Constriction of the 
Trachea, probably syphilitic in origin. Also a case showing 
the result of an Incomplete Killian Operation for Frontal 
Sinusitis with Immediate Suture of the Wound. 

Dr. Jobson Hoknb exhibited a specimen showing a Pedun¬ 
culated Papilloma in the Trachea, a Microscopical Section of 
a Sessile Papilloma of the Trachea, a specimen of a Trachea 
showing Pachydermia Syphilitica extending from the Larynx, 
and a Section of a Diphtheritic Membranous Cast from the 
Trachea. He also showed a man, aged 37 years, presenting 
a Cervical Tumour of 20 Years' Duration. 

Dr. James Donblan showed a case of Tumour of the 
Right Lobe of the Thyroid Gland with Paralysis [of the 
Right Cord. 

Dr. E. Cresswbll Baber exhibited a specimen of 
Carcinoma from the Inferior Turbinal of a woman, aged 
80 years. 

Sir Felix Semon produced references to an Epiglottis 
Holder in uBe over 40 years ago, which he had promised at 
the previous meeting. 


UNITED SERVICES MEDICAL SOCIETY. 


Operation for Recurrent Hernia. 

A meeting of this society was held on Jan. 9th. In the 
absence of the President the chair was occupied by Deputy 
Inspector-General A. W. May, R.N. 

Major M. P. C. Holt, D.S.O., R.A.M.C., read a paper on 
the Advisability of Operation for Recurrence of Hernia in 
the Services. Reference was made to the frequency with 
which a man who suffered from recurrence of hernia after 
operation was invalided, thus causing loss of service to the 
State and financial loss to the individual who often had 
great difficulty in obtaining a livelihood in civil life. The 
principal object of the paper was to combat opinions which 
led to this practice. There was abundant evidence that 
recurrence of hernia offered a distinct probability of cure by 
operation in not less than 80 per cent, of cases. The factors 
which tended to briDg about recurrence were: 1. Sepsis. 
This might be due to (as) imperfect technique ; (2>) accidental 
infection of the dressings ; and (o) uncontrolled curiosity 
on the part of the patient leading him to insinuate his hand 
under the dressings. Infection of the deeper parts gave rise 
to a mass of non-contractile Bear tissue which eventually 
gave way. 2. Injudicious selection of cases such as those 
shown— (a) general muscular debility ; (b) extensive 

fatty degeneration; (<t) extensive cough during or 

for a few weeks after operation; and ( d) organic disease. 

3. Errors in technique, (a) The attempt to confine within 
the abdomen large masses of omentnm or extensive coils of 
intestine ; (7») the obliteration of the conjoined tendon ; and 
(e) the transplantation of the cord without excision of veins. 

4. Faulty after-treatment (1) on the part of the surgeon— 
(a) too short a period of confinement to bed and (b) the pre¬ 
scription of a truss which necessarily caused by its pressure 
some atrophy of the parts ; and (2) indiscretion on the pait 
of the patient. Two instances were given : in one the man 
within a week or two of leaving hospital attempted to lift a 
heavy wardrobe by the plinth; in the other the patient took 
It upon himself to ride and put his horse at a jump. The 
horse “pecked” and the rupture recurred. A per¬ 
centage of 2'6 recurrences after primary operation was 
adopted as a standard. Statistics showed that if the 
cure remained good for 12 months recurrence became 
very improbable. The conditions mentioned above, which 
contra-indicated operation in the first instance, applied still 
more forcibly to operation for recurrence ; generally speaking, 
a second operation should be performed if the condition of 
the abdominal parietes warranted it. The operation would 
probably be futile when the primary operation had been 
effectual for a number of years and recurrence was asso¬ 
ciated with precocious senile change. Only once had Major 
Holt refused to operate for recurrence—in the case of a 
middle-aged non-commissioned officer of unduly lax, almost 
fiabby, habit of body, with an enormous gap in the inguinal 
region on both sides. Irreducibility due to adhesions 
should be an additional incentive to operation for the 
removal of an extremely dangerous condition. In describing 




162 The Lancet,] 


EDINBURGH OBSTETRICAL SOCIETY. 


[Jan. 18, 1908. 


the technique of the operation for recurrence Major 
Holt laid stress on the necessity of carefully removing 
all cicatricial tissue (avoiding damage to the vaa deferens) 
and the reconstitution of an inguinal region by the union 
of normal tissues. Reference was made to different ways of 
filling up the gap—e g., transplanting the rectus muscle and 
suturing it to Foupart’s ligament, mobilising the internal 
oblique anl stitching it to the upper and outer half of 
Foupart’s ligament, mobilising different sections of the 
aponeurosis of the external oblique, accurately lacing the 
fibres of the aponeurosis by a series of fine kangaroo tendon 
stitcheB, and by the implantation of silver filigree. Major 
Holt had operated on 14 cases of recurrence and, so 
far as he had been able to ascertain, there had been 
no further recurrence. In conclusion, it was suggested 
that the decision as to the right course to pursue in 
the case of recurrence of hernia was a matter which 
concerned every administrative and executive oflioer in 
the Services. 

Major C. G. Spencer, R.A.M.C., had been struck by the 
tendency to recurrence on either side of the scar. He 
regarded as very important points the removal of veins from 
the cord and the provision of a good posterior wall to the 
inguinal canal. The implantation of silver filigree in suit¬ 
able cases was regarded with favour. 


EDINBURGH OBSTETRICAL SOCIETY. 


Hyperemetit Gravidarum. 

A MEETING of this society was held on Jan. 8th. 
Professor W. Stephenson, the President, being in the 
chair. 

Sir J. Halliday Groom read a paper on Hyper- 
emesis Gravidarum and exhibited a uterus in the sixth 
month of pregnancy with complete placenta prsevia obtained 
from a patient who had recently died in hospital from per¬ 
nicious vomiting. There was also a fibroid in the wall, close 
to the placenta. After giving details of the case he 
classified hyperemesis under three heads—namely, reflex as 
from displacement, neurotic, and toxaemic, due to toxins 
arising in the bowel, liver, kidneys, &c., or from the uterine 
contents. If the urine contained well-marked indications of 
liver and kidney derangement then it was time to inter¬ 
fere. He did not approve of the slow method of 
delivery; this method took a long time, even two or 
three days, and as the condition of the patient was urgent 
it was better to perform rapid delivery. He would use 
the finger or other means for dilatation, but not Bossi's 
method. 

Dr. S. SLOAN (Glasgow) remarked how difficult it was to 
decide when abortion or premature labour should be induced. 
The knowledge that these cases might terminate favourably 
was sometimes really fatal to the case, as operation would be 
postponed on some improvement occurring and afterwards 
might be deemed necessary when the patient's condition was 
almost hopeless. 

Dr. F. W. N. Haultaix said that there were two main 
causes underlying hyperemesis—namely, (1) nervous condi¬ 
tions and (2) toxic conditions. The former were mostly due 
to distension of the uterus, and if the distension were rapid 
there might be very severe vomiting as in hydramnios. Dis¬ 
placements were also probably a cause of vomiting. The 
leases due to distension were met with in the early months ; in 
the later months toxic causes were the source, as for instance 
in the vomiting associated with albuminuria. Sir Halliday 
Croom's patient began to vomit at the third month and this 
would show that it was due to some disturbance of the 
distension of the uterus. There were both the placenta 
prsevia and the fibroid in the wall to produce irregular 
distension of the uterus ; the case was therefore probably 
of nervous origin. With regard to the time when the 
uterus should be emptied his rule was always to ter¬ 
minate the pregnancy when the temperature of the patient 
was rising. 

Dr. R. P. Kan ken Lyle (Newcastle) narrated a case in 
which he or another medical man had produced abortion 23 
times. This patient whenever she was about two months 
pregnant would require to go to bed and would vomit 
incessantly very large quantities of jelly-like material which 
would set on being kept. No food could be retained and 
abortion had thus been procured all these times. 


Dr. J. Haig Fercusson mentioned that he depended on 
the pulse as a guide for determining the time to operate, as 
he considered the pulse-rate of more importance than the 
temperature. 

Dr. James Ritchie and Dr. W. Fordyce also took part 
in the discussion. 


Glasgow Medico-Chirurgical Society.—A 

meeting of this society was held on Dec. 20tb, 1907, Dr. J. 
Walker Downie, the President, being in the chair.—The Pre¬ 
sident made a brief reference to the loss which science had 
sustained by the death of Lord Kelvin.—Dr. J. G. Connal 
showed nine cases of Abnormal Pulsation in the Pharynx and 
read notes on three other cases (12 in all)—namely, six 
women, three men, and three boys. In three cases the 
abnormal vessel was bilateral. The pulsating vessel was 
Bituated below, and behind, the posterior pillar of the fauces 
and in most of the cases ascended to the naso-pharynx. In 
four cases it was small ; in the other eight it gave ene the 
impression of a large vessel. He thought in the slighter cases 
the vessel might be the ascending pharyngeal artery, bnt 
that in the other cases with more marked pulsation it was 
probably an abnormally tortuous internal carotid artery. An 
interesting point was that three of the cases were boys 
whose ages ranged from six to 11 years. All had nasal 
obstruction from tonsils and adenoids and in one of them the 
pulsation was bilateral. He also showed a girl, aged 15 
years, on whom he had operated for Chronic Purulent Otitis 
Media with Involvement of the Sigmoid Sinus. Purulent 
discharge from the right ear had persisted since child¬ 
hood and two days before Dr. Connal saw her she had 
had severe rigors. These continued after her admission. 
The temperature was 105 6° F. and the pulse was 
140. The auditory canal was occupied by granulations 
and foul-smelling discharge. There was marked tenderness 
over the mastoid. The mastoid was freely opened up and 
pus was liberated from between the sigmoid sinus and the 
bone. The sinus was freely opened up and the internal 
jugular vein was ligatured in the neck. A septic abscess 
developed in the lung. Pus appeared at the lower part of 
the sinus, as if from the petrous portion of the bone. This 
healed up and she was now quite well. The middle ear was 
practically dry.—Dr. Archibald Young showed a case of 
Multiple Exostoses of the Thorax and Long Bones in a 
man with well-marked rachitic deformities. The tumours 
corresponded in situation with the usual rachitic deformities 
—e g., a tumour over the tibial spine and another larger 
one over the junction of one of the lower ribs with its 
costal cartilage Tbe former appeared when the patient 
was 12 years of age and the latter when he was 22 
years. A large nodule on the clavicle appeared three years 
ago. when in his thirtieth year.—Dr. M. Logan Taylor gave 
a demonstration cf microscopic and museum specimens 
of Double Tumours. These comprised tumours which 
during their life-history passed into a perfectly distinct 
and different type of tumour. Thus in the ease of adeno- 
sarcoma, cultivated for 40 generations in mice, the carcino¬ 
matous element largely predominated. In one series np to 
the twelfth generation the carcinomatous elements were in 
excess; about the sixteenth they were equal, and at the 
fortieth the tumours were almost entirely sarcomatous. 
Primary carcinoma in a man with secondary deposits was 
followed by adeno-sarcomatons growths in the lymphatic 
glands. In a case of melano-sarcoma of the eyeball with 
deposits in nearly every organ primary carcinoma of tbe 
liver bad taken place. Some of tbe microscopic sections 
showed tbe two kinds of tumour in different parts of tbe same 
section.—Dr. Ivy MacKenzie made a short communication 
on the Spirociueia Pallida and its Etiological Relationship 
to Syphilis. The organism was demonstrated in abundance 
in the lesions of congenital syphilis. The evidence of this 
organism being the cause of syphilis was steadily growing 
stronger, but it could not yet be cultivated outside the living 
body, and inoculation into animals only gave rise to an 
indefinite disease with little resemblance to syphilis. 

West London Medico-Chirurgical Society.— 

A clinical meeting of this society was held on Jan. 3rd, Mr. 
Richard Lake, tbe President, being in the chair.—The 
following cases were shown amongst others. Dr. Seymour 
Taylor : A man, aged 59 years, with Dysphagia caused by an 
Aneurysm of the Third Part of the Aortic Arch. None of the 
cardinal signs of aneurysm was present but a bougie was 
obstructed 12 inches from the incisor teeth and a skiagram 



ThbLaKOBT,] HUNTERIAN SOCIETY.—NOTTINGHAM MEDICO-CHIRURGICAL SOCIETY. [Jan. 18,1908. 163 


showed the tnmcur. There was also extensive calcareous 
degeneration of the arteries.—Mr. E. Percy Palon : A man, 
aged 47 years, with Epithelioma of the Floor of the Month, 
attached to the Jaw, also involving the Tongue and Lymph¬ 
atic Glands.—Dr. Phineas S. Abraham: 1. An unusual form 
of Tinea Circinata on the Wrist of a girl, associated with 
Impetigo Contagiosa. 2. A Case for Diagnosis, in which the 
patient, a boy, aged five years, had an excavated ulcer at the 
left outer canthus, with greatly enlarged and indurated 
glands of the Bame side of the face and neck of 
six weeks' duration. 3. Four Baldheaded Children. The 
condition was caused by the x rays applied three months 
ago for the cure of ringworm.—Mr. W. S mpson Handley : A 
woman upon whom he had performed Gistrostomy and 
Excision of the Larynx and Part of the Pharynx for Epithe¬ 
lioma.—Mr. Aslett Baldwin : 1. A man, aged 30 years, after 
Removal of the Breast for Carcinoma. The patient was 
shown at the last clinical evening two months ago. There 
was then a deeply nicerated growth in the situation of the 
right breast with secondary growths in the skin and enlarged 
axillary glands. The breast, the sternal part of the pectoralis 
major, the deep fascia from close to the clavicle, in front of 
the sternum, from 2 to 3 inches below the xiphoid cartilage 
to the posterior boundary of the axilla, together with the 
axillary lymphatic glands, bad been removed. The patient 
was now doing his full work and coaid raise his hand 
and arm vertically above his head without difficulty. 
2. A girl, aged one year and eight months, with what was 
probaoly a Sarcoma starting in the Left Maxillary Antrum. 
Thfre were great prominence of the left eye and depression 
of the palate on the same side, also a large swelling in the 
right temporal region. Mercury had caused no alteration in 
the growths which were steadily increasing in size. They 
were first noticed on Dec. 17th. 

Hunterian Society.— A meeting of this society 
was held on Jan. 8th, Mr. F. Rowland Humphreys, the Presi¬ 
dent, being in the chair.—Dr. J. Dnndas Grant delivered the 
second Hunterian lecture on Some Important Aspects of Sup¬ 
puration of the Middle Ear. He referred to the extreme 
seriousness of the various complications of suppuration in the 
middle ear, suggesting that the aural surgeon probably saw 
more than his fair share and the general practitioner less, but 
whoe\er had experience of them realised the extreme danger 
and anxiety connected with them. He narrated a large 
number of cases from his experience of which the results 
had bien fatal ; he pointed out so far as possible the reasons 
for their having gone wroDg and how such results might, if 
possible, be prevented in the future. In some of the acute 
cases, however, incision of the tympanic membrane had 
been postponed or the opening of the mastoid cells had 
been relegated until infection of the blood or of the 
cranial contents had taken place. He discussed the 
reasons which had led to the delay, but in view of 
his later experience considered that these reasons 
were in many instances quite insufficient. By way of 
contrast he referred to some illustrative oases in which 
early intervention appeared to have been the means of 
averting dangerous complications. He expressed the opinion 
that with antiseptic precautions even those who did not 
profess to be operative exparts might put their patients in 
safety by making an opening in the mastoid cells when more 
skilled aid was not available. He advocated early and quick 
operation in diabetics in view of the rapidity with'which the 
mastoid bony tissue broke down in these subjects, though no 
doubt a positive result of the aceto-acetic test would be a 
contra indication. Among interesting errors in diagnos's he 
quoted a case of lateral sinus phlebitis, which had been pre¬ 
viously diagnosed as enteric fever, and one of enteric fever 
wbicb be himBelf had diagnosed as otitic septicemia. In 
another case he had found lobar pneumonia to be the cause 
of constitutional disturbances which had by others been 
attributed to purulent otitis. In another exceptional case 
certain cerebral disturbances were, in view of a history of 
former otorThcea, attributed by the physician in charge 
to a probable intracranial complication of middle-ear 
disease, but in reality Dr. Grant had attended the 
patient for condylomata of the meatus and the cerebral 
disturbances disappeared rapidly under treatment by means 
of mercury and iodide of potassium. The difficulties in the 
diagnosis of malignant disease and tuberculosis when affect¬ 
ing the external and middle ear were described and illustrated 
by cases occurring in Dr. Grant's experience. He con¬ 
sidered the recognition of cholesteatoma of the middle ear as 


of vital importance in chronic suppuration of the middle'ear 
and pointed out the dangers attending the use of watery 
solutions for instillation or syringing when this condition 
was present. Alcoholic solutions were, on the other hand, 
of the greatest value. Dr. Grant referred to the indebted¬ 
ness of Btudents of otology over the whole world to Dr. G. 
Newton Pitt for the invaluable statistical and pathological 
study of the fatal sequelae of suppurative middle-ear disease 
forming his Goulstonian lecture.—Dr. E. W. Goodall pro¬ 
posed and Dr. W. H. Kelson seconded a vote of thanks to 
the lecturer, which was carried by acclamation. 

Nottingham Medico-Chirurgical Society.— A 

meeting of this society was held on Jan. 8th, Dr. L. W. 
Marshall, the President, being in the chair.—Dr. M. L. 
Farmer showed a man, aged 47 years, who had been the 
subject of Alcoholic Neuritis affecting all four extremities. 
In the case of the feet symmetrical blebs and va90-motor dis¬ 
turbances had occurred reaching as far as the ankles. He 
had made a very good recovery.—Mr. A. R. Tweedie read a 
paper on Otosclerosis. He pointed out that although it had 
only recently been regarded as a pathological process 
distinct from other diseases, a very large amount of research 
work had been done in this direction. The chief result of 
this, however, was only to determine that the disease was 
essentially a localised osteitis. It commenced probably about 
the second or third decade in the immediate neighbourhood of 
the foramen ovale and led with varying degrees of rapidity 
to ankylosis of the stapedlo-vestibular articulation, and 
the chief clinical characteristic was a progressive deafness, 
which was unaffected by looal treatment. Mention was also 
made of the other adjacent areas in which the disease 
occurred and of its association with other local and general 
conditions. Mr. Tweedie urged its early diagnosis with the 
hope that in its incipient stages routine, tonic, alterative, 
and hygienic treatment might arrest its further progress.— 
The President, Dr. J. A. Waring, Mr. J. Mackie, and Dr. 
A. J. Sharp discussed the paper and Mr. Tweedie re. lied.— 
Dr. J. Watson showed specimens of Ovarian Tumours 
removed by operation, two of which were dermoids and a 
third was a cyst where torsion and consequent pain and 
haemorrhage had occurred. A fourth was a oroad ligament 
cyst containing 21 pints of fluid. The capsule was so lax 
that it might have caused some confusion with general 
ascites or hydatid. 


King’s College (University of London).— 

The following Bhort course of lectures will be delivered in 
the physiological laboratory. King's College, London, daring 
the present term : l. Professor T. G. Brodie, M.D. Lond., 
F.R.S., on Tissue Respiration (with demonstrations). Four 
lectures, on Mondays, Jan. 20th and 27rb, and Feb. 3rd and 
10th, at 4.30 p m. 2. Dr. F. W. Mott, F.R.S., on the Physio¬ 
logy of the Emotions. Two lectures, on Mondays, Feb. 17th 
and 24th. at 4 30 P.M. 3. Professor W. D. Halliburton, 
M.D., F.R C.P., on Degeneration and Regeneration of 
Nerves. Two lectures, on Mondays, March 2ud and 9th, at 
4 30 P.M. These lectures are free to all students of medical 
schools In London, to all internal students of the University 
of London, and to medical men on presentation of their 
cards. 

City of Westminster Philanthropic Society. 
—We have received from the Mayor of Westminster 
an appeal on behalf of this society which exists for the 
relief of distressed persons residing within the City of 
Westminster on the recommendation of its members. A 
large amount of the relief is given in provisions and coal, 
but money grants are also made to suitable cases. The 
funds of the society are not sufficient to cope with an excep¬ 
tional distress that prevails in the poorer parts of this ancient 
city, and it is hoped that the wealthier inhabitants, of whom 
there are a great number, will generously meet the appeal 
which is now being made by forwarding sums of money to 
the secretary at Caxton Hall, Westminster. The feeding of 
the huDgry poor is not only an act of charity that has been 
honoured in England at least since the days of good King 
Wenceslas but it is of vital importance for the welfare of 
the nation. It must never be forgotten that whilst people 
are starving they are too often breeding, and the health of 
the youngest citizens amongst them should surely be a 
matter of concern to the inhabitants of a wealthy borough 
such as Westminster, even if they are not moved by the mis¬ 
fortunes of the hungry parents. 




164 The Lancet,] 


REVIEWS AND NOTICES OF BOOKS. 


[Jan. 18, 1908. 


|leirietos snfr fUfa of goofes. 


Prostatic Enlargement. By Cuthbert S. Wallace. M.B , 
B.S. Lond., F.E C.S.Eng., Surgeon to the East London 
Hospital for Children and Surgeon to Out patients, 
St. Thomas’s Hospital; Teacher of Practical and Opera¬ 
tive Surgery in St. Thomas’s Hospital Medical School. 
Bacteriology: By Leonard S. Dudgeon, M.R OP. Lond., 
Bacteriologist to St. Thomas's Hospital; Director of the 
Laboratories and Joint Lecturer on Pathology in the 
Medical School. London : Henry Frowde and Hodder and 
Stoughton. 1907. Pp. 215. Price 12s. 6d. net. 

The removal of the enlarged prostate has now taken a 
recognised position in surgery and prostatectomy is well 
deserving of a special study. The book begins with an 
account of the surgical anatomy of the prostate. The 
main points in which the author differs from the current 
descriptions of the organ are these : he points out that 
the notch on the posterior aspect, which is supposed to 
indicate the division between the two lateral lobes of 
the prostate, does not exist; he shows that the bladder 
wall and the prostate gland are inextricably mixed and that 
there is no definite point where it can be said that one ends 
and the other begins. He agrees with every anatomist that 
there is no real third lobe. The original description of a 
third lobe was dne to Sir Everard Home but it was almoet 
certainly based on notes made by Hnnter and the account was 
probably not improved by its adopter. As Mr. Wallace 
points out, what is described as the third lobe is directly 
continuous with the rest of the gland ; it has no lateral 
boundaries, while the anterior boundary has only the width 
of the urethra and the posterior that of the combined 
diameters of the ejaculatory ducts. The histology of the 
prostate is fnlly given and the vessels, lymphatics, and the 
development are described. 

An interesting account is given of the experimental patho¬ 
logy and function of the genital glands. Long ago Hunter 
showed that castration in yonth is followed by want of 
development of the prostate, and Griffiths in 1889 showed 
that atrophy followed castration performed in adult life. 
Home observers have claimed that removal of one testis leads 
to atrophy of the corresponding half of the prostate bnt 
experimental research has shown that if one testis be left 
intact the proBtate and vesiculse seminales are of full size. 
As to the function of the prostate, it used to be said that it 
was a sphincter of the bladder, but this view is now given 
up, for it is absent in the female, and in many animals its 
form would render it incapable of such a function. It is 
evidently a sexual gland, for it is confined to the male sex ; 
it enlarges rapidly at puberty ; it exhibits seasonal activity in 
the mole and the hedgehog which pair only at certain times 
of the year ; it fails to develop in those castrated in infancy, 
and it atrophies after castration in adults. Its function is 
probably to dilute the testicular fluid. The functions of the 
vesiculie seminales and Oowper’s glands are discussed. 

The chapters on the Morbid Anatomy and Histology of the 
Prostate are good. Mr. Wallace describes how the first 
appearance of any hypertrophy is the presence of yellowish 
white specks, consisting chiefly of glandular tissue lying in 
a fibro-muscular stroma. There are some cases, about 15 
per cent., in which the enlargement is “fibrouB" or 
■“ diffuse ” ; clinically there is no difference but any attempt 
to enucleate a fibrous prostate fails. Histologically many of 
these cases show much atrophy of the gland tissue, with an 
intricate interlacing of bundles of fibres. Many of these 
fibres are muscular and no evidence of inflammation is 
present. 

The chapter on the B icteriology has been written by Mr. 
Leonard S. Dudgeon and the main conclusions are that 
any bacterial infeotion present in an enlarged prostate is 


secondary, that a bacteriological examination of the urine 
may throw little or no light on the condition of the prostate, 
and that there is no evidence to support the view that 
enlargement of the prostate is gonorrhoeal in origin. The 
etiology of the disease is very fully discussed, and of the 
nine theories mentioned he claims that that which looks 
upon the enlargement as neoplastic best accounts ,for aU 
the facts. 

The portions of the book dealing with Treatment are 
naturally of the chief interest to surgeons. Both vasectomy 
and castration are powerless to do good in prostatic enlarge¬ 
ments and practically only removal of the enlargement need 
be considered. In this country the suprapubic route has for 
several years now been considered preferable but abroad the 
perineal route is usually chosen. Mr. Wallace holds that, 
though the perineal route is the better for fibrous prostates 
and should be used if the diagnosis of a fibrous prostate is 
certain, the suprapubic operation is the better. The mortality 
is practically the same. We agree with the view expressed 
by the author that "enucleation" of the prostate is a 
removal of an adenomatous mass from within a "capsule” 
formed by the outer portion of the gland. The final 
chapter deals with Carcinoma of the Prostate. It is not 
an uncommon disease and provides about 10 per cent, of 
cases of prostatic enlargement. As to treatment very little 
has been done. Total removal of the carcinomatous prostate 
is possible only by the perineal route bnt it is doubtful if the 
benefit is commensurate with the risk. 

In conclusion, we may say that the book is all that could 
be asked for on Buch a subject ; it is careful, judicious, and 
complete. The printing is perfect and the illustrations have 
come ont very well. 


Human Anatomy , including Structure and Development 
and Practical Consideration!. Edited by George A. 
Piersol, M.D., 8c.D., Professor of Anatomy in the 
University of Pennsylvania. London and Philadelphia : 
J. B. Lippincott Company. 1907. Pp. 2083. Price 
30i. net. 

This large book, containing over 2000 pages and 1734 
illustrations, many of which are coloured, is the joint work 
of five American authors under the able editorship of Dr. 
Piersol. The sections which the different writers have 
contributed are as follows: 1. The introductory, histological, 
and embryological paragraphs throughout the work and the 
description of the central nervous system, including the deep 
relations of the cranial nerves, of the organs of special sense, 
of the carotid, coccygeal and aortic bodies, and of the uro¬ 
genital system, by George A. Piersol, M.D., Sc.D., Professor 
of Anatomy in the University of Pennsylvania. 2. The 
description of the skeleton, including the joints, and that of 
the gastro-pulmonary system, and of the accessory organs of 
nutrition, by Thomas Dwight, M.D., LL.D., Parkman 
Professor of Anatomy in Harvard University. 3. The account 
of the cerebro-spinal and sympathetic nerves, by Carl A 
Hamann, M.D., Professor of Anatomy in Western Reserve 
University. 4. The systematic description of the muscular 
and of the blood- and lymph-vascular systems, by J. Playfair 
McMurrich, Ph.D., Professor of Anatomy in the University 
of Michigan. 5. Practical considerations, by J. William 
White, M.D., Ph.D., LL.D., John Rhea Barton Professor of 
Surgery in the University of Pennsylvania. 

The general plan of the work is similar to that employed 
in the majority of anatomical text-books, a general account 
of cytology, embryology, and histology being given in the 
opening chapters, while the remainder of the book is divided 
into sections in which each system is very thoroughly 
described. In addition, each section is prefaced by a special 
account of the embryology and histology of the tissues and 
organs under consideration and concluded by a chapter on 
practical considerations, or in other words, surgical applied 



thb Lancht,] 


REVIEWS AND NOTICES OF BOOKS. 


[JAN. 18. 1908. 165 


anatomy. These “practical considerations” constitute an 
important feature of the book and are very ably set forth by 
Dr. White, whose experience as a surgeon enables him to 
point out clearly and briefly the important relationship 
between clinical phenomena and anatomical facts. The 
account of the articular system is incorporated with that of 
the osseous system, each joint being described in connexion 
with the bones which enter into its formation. This is un¬ 
doubtedly a wise proceeding, as the student Is far more likely 
to retain the important facts relating to the joints while the 
anatomy of the bones is fresh in his memory. In the section 
on myology a morphological classification is adopted and 
followed as far as possible, and the important variations as 
well as facts of morphological interest are given after the 
description of each muscle. The description of the vascular, 
lymphatic, and nervous systems is well up to date 
and the important variations of the vessels and nerves, 
together with their development, are clearly and accurately 
set forth. The remaining sections on the uro-genital system 
and the organs of special sense are well writtten and com¬ 
plete a work which contains a vast amount of accurate 
information. 

The illustrations, of which more than 1500 are original, 
are naturally of great importance in a book of this nature. 
Though the authors have been more than liberal in this 
respect the reproductions in many instances leave much to 
be desired, for several of the figures are so fiat and indistinct 
as to be of little practical value. This is the only adverse 
criticism which we have to make, for in every other respect 
the book does great credit to both authors and publishers, 
and we have no hesitation in saying that it should prove 
of the greatest value as a sound text-book and as a work of 
reference. 


Abel's Laboratory Handbook of Bacteriology. Translated 
from the tenth German edition by M. H. Gordon, II.A., 
M.D. Oxon., B.Sc. With additions by Dr. A. C. Houston, 
Dr. T. J. Horder, and the Translator. London : Oxford 
University Frees. 1907. Fp. 224. Price 5». net. 

A BOOK the popularity of which in Germany is such that it 
has reached a tenth edition in ten years naturally arouses 
high expectations which are not likely to be dispelled by its 
perusal. A translation of this book by Dr. M. H. Gordon 
with sections added by a trio of bacteriologists of such 
reputations as the translator and his coadjutors could scarcely 
fail to be even more valuable than the excellent original. 
Laboratory handbooks fall into one of two categories : they 
are designed to supply complete instruction in the technique 
of the science with which they are concerned, or they are 
designed to supplement personal instruction and to furnish 
some guidance to those already in part conversant with 
laboratory methods. It is to the latter category that this 
book belongs and, as the author states, it is intended “to 
give practical hints and to collect in practical form those 
technical details which so easily slip the memory.” It is 
also intended in the first place for the use of the physician 
and the veterinary surgeon. 

The book practically divides itself into three parts. What 
may be regarded as the first part treats of general 
sterilisation, cultural, and staining methods; the second 
deals with special cultural and staining methods applicable 
to particular micro organisms , and a third part, consisting 
largely of the sections added by, or amplified by, the English 
contributors, is concerned with means for obtaining materials 
for bacteriological examination and with methods for the 
investigation of air, water, sewage, and various materials 
which may be used for food. Speaking generally, what has 
been described as the first part is very good and the direc¬ 
tions given are simple and clear. The difficulties in making 
nutrient agar seem perhaps a little exaggerated and we miss 
any reference to the use of chloroform in the preparation of 


blood serum—a method which avoids many troubles. The 
methods for examining the chemical activity of organisms 
are well described and the same may be said of the staining 
methods given. The familiar Jenner stain appears under 
another name. The treatment of special methods adopted 
for the culture or d&monstration of particular organisms is 
very good and full, especially those which deal with the 
bacteriological diagnosis of enteric fever and cholera. In 
this portion of the work especially the author justifies the 
claim advanced in his preface— ‘' to be clear and concise and 
to bring forward only reliable and fully proved methods of 
examination which are as simple as possible to undertake and 
to put into practice.” 

Subjects not usually dealt with in laboratory handbooks 
are found in the later sections. The methods of examining 
blood in relation to immunity form the subject of one of 
them, and in this the demonstration of “ substance sensi- 
blisatrice ” and stimulins and the estimation of alexin and of 
the bacteriolytic, phagocytic, and opsonic power of serum 
are given, together with the mode of determining the 
opsonic index. The quantitative estimation of agglutinin and 
bacteriolysin in serum is well described in connexion with 
bacillus typhosus and spirillum choleric, but the description 
of the method of standardising antitoxin is very inadequate. 
The section dealing with the bacteriological examination 
of water, milk, shell-fish, sewage, and so on, is revised and 
amplified by Dr. A. 0. Houston, and it certainly adds much 
to the value of the book that this section should be treated 
by an acknowledged authority on the subject, who has him¬ 
self created many of the methods employed and furnished 
data which form the standards by which pollution is esti¬ 
mated. The same may be said of Dr. Gordon’s section on 
dust and air. 

The book is bound in oil-cloth so as to resist the dangers 
of the laboratory bench and it is well printed and prac¬ 
tically free from errors. On p. 169, however, a pipette is 
said to be graduated in " centimetres ” (cm.) instead of 
“ cubic millimetres ” (cmm.), and when the colour is 
removed from a fluid it is said to be “discoloured” 
(p. 46). There is no doubt that this volume will be found 
in all laboratories, as it is full of useful and accurate 
information. 

A Manual of the Diseases of Infants and Children. By John 

Ruhrah, M.D. Illustrated. London and Philadelphia : 

W. B. Saunders Company. 1907. Pp. 404. Price 10x. 

This little manual is one of the most condensed works on 
the subject of the diseases of children with which we are 
acquainted. In less than 400 pages the student will find all 
the information that he can possibly require for clinical use 
or for examination purposes. The only objection that we can 
urge to the method of condensation which has been adopted 
by the author is that the inexperienced student will find a 
difficulty in distinguishing between the essential and im¬ 
portant details and those which are of quite secondary value, 
since both kinds appear side by side without any means 
of differentiation. The arrangement of the book is 
simple and well designed for reference purposes. For 
instance, taking at random the chapter on the Blood in 
Infancy and Childhood we find it divided into ten sub¬ 
sections of an average length of one and a half pages. The 
subsections refer to Buch symptoms or groups of symptoms as 
the following: chlorosis, pernicious ansemia, secondary 
anaemia, leukaemia, haemophilia, and so on, and each of these 
subsections is freely paragraphed with from 10 to 12 headlines 
printed in distinctive type. Each page consequently looks 
something like a dictionary or encyclopaedia, and giving the 
book every credit for excellence as a work of reference it is 
just about as interesting to read. The worst feature of this 
synoptic method of description is that the directions for 
treatment are practically useless ; the whole question of 
c 3 




166 TH> LANCM,] 


REVIEWS AND NOTICES OF BOOKS. 


[Jan. 18.1908. 


treatment is dismissed in certain sections with Bach laconic 
remarks as “ unsatisfactory ” or “ symptomatic.” 

The illustrations are very liberal and in many instances 
they supplement in an excellent manner the brevity of the 
text. On the whole we like the general appearance of this 
little volume; it is accurate to an unusual degree and re¬ 
plete with all the latest information contained in the larger 
text-books and important monographs in the domain of 
paediatrics. A short chapter at the end of the volume 
explains to the student where and how to obtain a 
bibliography on any subject connected with the diseases of 
children, so that to some extent the author helps his 
readers out of the difficulties into which his method of 
handling the subject occasionally leads them. 


A Text-book of Histology. By A. A. BdHM, M.D., and 
M. von Davidoff, M.D. Edited by G. Carl Huber, 
M.D. Second edition, revised and enlarged. London: 
W. B. Saunders and Co. 1907. Pp. 528. Price 15s. net. 

The first edition of this work was reviewed at some length 
in The Lancet of March 23rd, 1901, p. 867. Considerable 
additions have been made in the new edition and on the 
whole it may be said that the book has been brought 
up to date. There is, however, an important point which 
requires treating of at some length at the present time. 
The new edition of this book makes it very evident that 
the time has arrived when “histology ” as the term haB 
hitherto been understood must be separated from the finer 
microscopical methods oommonly known as “ cytology.” 
With the comparatively crude methods which were almost 
universal up to 10 or 15 years ago the microscopist who 
studied the tissues of the body was really able to do no more 
than to study the grouping and arrangement of the cells in 
the various tissues and organs. With the cell itself he had 
very little to do but dealt only with masses of cells. At the 
present time, however, it is becoming more and more obvious 
that the study of the cell as a unit is necessary on a great 
many occasions. It is on this acoount, apparently, that we 
find attempts to give a skstoh of our knowledge with regard 
to individual cells in text-books of what ought now to be 
called “gross histology.” We might almost say that 
“cytology” now bears the same relationship to what has 
hitherto been known as “ histology ” as “ histology " bore to 
“ macroscopic anatomy." Thisconfusion of ideas with regard 
to the general charaoter of the term “ histology ” as at present 
used is accentuated in the volume under review. At least 30 
pages are devoted to the description of phenomena confined 
to individual cells. Indeed, we should imagine that the 
authors intend to give a sufficiently extensive and detailed 
sketch of our cytologlcal knowledge to be useful to the 
student. As this book appears to aim at more complete¬ 
ness in this respect than any other volume of the kind 
which has come to our notice, it seems desirable to point 
out that in so far as the information with regard to 
cells, qua cells, is concerned it is out of date. It seems 
doubtful indeed whether any student could gain an 
aocurate idea even of the processes of cell division from 
the information which is contained in the book. When 
it comes to the more complicated cell phenomena, such as the 
maturation of the sexual elements, both in the male and 
female animal, or of fertilisation, the descriptions are difficult 
for even a well-informed reader to follow and are sometimes 
inaccurate. A very similar criticism might be made with 
regard to the methods of fixation, imbedding, and staining. 

With respect to what we are inclined to call “gross 
histology,” the information conveyed by the authors is 
precise and clear. The book is profusely illustrated and 
forms one of the most desirable text-books which we have 
met, as all the tissues and organs are dealt with very com¬ 
pletely yet concisely, and the volume is not too bulky to be 
convenient. 


LIBRARY TABLE. 

Healthy Boyhood. By Arthur Trewby, M.A. Privately 
printed for the Author. 1907. Pp. 63. Price Is. 6d., from the 
Author, Fenton House, Hampstead Heath, London, N.W.— 
This admirable book contains commendatory prefaces by 
Lord Roberts and Sir Dyce Duckworth which we are fully 
able to endorse. It is intended to be put into the hands of 
boys nearing the age of puberty to serve as a friendly 
guide and defence to them in that perilous time which must 
leave for good or ill an ineffaceable mark on all men’s lives. 
We have often said, and we feel it our duty to insist, that 
the parent who lets his child embark on the troubled waters 
of sexual life without showing him the course which he 
should strive to steer fails signally in carrying out his trust. 
Some fathers have not their children's oonfidenoe and 
would feel it as awkward to speak to their sons on this 
intimate matter as to a stranger and in such a case 
the guidance that comes naturally from a father may 
be given by the medical adviser. In either case suoh a 
talk would be made much easier if the boy had first been 
given this small book to read. It is a plain statement, 
written in the easiest language, of the fundamental facts 
that concern the reproductive function throughout the whole 
gamut of life, and without being in any way “ goody” it has 
a direct and simple earnestness in its manner of showing the 
inherent purity of that function in man and the terrible conse¬ 
quences of its abuse that must make any right-natured child 
feel that it is a word spoken from the heart of a true friend. 
It may well save many innocent children from falling into 
the snare of self-abuse, and for the boy who is already in 
the toils there are sound advioe and encouragement. The 
book deals almost entirely with these matters, although a 
few pages are devoted to more general hygiene. We could 
wish a boy entering his public school no better present 
and it should be welcome to many parents. The author 
has bad the preface addressed to parents and schoolmasters 
lightly pasted in, so that it may be removed before the book 
is given to the boy. 

Consumption: Treatment at Home and Rulet for Living. 
By H. Warren Crowe, M.D. Oxon. Second edition. 
Bristol: John Wright and Co. 1907. Pp. 30. Price 1*.— 
Dr. Crowe argues that many patients suffering from 
pulmonary tuberculosis are unwilling or unable to go to a 
sanatorium or to take advantage of some recognised climatic 
resort. Such patients require to be treated at home, but the 
“open-air treatment ” depends for its success upon the exact 
observance of numerous details. Dr. Crowe believes that 
many medical practitioners experience difficulty in finding 
time to drill their “consumptive” patients in these details 
and he has therefore written this book as a partial 
substitute for suoh practical training. As supplementing 
the directions given by practitioners to their patients it 
may prove serviceable, since it contains much useful 
advice, but we presume that it is in no way intended 
to be used by patients without medical control. Sanatorium 
treatment is now being considerably modified by the institu¬ 
tion of graduated manual labour. If this is carried out 
without skilled supervision harm will assuredly follow, 
whilst with that supervision most promising results have 
been obtained. More than ever, then, is it now necessary 
that “ open-air treatment ” should be under medical direc¬ 
tion. Nevertheless, a study of this little book by patients 
will save much repetition on the part of the medical practi¬ 
tioner. We are entirely in agreement with Dr. Crowe’s 
remark that if patients can afford to spend a few months at 
a sanatorium they will be properly instructed in the personal 
care of their health and the chances of their recovery will be 
much increased. Unfortunately such a course is not always 
possible and then “home” treatment must be attempted. 
. Dr. Crowe’s directions are expressed in plain and direct 




Th* Lancet,] 


REVIEWS AND NOTICES OF BOOKS.—NEW INVENTIONS. 


[Jan. 18,1908. 167 


language and patients should have no difficulty in under¬ 
standing them. 

A Course of Leoturet to Midmires and Maternity .Yuries. 
By W. E. Fothergill, M.A., B.Sc., M.D. Edin., Lecturer 
in Obstetrics, Victoria University of Manchester. With 67 
illustrations in the text. London and Edinburgh : William 
Green and Sons. 1907. Pp. 260. Price 4s. 6 d. net.—In an 
introduction in which he discusses the chief duty of mid- 
wives and maternity nurses Dr. Fothergill insists upon the 
fact that the first duty of the midwife is to protect her 
patient from the risk of puerperal fever, a risk to which 
every woman is exposed at her confinement, and the second 
duty of the midwife or monthly nurse is to be able to 
recognise quickly the danger-signals which give warning of 
coming complications and to secure medical assistance, so 
as to safeguard her patient. Bearing these two duties in 
view, the author has divided bis book into two parts, the first 
dealing with the proper management of normal labour and 
the second dealing with the various complications of ab¬ 
normal pregnancy and the care of the mother and of the 
child during the puerperium. After a short account of 
obstetric anatomy there are chapters devoted to menstrua¬ 
tion, pregnancy, management of the patient during preg¬ 
nancy, and labour as observed at the bedside. These sections 
are written clearly and concisely and are good examples 
of how such information should be given in a text-book 
intended for midwives. The difficult subjects of the factors 
involved in labour—namely, the powers, the maternal 
passages, and the passengers, or the child, membranes, 
and placenta—are next discussed, and as the various points 
are Illustrated by a number of excellent pictures and 
described in simple language they can be easily understood by 
any woman of average intelligence. In the same manner the 
mechanism of labour is discussed and to this section are 
added a number of drawings of frozen sections illustrating the 
various stages of the process. The most important functions of 
a midwife or nurse are considered under the heads of the 
management of labour, the puerperium, and the newly bom 
child, and the adoption of short tabular statements forming a 
rltume of the most important teaching of each section will 
be of great assistance to nurses using this book. In the 
second part of this work, dealing with abnormal pregnancies, 
Dr. Fothergill has chosen very judiciously the important 
subjects on which to lay stress. The section on delay and 
obstruction to labour is especially good, and here again the 
adoption of tabular statements is of great assistance in 
making the teaching clear and easy to comprehend. Much 
stress is rightly laid on the important distinction between the 
symptoms of lingering and obstructed labour. For the 
treatment of post-partum haemorrhage the author very 
strongly recommends compression of the abdominal aorta 
rather than any attempt being made to carry out bimanual 
compression of the uterus or the administration of an intra¬ 
uterine douche. As he contends quite rightly, this method 
is certain, speedy, involves no risk of causing infection, 
requires no special apparatus, and is easier for a midwife to 
employ than either bimanual compression or intra-uterine 
douching. In an appendix to the book extracts from the 
rules of the Central Mid wives Board are given. As we have 
indicated, this is a most excellent manual and one which we 
can recommend strongly to midwives and nurses. 


JOURNALS AND MAGAZINES. 

Brain: A Journal of Neurology. Vol. XXX. No. 119. 
London: Macmillan and Co., Limited.—The latest number of 
Brain is rendered particularly interesting by the inclusion in 
it of the lecture by Mr. C. F. Beadles delivered at the Royal 
College of Surgeons of England on Aneurysms of the Larger 
Cerebral Arteries. The subject is discussed very fully, 
numerous cases are quoted, and it is shown how curiously 


variable and elusive such cases are in their symptomatology 
and how almost impossible of diagnosis they still remain. Dr. 
J. A. Ormerod contributes a clinical and post-mortem account 
of two cases of Disseminated Sclerosis, bringing into promi¬ 
nence some of the difficulties in the diagnosis of such cases, 
even when marked changes are present in the nervous 
system. The other paper is one by Dr. Charles Bolton and 
Dr. S. H. Bown on the Changes in the Central Nervous 
System in Experimental Diphtheria. They conclude that 
the poison direotly causes acute degeneration in certain 
cells in the central nervous Bystem and also directly affects 
peripheral nerves and causes fatty changes in the heart 
muscle. Two interesting reviews are included, one by Dr. 
W. McDougall on Professor Sherrington’s “ Integrative 
Action of the Nervous Bystem ”; and the other by Dr. 
S. A. K. Wilson on Ren6 Cruchet’s “ Traite des Torticolis 
Spasmodiques.” So that it will be seen that the number well 
maintains the high character of the journal. 


fttfo Intentions. 


THE “BED-EASEE”: AN IMPROVED FORM OF 
BED-PAN. 

Ws have received from Dr. F. S. Pitt-Taylor of Birken¬ 
head a new form of bed-pan which he describes as “an 
anatomical hygienic bed utensil or bed-pan satisfactory to 
both patient and nurse.” The paper in which he explains its 
construction and advantages is of such length that we are 
unable to publish more than the following selection from 
the principal passages. 

Fig. 1. 



Fig. 1 is a plan view which shows that the opening 
is egg-shaped and that sufficient length is provided for 
male patients. The reason why the seat of a water- 
closet is comfortable is because the weight of the body 
is transmitted through the muscular pad of the thighs 
and buttocks to the seat, the muscles acting as a soft 
cushion. This principle—i.e., making the muscles act as 
natural cushions—has been applied in the construction of 
the 11 bed-easee, ” for two wide lateral wings are provided to 
carry the weight of the body. The upper surfaces of these 
wings slope downwards and inwards and are slightly con¬ 
cave, thus adapting themselves to the convex surface of the 


Fig. 2. 



buttocks. At the posterior end of the utensil (shown In 
Fig. 2) the wall of the pan is lowered so as to be out of the 
way of the bones of the spine and sacrum. This method of 
supporting the body renders the use of the “bed-easee” 
perfectly comfortable whether the patient is lying down, 
reclining, or sitting upright. The whole of the interior is 




168 The Lancet,] 


NEW INVENTIONS.—MEDICINE AND THE LAW. 


[Jan. 18, 1908. 


visible, so that effectual cleansing presents no difficulty. The 
front part of the utensil is raised for the convenience of male 
patients and yet is not so high as would interfere with 
douching in the case of females, for which this bed-pan, 
having a capacity of over two quarts, is well adapted. The 
contents are easily emptied out from this end or over one wing 
posteriorly. To place it in position it should be laid on the 
bed between the patient’s knees, if possible with the handle 
end pointing to the patient’s feet. He then raises himself to 
the necessary extent, with or without the help of the nurse, 
who then pushes or pulls the utensil under him. It is easily 
adjusted in a correct position on account of the lateral wings 
serving as handles for the patient to grasp. The utensil has 
a well-fitting cover, shown in Fig. 3, which is a perspective 


Fig. 3. 



view of the whole. Both utensil and cover are substantially 
constructed in glazed earthenware and their weight in conse¬ 
quence may be regarded as a drawback. Dr. Pitt-Taylor, 
however, says that this is amply compensated by the various 
advantages which the utensil possesses. The “bed-easee” 
can be obtained from Messrs James Woolley, Sons, and Co., 
Limited, of Manchester. The price is 11*. without the cover, 
or 14*. with the cover. 


A NEW EVE-DROP BOTTLE STAND. 

The accompanying illustration shows a portable and 
compact eye drop bottle stand which was designed by me on 
the ordinary cruet principle, and has been supplied to the 
Guest Hospital at Dudley by Messrs. Mayer and Meltzer of 
71, Great Portland-street, London, W. It is circular in shape, 
eight inches in diameter, and holds one dozen one-ounce 
drop bottles with ground glass stoppers, which serve as 



"AVC* ft NU.TIU LOUftOft 


droppers. It is a great improvement on the ordinary 
wooden stands which hold from four to six bottles and which 
so frequently get upset. This stand is made of electro-plated 
metal. It has been in use for nearly two years and is still in 
perfect order. I can recommend it strongly in the out¬ 
patient departments of the eye hospitals or in the eye out¬ 
patient departments of the general hospitals ; the number of 
bottles which it holds being one dozen the surgeon has at 
his command so many varieties of eyedrops in different 
strengths. S. B. Gadgil, 

Late Senior House Surgeon, Gueet Hospital, Dudley. 


MEDICINE AND THE LAW. 


“ Chrutian Science Treatment.” 

An inquest was held recently at Richmond upon the body 
of Mary Elizabeth Dixon, 58 years of age, who when suffering 
from bronchitis refused medical aid and preferred to rely 
upon “ Christian Science treatment.” This was admini¬ 
stered by Edith Davidson who explained at the inquest that 
she was not a "practitioner” but only a “student.” Her 
intervention had been successful, she said, on a previous 


occasion when the deceased had a cold, but owing to her 
“lack of understanding" in the more serious case of 
the bronchitis it was ineffective and the patient died. 
The deceased had also been attended by Bessie Hales 
who said that she was a trained nurse of nine years’ 
experience recently converted to "Christian Science.” The 
coroner, Mr. M. H. Taylor, questioned these two witnesses 
closely as to their tenets without extracting anything very 
novel to those accustomed to the answers given by “Christian 
Scientists ” in similar circumstances. The jury returned a 
verdict of death from acute bronchitis in accordance with 
the medical evidence and at first added that the death had 
been accelerated by the gross neglect of the two women 
mentioned and especially by that of the ex-nurse. The 
coroner, however, pointed out that this amounted to a verdict 
of manslaughter and at his suggestion Bevere censure for 
the neglect to secure medical aid was substituted for the 
addition. 

iledioal Evidence in Catet of Cruelty to Children. 

Charles George Golden Rushworth, solicitor and secretary 
to the York education committee, and his wife Sarah 
Katherine Rushworth were charged recently under five 
summonses with repeated acts of cruelty towards two girls, 
aged respectively 14 and 13 years, whom they had adopted. 
The cruelty consisted in treatment of the kind usually to be 
found in such cases—insufficient food, insufficient clothing, 
compelling to sleep in unsuitable circumstances, beating, 
drenching with water, scalding, and burning with hot 
iron. The summonses were heard by the petty sessional 
bench of the Eastern Ainsty division and the defendants 
were convicted, the man being fined £50 and ordered 
to pay the costs of the prosecution, and the woman 
being ordered to be imprisoned for nine months in the second 
division and to pay the costs of the prosecution. The case 
has been fully reported in the newspapers and contains 
features, as has been suggested above, common to others of 
cruelty to children and young persons in a helpless position. 
In particular, it will have been observed that as to the acts 
alleged there were direct contradictions by the witnesses 
on either side and explanations given by them or by 
counsel with regard to these acts, creating a con¬ 
flict of evidence only to be determined by the 
impartial testimony of independent observers. This 
was supplied by two medical witnesses, Dr. Robert 
Draper and Dr. William Arthur Evelyn, who had examined 
the children before proceedings were taken and who 
spoke to their improvement since their removal to suitable 
surroundings. They agreed that the various scars which 
they found were consistent with the children’s stories of 
burning with a flat-iron and with a poker, with kicks upon 
the shin, and with the other treatment described, and, equally 
important, that they were not consistent with accidental or 
self-inflicted injury arising in the various ways alleged 
by the defence. A small but important point was 
brought out in the evidence of Dr. Draper where be 
said with regard to certain scars upon the foot of one of the 
little girls that she accounted for them by saying that she 
had caused them herself. There could have been no reason 
why she should not have imputed them as well as the other 
marks on her person to the female prisoner if she had been 
bringing false accusations against her.. Considerable import¬ 
ance must have been attached by the magistrates who heard 
the case to the medical evidence as to the increase of 
weight in the child who had been ill-treated for a 
longer time than the other. This little girl, who when 
first rescued weighed about 5 stones 3i pounds, after six 
weeks of kind treatment and proper feeding weighed 6 stones. 
Such a fact where a child is said to have been starved is one 
from which any layman can draw his own conclusions and must 
always be difficult for the most ingenious defender to explain 
by any theory consistent with bis client’s innocence of de¬ 
liberate cruelty or neglect. Another point in the case of the 
Rushworths, for which a parallel could be found in many of 
the noted trials in which cruelty to children has been 
charged, consisted in the allegation by the defendants that 
one of the children was "dirty in her habits,” in order to 
justify their denial to her of proper bedding and clothes. 
This, again, was dealt with by the medical evidence, with the 
explanation that aDy incontinence if it existed was likely to 
have been caused by the treatment to which the little victim 
was subjected. Of course, in no circumstances could it 
justify or excuse severity or cruelty. No question was raised 
as to the mental condition of the female prisoner. We 
understand that the male defendant is about to appeal from 
the sentence. 





The Lancet,] THE RESPONSIBILITIES OF OPERATING SURGEONS AND ANAESTHETISTS. [JAN. 18,1908. 169 


THE LANCET. 


LONDON : SATURDAY, JANUARY 18, 190S. 


The Responsibilities of Operating 
Surgeons and Anaesthetists. 

WE publish in another column an interesting communica¬ 
tion from the pen of Dr. Dudley Buxton dealing with the 
medical point of view as to the degree of responsibility 
toward the patient that exists between the operating 
surgeon and the anaesthetist. Our able contemporary the 
Law Journal, in the iSBue of Dec. 14tb, 1907, published a 
short editorial article dealing with the legal aspect of this 
most important question. The matter has been ventilated 
in our columns in connexion with inquests held upon 
patients dying under anaesthetics, but it is not a little 
surprising that a subject so important to the profession and 
to the public at large should have received so little atten¬ 
tion in works dealing with anaesthetics and published in the 
United Kingdom. With one exception no reference is made 
to it in them and even the leading authorities upon the 
medico-legal side of our profession dismiss the problems 
involved with cursory paragraphs. 

The article in the Law Journal proves that forensic and 
nodical minds fail to look at questions which lie in the 
borderland between physic and law from the same stand¬ 
point. We are told, for example, that the evidence given 
at an inquest before the coroner for Southwark disclosed : 
“(1) that it is by no means an universal practice in hos¬ 
pitals to have anaesthetics administered by a regularly 
trained anaesthetist and that on occasion they are adminis¬ 
tered by any member of the hospital staff and even by 
newly-fledged practitioners, whose knowledge of drugs is 
by no means equal to that of an ordinary chemist ; 
(2) that the apportionment of the responsibility for the 
anesthetics between the operator and the anesthetist 
is not clearly settled.” With regard to the first point, 
we presume that the writer is not aware that even 
“ newly-fledged ” practitioners are instructed not only 
in the properties of anaesthetics but in the methods of 
their use. To compare them in this regard to ordinary 
druggists is to admit ignorance of the matter at 
issue. It must be conceded, we fear, that although 
medical men in England are obliged now to be in¬ 
structed in the production of anaesthesia and to be 
“signed up" for attendance at a certain number of cases 
when anaesthetics are used before they can be admitted 
for their final examination, yet for the character of 
the instruction and the efficiency of the student the 
public have to aocept the guarantee of the staff anaes¬ 
thetist, since no examination is imposed by the examining 
boards. Occasionally questions are asked but no practical 
work is required. At present the anaesthetist who is 
attached to the hospital is practically the only safeguard 
between the public and the “ newly-fledged ” practitioner. 


When we pass to the second point—viz., the apportion¬ 
ment of responsibility between the operator and the 
anaesthetist—a more complex problem is presented to us. 
We have always contended that no operator can accept the 
responsibility for the conduct of the anesthesia; be must 
either give divided attention to his own work or to that of 
another man, and in either case he must fail to accomplish 
the best that is possible for his patient. We are excluding 
purposely those occasions, which are probably few enoogh, 
in which through an emergency the anaesthetic must be 
given by a person inexperienced in the matter; in such an 
instance the operator has to do the best he can, but we 
contend that such emergencies should never be the result 
of the operator’s want of forethought if he wishes to escape 
liability for any accident. Admitting, then, that in hospital 
or private practice the necessity for the use of anaesthesia 
arises it will in most cases devolve upon the surgeon 
to call to his aid some person to give the chloroform or 
ether. In hospital he will follow the routine of the institu¬ 
tion and obtain the help of an anaesthetist who is usually a 
member of the staff, and whose duty it is to attend at speci¬ 
fied times. In this case the responsibility for the conduct of 
the anaesthesia will rest upon this officer. It is probable 
that whenever a hospital staff or board of governors elect 
such an officer they do so with the understanding that he 
will accept this responsibility and be competent to do so 
without any supervision by the operator, since the latter 
presumably does not know more than his colleague in the 
field of the latter's special study. When, however, this 
officer is absent—and we gather from the reports of inquests 
which we have published at many or at all hospitals a large 
number of anesthetics must be given by persons other than 
the staff anesthetists—the operator accepts the responsi¬ 
bility of allowing Borne person of more or less skill to 
undertake the anaesthetising of his patient. This is a 
legitimate position but we cannot agree with the conten¬ 
tion that if his choice falls upon someone whom he has 
reason to believe to be inexperienced he, the operator, 
can supplement the inefficiency of the anaesthetist by any 
supervision which he may exercise while he is engaged in 
operating. We believe it is held by some coroners that 
if a fatality arises in such circumstances and it can be 
shown that the death was the result of inexpertness or 
carelessness in the administration of the anaesthetic the 
responsibility would be laid upon the operator. We notice 
that speaking at a recent inquest the coroner for Southwark 
stated that the surgeon was legally responsible for the 
anaesthesia as well as the operation. He does not, however, 
give any authority for this view and we are not aware that 
any decision upon the point has been arrived at in the law 
courts, except in cases in which the surgeon has himself 
given the anaesthetic and has performed the operation. If 
the law is as asserted it seems time that such an anomalous 
situation should be terminated. In private practice the 
operator who selects a person of small experience or 
permits the selection of such an anaesthetist in a grave 
case would accept a very serious responsibility, but in 
hospital practice many thiDgs have to be considered. It 
is almost inconceivable that any well-ordered hospital 
should not have proper provision made for the giving of 
an aesthetics in cases of emergencies. Many have resident 



170 The Lancet,] COUNTY MEDICAL OFFICERS k THE INSPECTION OF SCHOOL CHILDREN. [Jan. 18, 1908. 


amLMthetists, others have resident medical officers who are 
skilled in giving anesthetics, and such would be available 
at all times. When no competent person is obtainable it 
seems to us that the surgeon incurs a very grave responsi¬ 
bility in pursuing an operation without competent help and 
would be wise if he insisted upon the remodelling of the 
department of anaesthetics in his hospital. 

The public, as well as the medical profession, regard 
the duties of an anaesthetist in a very different 
light from that which obtained a few years back. 
Then the chloroformist was “the assistant”; he received 
the odd shillings from the surgeon's fee, or even less, and 
was a house surgeon or some junior who looked to his 
teacher or friendly helper for a few guineas until practice 
came his way. To-day the anaesthetist devotes many years 
to hospital work and pursues his own branch as assidu¬ 
ously as does the physician or the surgeon, and is usually 
a man holding degrees equivalent to theirs. This change 
of status has been, however, only gradual and has been 
the work of comparatively the last few years. It is this 
fact that has brought about much confusion as regards this 
question of responsibility. Patients even now often regard 
the choice of the anaesthetist as being one of the duties 
of the surgeon and so fasten this responsibility rather 
unfairly upon him. There can be no doubt, we 
think, that the ideal is attained when the anaesthetist 
is genuinely a competent and scientific exponent of 
his own branch as is the physician or surgeon in his. 
Knowledge in the administration of anaesthetics involves 
more than a mere manipulative skill and presupposes 
a painstaking apprenticeship. Responsibility in such 
cases can be relegated upon the right shoulders, and 
the position, which, we submit, is untenable, must be 
relinquished that a surgeon can make himself re¬ 
sponsible for the choice of agents, of methods, and the 
conduct of the amesthesia when undertaken by another man. 
It follows upon this that those anaesthetists who make a 
specialty of their branch of the profession and who devote 
many hours a week to hospital work should be granted the 
same status as other members of a hospital staff ; they should 
have their position of responsibility brought clearly before 
the public. If they are to be held responsible for the life of 
the patient, and we submit that such should be the case, 
they should reap both pecuniary and social reward for 
their services. Many will agree with a distinguished 
anaesthetist who has urged the importance of all staff 
anaesthetists possessing degrees as graduates in medicine 
or surgery or equivalent diplomas from the Royal 
Colleges. Such officers should undertake not only 
lectures but thorough clinical instruction at the schools 
to which they are attached. In this way students 
would learn to appreciate fully the gravity of their 
future work when called upon to give an anaesthetic 
and would learn also that most difficult of all lessons, 
to master their own limitations. It is surely severe 
enough a strain upon the modern surgeon to have to operate 
upon the complex cases which daily fall to his lot without 
being obliged to supeiintend the heedless or timid anres- 
thetis! to whom are occasionally relegated duties for which 
lack of previous training or limited experience renders him 
unfit. 


County Medical Officers of Health' 
and Organisation for the Inspec¬ 
tion of School Children, 

County councils in England and Wales were created by 
the Local Government (England and Wales) Act, 1888, and 
one of the provisions of that Act enabled county councils, 
if they saw fit, to appoint and to pay one or more medical 
officers of health. The duties of this new official were 
not defined by the Act but it has recently been suggested 
that the Local Government Board should obtain power 
to make regulations with respect to them. It was indeed 
at one time suspected that the Board regarded with a 
certain amount of alarm the devolution to the newly 
formed and untried councils of responsibilities which 
hitherto had been exclusively borne by the Board itself. 
But however this may have been, one of the first acta 
of some of the largest and most important councils 
was to form a committee to deal with public health ques¬ 
tions, and steps were also taken by them to appoint a 
medical officer of health to advise that committee. The 
county councils of Lancashire, the West Riding of York¬ 
shire, Staffordshire, Durham, and London in England and 
of Glamorgan in Wales elected as their medical officers 
of health gentlemen who were required to devote them¬ 
selves exclusively to the service of their respective 
counties. Other councils, including those of Worcester¬ 
shire and Essex, took advantage of a provision in the Act 
which enabled arrangements to be made for rendering the 
services of the county medical officer regularly available in 
the district of a district council. In subsequent years other 
county councils have appointed either whole-time officers or 
engaged the services of an officer for special duties such as- 
editing and epitomising the annual reports of the medical 
officers of health to the urban and rural districts. The 
principle of medical advice being asked in county adminis¬ 
tration has now been well established. 

It was no doubt contemplated at the time of the passing 
of the Act in 1838 that eventually every county council 
would have the advantage of the advice of an adequately 
paid whole-time medical officer, but progress is slow and up 
to the present time there are only about 24 such officers in 
England, and still only one in Wales. The usual excuse 
made by those councils which hitherto have failed to make 
a proper appointment is that there is little necessity for 
a medical officer owing to the absence of any definition 
of his duties. With the passage of the Mid wives Act and 
the latest Education Act which requires that every public 
elementary school child shall be medically examined at stated 
periods this excuse is no longer available, and it must not 
be supposed that prior to the dates upon which the two- 
Acts of Parliament named came into force there were no 
obligations cast upon county councils as regards the public 
health. One of the most important statutory duties of a 
county council is to make a representation to the Local 
Government Board if it appears from any of the reports of 
the district medical officers of health that the Public Health 
Act, 1875, has not been properly put in force in a particular 
district, or that any other matter affecting the public health 
requires to be remedied. From time to time this repre¬ 
sentation has been made by those councils who employ a 





The Lancet,] 


THE DESTINY OF CASE BOOKS. 


[Jan. 18,1908. 171 


-whole-time medical officer of health, bat, so far as we are 
.aware, it has rarely, if ever, been made effectively elsewhere. 
With regard to the prevention of the pollution of rivers a 
county council has the same powers as those possessed by 
sanitary authorities vested with the powers required for 
patting in force the Rivers Pollution Prevention Act, and at 
least two county councils, those of Lancashire and the West 
Biding, have done excellent work in this direction. Another 
very important power vested in county councils, but one which 
is rarely exercised, is that of making by-laws with respect to 
their counties. It is true that this power cannot be enforced 
in a borough, however small it may be, but there are 
many parts of counties outside the boroughs where the model 
series of by-laws issued by the Local Government Board or 
modifications of that series might with considerable advan¬ 
tage be enforced. The Isolation Hospitals Act, 1893, is 
an enactment which can only be administered by a county 
council. In case, however, a council desires on its own 
-initiative to put the Act in force the first step to be 
-taken is to direct the county medical officer of health to 
snake an inquiry as to the necessity for an isolation hospital 
in a particular district or districts, and acting on his 
Advice the council may require that such a hospital 
fih&ll be provided. Where there is no county medical 
cfficer of health the Act is for all practical pur¬ 
poses an adoptive one. We have said enough to show 
that there is sufficient work to be found in the larger 
counties to take up the whole time of a medical offioer of 
health, and in the smaller ones where his appointment is 
objected to upon financial grounds there ought not to be 
much difficulty in combining for the purposes of making a 
joint appointment two or more administrative areas which 
Are not at too great a distance one from the other. We have 
reason to believe that the Local Government Board would 
not raise any objection to such combinations, although 
hitherto none have been made. 

As might have been expected, when the Midwives 
Act came into force some difficulty was found in 
administering it properly in those counties where the 
councils had not thought fit to appoint a medical officer 
«f health, but a great deal of ingenuity has been exer¬ 
cised to avoid taking this step. In some counties a 
trained nurse has been engaged to see that the Act is 
carried out, in others the clerk to the council has been 
intrusted with this duty, while in at least one county 
the duty has been actually placed upon the police. 
The recent Education Act imposes upon the local education 
authority, which is in most cases the county council, the duty 
of providing for the medical inspection of children imme¬ 
diately before, or at the time of, or as soon as possible after, 
their admission to a public elementary school and on such 
other occasions aB the Board of Education may direct. But, 
unfortunately, the reports which are appearing of the delibera¬ 
tions of some county councils disclose an inclination to do as 
little as possible in order to conform to the mere letter of their 
legal requirements. There is displayed no sense of responsi¬ 
bility towards the children nnder their charge, no suggestion, 
except that of reducing expenditure to the very smallest 
sum possible, appearing to receive mnch consideration. 
We know very well that the cost of local government and 
education in this country is very heavy, while it is generally 


conceded that it also falls with particular weight upon one 
class—the professional class to which oar readers belong. 
But the economy that is directed towards paying for the 
inspection of school children may prove an extravagant 
policy. If the medical inspection of the children is to do 
anything it is to find out the physically unfit, and a wise 
and far-seeiDg education authority will not be satisfied with 
merely making records of such discoveries but will take 
some steps to bring tbe conditions revealed by the inspections 
to the notice of tbe parents and to persuade them of the 
necessity of seeking medical advice. 

It may certainly be anticipated that one effect of the 
Education Act and of the Memorandum relative thereto 
which was recently issued by the Board of Education will be 
to stimulate county councils to appoint whole-time county 
medical officers of health. It is possible, too, that in the 
not far distant future alterations in the administration of the 
Poor-law may throw upon county councils certain duties 
which are at present discharged by the guardians and 
district medioal officers, and if this be so there will be a 
further demand for county medical officers of health. 


The Destiny of Case-books. 

As will probably have been noticed by those medical 
men who were sufficiently Interested in the Druce case 
to read the report of the proceedings before Mr. Ploxvdbn 
at the police court, it was stated by counsel that evidence 
as to the illness and death of the late Mr. T. C. Drugs 
would be submitted if necessary from tbe case-books 
of the late Sir William Fergusson. A few months ago 
we referred in the columns of The Lancet 1 to the possible 
destiny of the case books of deceased practitioners, and we 
think that we may well call the attention of the medical 
profession to the matter in a little more detail. We are not 
now concerned with the purely legal questions which might 
have arisen had the evidence in question been actually 
tendered. We may, however, suggest that from an ethical 
point of view there can be little or no objection to informa¬ 
tion beiDg obtained from a deceased medical man’s case¬ 
books which he might himself reasonably be called npon to 
afford were he alive. In the case of the living practitioner 
it must be his duty at times to break silence in his patient’s 
interest or in that of the patient’s descendants, while the 
cause of justice may have paramount claims over all other 
considerations or may leave the practitioner bound to main¬ 
tain secrecy to the utmost extent in his power. No circum¬ 
stances, however, impose upon the medical man the obligation 
to leave behind him records of his practice which on the 
occurring of some not-to-be-foreseen contingency may become 
useful to someone, and which nnder equally conceivable con¬ 
ditions may prove agents for mischief. What, then, is he to 
do with case-books, seeing the potentiality for good and 111 
which may lie between their covers ? 

When the successor to a practice takes over old case- books 
which obviously may be useful to him the books remain in 
proper custody; this is a situation to which we are not 
referring. We are considering rather the transfer of property 
which occurs when the last person professionally interested 

x Tbe Lancet, July 27tb, 1907, p. 240. 




172 The Lancet,] THE PARAVERTEBRAL TRIANGLE OF GKOCOO IN SUBPHRENIC ABSCESS. [Jan. 18, 1908 


in the records dies, while it must be recollected that it is 
the case books of great consultant physicians and surgeons 
that will generally be in question and that these men do not 
and cannot transfer their practices. When such a man dies 
his case-books may fall into the hands of those indifferent to 
their use or abuse, either immediately or in the course of a 
few years. It is, of course, competent for him who has com¬ 
piled them to order their destruction in his will, and the 
question whether it is desirable for him to do so is one for bis 
serious consideration. From a scientific point of view their 
preservation may be of considerable importance, but the 
probabilities, nowadays at any rate, point rather the other 
way. The consulting physician or surgeon of eminence leaves 
in the records of the hospital in which he has enjoyed his 
principal opportunities for advancing the science to which 
he has devoted his lifetime a full account of what he has 
achieved, systematically compiled and preserved by the regis¬ 
trar. This account is supplemented by his communications 
to professional societies and journals, and his case-books 
would not be as a rule required to support his scientific 
views. If the private practice of any medical man, what 
ever his position in his profession, has afforded him the 
means of increasing the knowledge of his fellows through his 
attendance on a case of an exceptional nature, he has 
probably made public during his lifetime all that it 
is desirable should be known upon the subject. The 
preservation or the destruction of his private case book 
must therefore be regarded as a question of interest from 
a social rather than from a scientific point of view ; 
the volume may contain memoranda relating to facts 
the proof of which some person interested may desire 
to establish and, on the other hand, it may carry in 
adjacent pages records the publication of which would 
cause incalculable distress to the persons concerned and to 
those connected with them. 

What should be done with case-books ! Whereas their 
destruction is a simple matter requiring little beyond a 
lucifer match, their preservation under such conditions 
that they shall be of use if needed, without the possibility 
of their misuse, presents some difficulties. If they are 
bequeathed to an individual trustee or to trustees with in¬ 
structions for their safe keeping and ultimate destruction, 
these, like the testator, are mortal; and for other reasons 
than their decease the trust may not be carried out. There 
are organisations in connexion with the medical profession 
which might undertake the safekeeping of case-books 
subject to conditions for their production for purposes 
and with precautions which would have to be defined 
rigidly—always supposing that it is the view of the 
medical profession that the claims of society make the 
preservation of case books advisable. It is not, however, 
to be imagined that any existing body would under¬ 
take such duties willingly, nor could it do so without 
considerable outlay for storage and the provision of proper 
custodians. Moreover, the task would not be rendered less 
irksome and unremunerative by the fact that inspection of 
the note-books thus stored and guarded, or rather of 
individual notes contained in them, would be necessary 
only on . rare occasions. As the matter stands at present 
case books if preserved may be in some instances of scien¬ 
tific and in others of historic value as the contemporary 


notes of a trustworthy and impartial observer upon matters 
of fact within bis cognisance. If they are destroyed a 
patient's interests as distinct from his bodily health may be 
prejudicially affected. Their preservation, however, con¬ 
tains a distinct element of danger, as in the hands of the 
unscrupulous they may become a weapon for the purpose of 
blackmail or some other form of oppression, and the clear¬ 
ness and fulness which are most likely to render them of 
service for good will cause them to be proportionally 
effective for evil. 


Jmurtatmits. 


"Be quid nimis." 


THE PARAVERTEBRAL TRIANGLE OF GROCCO 
IN SUBPHRENIC ABSCESS. 

In 1902 Grocco described a new sign of pleuritic effusion, 
a paravertebral triangle of dulness on the opposite side. 
The experience of many observers has shown that this is a 
valuable sign of pleural effusion 1 and, indeed, is almost 
pathognomonic. Dr. William Ewart has explained the 
mechanism of the sign as follows.' 1 The fluid in the pleura 
acts as a mute applied to the vertebra; and damps the vibra¬ 
tions conveyed to the surface by the compound pleximeter 
made up of the vertebral spines, transverse processes, and 
heads of the ribs. As a remarkable confirmation of this 
view he mentioned a case in which this damping was pro¬ 
duced by a subdiaphragmatic abscess. The presence of 
a low but rather broad triangle of Grocco led him 
to diagnose empyema but no pus was found in the 
chest and the triangle vanished when a lumbar abscess 
was emptied. In the Journal of the American Medical Asso¬ 
ciation of Dec. 28th, 1907, Dr. K. H. Beall has reported a 
similar case of this rare condition which, not knowing of Dr. 
Ewart’s case, he regards as unique. It may be pointed out 
that the intimate anatomical relations of the pleural cavity 
and subdiaphragmatic region cause collections of fluid in 
the latter to produce the other signs of pleural effusion and 
lead to mistaken diagnosis. In Dr. Beall's case a man, 
aged 38 years, was admitted into the Johns Hopkins Hos¬ 
pital on August 21st, 1907, complaining of “pain in the 
liver.” His illness began about a month before, when 
he was much exposed to cold, with a sharp stabbing 
pain in the right axilla which was much aggravated 
by deep breathing. The pain increased gradually and 
became persistent. There was a painful cough without 
expectoration. The patient could not lie on his right side 
in consequence of increased pain and occasionally had 
night sweats. He lost 40 pounds in weight. Oa admission 
he was emaciated and his skin was sallow. The right axilla 
was fuller than the left and the interspaces were not so well 
marked as on the left. There was scarcely any expansion 
on the right side and Litten's sign was absent. Vocal 
fremitus was much diminished over the lower part of the 
right lung but was plainly felt to the base. On the left side 
resonance to percussion was normal except for a para¬ 
vertebral triangle of dulness 6 by 6 centimetres. The 
note over the upper right lobe was high-pitched and began 
to be dull at the third rib in the mammillary line and was 
flit at the nipple in the fourth interspace. The line of 
flatness dipped towards the sternum and extended straight 
around to the right, being at the sixth rib in the 
axilla. There wsb moveable dulness over the front of 
the right chest for two centimetres. The vertebral 


1 The Lancet, March 30th, 1907, p. 902. 
2 The Lancet. July 22ud, 1905, p. 216. 





The Lancet,] 


THK METROPOLITAN WATER-SUPPLY. 


spines were resonant as low as tbe tenth spine where 
the note was Sat. From this point the line of flatness 
extended upwards over the right back to just above the 
angle of tbe scapula and then fell to the sixth rib in the 
middle of the axilla. On the left side the respiratory sounds 
were loud and clear. Over the right upper lobe respiration 
was harsh ; lower it was mnch enfeebled, thongh still harsh, 
and over the flat area was almost absent. Over the upper 
part of the right lower lobe the respiration had a slight 
tubular quality. Vocal resonance was very loud over the 
right apex and very feeble over the flat area. There was no 
visible or palpable cardiac impulse. The abdomen was a little 
fuller on the right than on the left side. There was slight 
resistance to palpation over the whole abdomen which was 
more marked on the right side. In the right hypochondrium, 
axilla, and flank there was slight tenderness. The tempera¬ 
ture ranged from 98° to 99'8° F. Aspiration in the eighth 
interspace yielded a small amount of pus. The eighth rib 
was resected and the pleural cavity was opened and found 
to contain no fluid. The pleural cavity was then shut off 
by suturing to the diaphragm and by packing. A piece of 
the ninth rib was excised, the wound was packed off with 
gauze, and tbe diaphragm was incised. About 400 cubic 
centimetres of thick pus were removed from an abscess under 
the diaphragm. The liver was much enlarged. A tube was 
inserted and the wound was packed with iodoform gauze. 
Uneventful recovery ensued. The pus contained much bile 
but was sterile. 


THE METROPOLITAN WATER-SUPPLY. 

The Water Examiner’s report to the Local Government 
Board on the condition of the metropolitan water-supply for 
last August (dated October, 1907), contains a summary state¬ 
ment by Mr. C. Perrin, with added tables and appendices 
containing the reports of analyses made by Dr. T. E. 
Thorpe on behalf of the Local Government Board and 
by Dr. A. C. Houston, director of water examinations to the 
Metropolitan Water Board. It is surprising to read that 
the average daily natural flow of the Thames at Teddington 
Weir was during August 49'4 million gallons below the daily 
average for the 24 preceding years. The water at Hampton, 
Molesey, and Sunbury was in good condition during 
August ; the filtered supplies distributed from the Thames 
works were all clear and of good quality ; the Lea supplies 
and Kent wells were also satisfactory. The report further 
states :— 

The results of the bacteriological examination show that the filtered 
water contained on an average 119-3 microbes per c.c. (inclusive of 
results) and 10 9 microbes per o.c. exclusive of 49 samples which con¬ 
tained 100 or more microbes per c.c. The water supplied U) tbe Kent 
district contained the lowest average number of microbes—via.. 31 per 
c.c., and that supplied from the works of the Grand Junction Division 
of the Southern District at Kew Bridge the highest—viz., 1027 3 per 
c c.; exclusive of samples containing 100 or more microbes per c.c., the 
average number was 21 0. The Southwark and Vauxball water con¬ 
tinues to show a marked improvement. 649 samples of filtered water 
(including the Kent unfiltered well water) were examined for B. coli. 
“Typical'' B. coll were fouud in 1 c.c. In 0 6 per cent, of the samples. 
Dr Houston 'b report also shows that in August whereas 7b 0, 75-0, and 
50 per cent, of the samples of raw Thames, JLea, and New Itiver water 
respectively contained typical B. coil in 1 c.c. or less of water, 89 2, 89 9, 
and 93'6 per cent, of the littered water samples derived from the Thames. 
Lea, and New Itiver respectively contained no typical B. coli even in 
100 cubic centimetres. 

Sinee the Walton reservoirs were brought into use a very marked and 
progressive Improvement in the quality of the water from the South- 
wark and Vauxball division works at Hampton baa taken place. The 
firstrctass samples have increased from 6 1 to 88'b per cent, during the 
present year. All the samples of filtered water examined by Dr. 
Houston were free from any appreciable amount of suspended matter. 
The proportion of brown tint observed in a 2-foot tube, ascertained 
by a comparison with a standard tint of brown opposed to 20 mm. 
In thickness of blue tint, ranged from 0 to 18 degrees. The Lambeth 
water exhibited the deeper average tint of brown. 

A systematic investigation has been commenced by the 
Board on the benefit of increasing the storage accommoda¬ 
tion at the various works and the inquiry will last over a 
year. Meanwhile an example of the disadvantage of storing 
has come prominently forward at the Staiaes reservoir where 
during the summer an abnormal development of algae 


[Jan. 18, 1908. 173 

(oscillaria) occurred and caused trouble in the filtration of 
the West Middlesex and to a less extent the Kempton Park 
and Grand Junction water. The algae are innocuous alive 
but obviously a source of danger from decomposition, and 
they were treated with copper sulphate tied up in sacks hung 
over the side of a boat which was rowed about until the salt 
was dissolved ; this procedure reduced the oscillaria in one 
reservoir from over 7000 to about 10 per cubic centimetre 
within three weeks ; the water passing subsequently was 
daily tested to prove the absence of copper. It is pointed 
out that an improvement of the circulation of water 
at Staines reservoir is desirable. The report for September 
(dated November, 1907) urges that more storage capacity 
is necessary at the Kew Bridge works, where at present 
practically raw river water is treated. September was 
a very dry month, the rainfall being only one-third of 
the average, and the average Thames flow being only 
348'5 million gallons, which is 130 • 4 million gallons 
below the daily average for the 24 preceding years. In 
spite of this the Thames water remained in good condition 
and the proportions of organic impurity present in its five 
supplies were lower than in August, having in fact steadily 
decreased since last May. The New River, Eastern district, 
and Kent well water were all of good qualtity, the last 
being classed as usual as “excellent.” As regards the 
bacteriological examination typical bacilli coli were found 
in 1 cubic centimetre of 0'2 per cent, of 633 samples. 
40 folio pages of the report for September are devoted 
to a summary of the chemical and bacteriological exa¬ 
mination of the Lea valley deep-well waters by Dr. 
Houston. The estimated population supplied during 
September in all districts was 6.942,333, the number of 
separate supplies being 1,070,046, with a daily average of 
212 gallons for each supply. In writing of the water-supply 
of Loudon we may add that it has been stated semi-otflcially 
that the new scheme for supply which the Metropolitan 
Water Board has under consideration, and to which we 
referred in a recent issue of The Lancet, contemplates 
the construction of a basin nine miles in area and entails 
the tapping of a tributary of the Thames the identity of 
which is not yet made public. It is calculated that this 
supply would meet the needs of 12,000,000 people, the 
estimated population in 1941, and it is further stated that 
later it could be increased to meet the needs of the 
16,000,000, tbe estimated metropolitan population in 1961. 


A PIONEER OF MODERN MEDICAL WOMEN 
AND HER PREDECESSORS OF THE 
MIDDLE AGES. 

The Novae Vremya reportB that on Dec. 16th, 1907, many 
institutions and representatives of the medical world sent 
congratulations by telegraph to Nadezhda Prokoflievna 
Susslova-Golubeva who, it says, was the first female doctor, 
not only in Russia but in all Europe, now living in Aluscbta. 
It is just 40 years ago since she delivered her first lecture, the 
subject of which was the Profession of Doctor of Medicine 
for Women, which degree she was the first in Europe to 
obtain. Madame Susslova-Golubeva, says the Novae Vremya, 
attended the Medico-Surgical Academy lectures privately and 
in the year 1863, with the consent of the Curator of the 
St. Petersburg Professional Circuit, Delianolf, she passed 
her final examination at one of the gymnasia for male 
students. Tbe statement that she was the first woman 
in Europe to obtain a degree in medicine is certainly 
not correct, although Madame Susslova Golubeva was an 
early pioneer of medicine amongst modern women. If we 
look back far enough, however, we find that women once 
held a very honourable estate in European medicine. Tbe 
first famonB lady doctor was Trotnla, to whom is ascribed a 
work, “ De Muliernm Passionibus,” whioh appeared about 




174 The Lancbt,] TRAVELLING NEEDLES.—SOCIETY FOR THE DESTRUCTION OF VERMIN. [Jan. 18, 1908. 


the middle of the eleventh century. Her contemporary 
reputation was great and two centuries later a trouba¬ 
dour of France named Rutebccuf recorded the cheap jack 
speech of a travelling quack snch as may still be 
heard in our own provincial theatres who claimed 
as his great merit that he was a pupil of Trotula. 
That lady was of the school of Salerno, a uni¬ 
versity which conferred medical degrees on women as late 
as the fifteenth century. Amongst these graduates were 
Sichelguada who tried to put her knowledge of materia 
medica to account by poisoning her stepson but was pre¬ 
vented from doing so by her brother physicians who found 
her out and told her husband about it; Abella who wrote a 
medical work in Latin hexameters ; Calenda, a lady of great 
beauty, who married a nobleman of the Court of John II. of 
Naples in 1423; and later in that century Marguerite of 
Salerno, who was licensed to practise by the King of Poland. 
Roswell Park, in his History of Medicine, quotes Daremberg 
to the effect that these lady physicians were in great 
request on account of their talents and that they combined 
scientific knowledge with facetious playfulness in such ways 
as doctoring roses with powdered euphorbium for presenta¬ 
tion to admiring gallants, whose subsequent sneezings caused 
them much merriment. No medical degrees were granted to 
women in England until the last century, but Henry VIII. 
granted licences to practise medicine to certain women 
to attend the sick poor who could not afford to pay the 
fees of regular practitioners yet did not wish to depend 
entirely on charity. These were probably the first recognised 
women practitioners in England, although, of course, "wise 
women ” must have practised folk-medicine from the earliest 
times. 


TRAVELLING NEEDLES. 

Probably one of the most tedious and worrying little 
tasks which fall to the lot of the general practitioner or 
the house surgeon in hospital is the removal of needles 
which have accidentally entered the hands or feet of patients 
who are more often than not women. In the days before 
skiascopy the device was often resorted to of poulticing the 
injured member “to draw the needle to the surface,” usually 
with disappointing results, and a subsequent dissection 
amidst the maze of nerves and vessels in the deeper layers 
of the sole or palm was often fruitlessly abandoned. Even 
in these days when the shadow of the needle can be 
clearly seen by the aid of a fluorescent screen, and its 
position accurately marked on the surface, the surgeon often 
finds that the slippery intruder has managed to vanish 
from where he plainly saw its shadow a few minutes before, 
and the patient may have to submit to a general anaesthetic 
and an enlarged incision, followed by the confinement of her 
hand in a splint for some weeks, as the price of parting with 
the offending needle. In view of this experience, some 
practitioners have refused to search unless they could feel 
the point under the skin and, as a rule, provided that the 
needle was clean, after some days’ swelling and dis¬ 
comfort the band or foot has become quite recon¬ 
ciled to the presence of a foreign body in its midst. 
Many cases have been recorded, however, in which such 
needles, as well as those which have been swallowed by 
accident or perverted intention, start off on extraordinary 
wanderings in the body tissues and appear months or even 
years afterwards in the most unexpected places. Two such 
cases were recorded in our columns last week. One of them 
related to an Aberdeen lady who 30 years ago received a 
needle in her left foot, an event which she had forgotten 
until at the end of last year it presented itself in her right 
elbow and was easily removed. The other was reported from 
Vienna but is not so convincing as an instance of migra¬ 
tion. A labourer, apparently in perfect health, died suddenly. 


and at the necropsy four pieces of needle, each about 
an inch long, were found in the fat of the abdominal 
wall. The cause of death was btemorrhage into the peri¬ 
cardium from two small slit-like openings in the pulmonary 
artery which corresponded to similar slits in the pericardial 
sac ; no needle was found in the heart or lungs but it was 
considered that two may have entered the pulmonary artery, 
causing the slits and have been washed away during the 
necropsy. We do not consider this evidence conclusive of 
the guilt of the needle of its host's death, and such serious 
results of these curious migrations are fortunately very rare. 
Many of our readers could doubtless cite instances which 
have been fraught with no consequence worse than some dis¬ 
comfort to the patient, and we may mention two culled 
at random from our own files. One was recorded by Dr. 
D. Campbell Black in The Lancet of Nov. 8th, 1884, p. 853, 
and referred to a lady who had broken off a needle in the 
first joint of her left thumb. Dr. Black had searched for it 
unsuccessfully, and a year later “she felt a pricking sensa¬ 
tion in the right forefinger and having broken the skin she 
without difficulty removed the greater portion of the lost 
needle from the point of the finger.” We may recall one 
other remarkable case which was under the care of 
Dr. G. Wright Hutchison who treated it in the Belford 
Hospital at Fort William and recorded it in The Lancet 
of Jan. 18th, 1873, p. 91. The patient was a healthy 
Scotch girl, aged 20 years, who had no 6ign of 
hysterical tendency but was in the habit of putting 
pins in her mouth, and sometimes had been known to 
fall asleep without removing them. She was admitted 
to hospital having swallowed five pins accidentally, whilst 
fixing clothes, and by the help of emetics she was relieved 
of them. Returning home she began regularly to vomit pins 
and got rid of 23 in the course of a month. She then began 
to produce needles and in a fortnight 13 came out from the 
following situations—the left nostril, the origin of the 
sterno-mastoid behind the left ear, and a spot on the front 
of the right forearm; at the same time she continued 
vomiting pins until 75 had appeared. The needles were 
blackened and slightly eroded, and two of them were 
threaded with about three inches of thread. This perform¬ 
ance seems to rival that of the conjurer who produces 
foreign bodies from every part of his own, but Dr. Hutchison 
testifies to it in these words: “ The history of the case is 
almost incredible, but from what was observed in hospital 
and from the evidence of her mistress, which is thoroughly 
reliable, there can be no doubt of its being bona tide." The 
records of the asylums for the insane can possibly furnish 
somewhat similar instances. 


SOCIETY FOR THE DESTRUCTION OF VERMIN. 

In The Lancet of Nov. 9th, 1907, p. 1299, Sir Lauder 
Brunton emphasised the important connexion between the 
plague and rats and quoted Professor W. J. R. Simpson’s 
figures showing that no less than 1,060,000 deaths occurred in 
India during the first six months of 1907, and that out of 
these 632,000 occurred in the Punjab, which has a population 
of only 25,000,000—that is to say, 1 in every 40 of the in¬ 
habitants in that district died from plague between January 
and June. These figures were used with great effect by 
Sir James Crichton-Browne in his opening address as chair¬ 
man at the first general meeting of the Society for the 
Destruction of Vermin on Jan. 10th at the Hotel Mitropole. 
London. It waB certain, he said, that the outbreak of plague 
in Glasgow in 1901 was caused by rats, and he declared 
that if the plague was to be stamped out they must 
stamp out the rat. Danysz of the Pasteur Institute at 
Paris had produced a bacteriological preparation containing, 
he alleged, disease germs to which only animals of the rat 
genus were susceptible. When the bait charged with that 




The Lancet, 


HERNIA AS A RESULT OF ACCIDENT. 


[Jan. 18, 1908. 175 


particular living organism or virns was eaten b; these 
vermin they contracted a disease from which they died in 
from eight to 14 days and which they could communicate to 
other rats with which they might be brought into contact 
while in the diseased state. A contagious epidemic 
was induced in the rats in the locality in which the 
virus was employed, an epidemic not communicable to 
man but one which ought to clear ont the rats. It 
seemed certain that the virns, when in a fresh and an 
active condition, did no harm to cats, dogs, fowls, or 
human beings, but did kill rats which bad partaken of 
it and so affected them that they sought air and water 
and open spaces and did not die in their holes. The Board 
of Agriculture when publishing the results of some success¬ 
ful experiments on the destruction of rats by means of a 
preparation manufactured for that purpose had pointed out 
the ntility of clearing out the rat in small areas and 
had suggested that experiments on a large scale Bhould be 
carried out in county and district clubs. Sir James Crichton- 
ISrowne urged that a general movement for the destruction 
of rats should be initiated and that the whole nation should 
take the matter up. On the motion of Sir Lauder Brunton, 
seconded by Dr. F. M. Sandwith, it was resolved that a 
national society Bhould be formed for the destruction of 
vermin. The meeting was addressed by several speakers 
and especial interest was shown in the remarks of “ Com¬ 
missioner" Nicol who described how the Salvation Army 
were lighting the plague in India by introducing European 
cats and breeding them as fast as they conld on cat farms. 
It was formally announced that Sir Lauder Brunton had 
been elected chairman of the society with Lord Avebury as 
treasurer. Dr. A. E. Moore of Paignton is the secretary 
and the executive committee numbers amongst its members 
Sir Rubert Boyce, Dr. C. J. Martin, and Dr. Sandwith. 

THE MEDICAL INSPECTION AND TREATMENT 
OF SCHOOL CHILDREN IN PRIMARY 
AND SECONDARY SCHOOLS. 

The sixth annual meeting of the North of England Educa¬ 
tion Conference was held at Sheffield on Jan. 3rd and 4th 
under the presidency of Professor M. E. Sadler, M.A., LL.D. 
The following interesting list of papers occupied the atten¬ 
tion of the conferenceThe Functions of a Modern Uni¬ 
versity, by Dr. W. M. Hicks, F.R.S., and others; the 
Medical Inspection and Treatment of School Children in 
Primary and Secondary Schools, by Dr. Clement Dukes, 
physician to Rugby School, and Dr. R. H. Crowley; the 
Teaching of History, by Mr. H. J. Snape, M.A. ; Holiday 
and Open-air Schools, by Mr. C. H. Wyatt, M.A., and Mr. 
Ernest Gray, M.A. ; Compulsory Attendance at Evening 
Schools, by Mr. J. Crowther, B.Sc., and Principal J. H. 
Reynolds, M.Sc. ; the Mode of Preparation of the Primary 
Teacher before Entering the Training College, by Miss Byles 
and others ; Treatment of Physically and Mentally Defec¬ 
tive Children and their After-care, by Miss M. Dendy; 
House craft in Schools for Girls, by Miss M. Taylor 
and Miss I. Cleghorn ; and the Cultivation of Artistic 
Perception in Children, by Mr. T. R. Ablett and Mr. 
J. A. Pearce. The broad medical bearings of the greater 
part of these subjects will be obvious to our readers, whose 
attention must have been drawn to the physical conditions 
of education by the passing of the recent Act to enforce the 
medical inspection of school children. The conference was 
fortunate on hearing the opinion of Dr. Dnkes on the best 
means of administering the Act, for his authority to speak on 
this subject cannot be denied. Dr. Dukes first referred to the 
useful work of the late Congress of School Hygiene in London. 
He proceeded to point out the enormous responsibilities of 
the county councils as the bodies upon which the inspection of 
echools and school children must devolve, and he entered a 


strong protest against the attempt to include the treatment 
of physically defective children under the same scheme at 
the public expense, which he holds would not only be a heavy 
national bnrden, but would tend to the deterioration of 
parental character and would also be an injustice to medical 
practitioners. Passing to consider who should be the officer 
to undertake the medical examination of the children, 
he urged that the time has come when every county council 
should employ exclusively a medical officer of health, with 
security of tenure, at the head of its health department, and 
that a special medical officer of schools should be appointed 
under him who should report t hrough him to the council. This 
officer could be helped by local medical assistants for smaller 
areas who would do the actual inspection of children with 
the assistance of reports made by intelligent teachers, whilst 
the medical officer of schools would organise the work, 
supervise it regularly in person, and analyse and coordinate 
the reports of his local assistants. If there be no county 
medical officer of health an officer of schools should be 
appointed directly under the health department of the county 
council. Dr. Dukes finally insisted that the inspection should 
include secondary as well as primary schools and that 
endowed public schools should not be exempt from it, 
remarking that the Congress of School Hygiene bad pre¬ 
sented a petition to the Board of Education to this 
effect. It is noteworthy that this expression of opinion 
should come from one who has been for many years 
medical officer to one of our leading public schools. 
There is no reason why the nation should allow 
the boys to whom she looks for her future leaders 
to run the risk of being brought up amongst ancient and 
imperfect hygienic conditions when she insists that those 
who will become the hewers o f wood and drawers of 
water shall be taken care of in a manner to fit them 
for their tasks. If the public schools have thoroughly 
efficient Bleeping, sanitary, and feeding arrangements for 
their boys they have nothing to fear from such an in¬ 
spection and if in these respects they have dragged behind 
the times the sooner they are made to put their bouse 
in order the better for the nation. It is a curious reflection 
that though the working man has to answer to the magistrate 
for his children’s absence from school his employer may 
bring up his son and heir, if he be so disposed, ignorant of 
the art of reading without incurring official censure. Every 
parent of any means is probably alive to the vital necessity of 
educating his children in the ordinary sense, but the 
importance of educating them in the hygienic sense is by no 
means so well appreciated by tbe wealthier classes and 
might be brought home to them with great advantage. 


HERNIA AS A RESULT OF ACCIDENT. 

The point whether a hernia is the result of an accident 
may be a difficult one. It was raised in a case of action for 
compensation brought against an employer which is reported 
by Dr. Ch. Faguet in the Gazette Btbdomadaire des Science! 
ifcdicalet de Bordeaux of Jan. 5th. After the manner 
of French tribunals Dr. Faguet was asked by the judge to 
report on the following case. A workman, aged 31 years, 
while carrying a heavy mould containing molten metal at 
4.30 p.m. on July 23rd, 1906, felt a sharp pain in the right 
groin. A medical practitioner saw him on the following day 
and found an inguinal hernia and the abdomen slightly 
painful. On Oct. 13th Dr. Faguet examined him and 
reported as follows. The man had always enjoyed 
good health and there was no history of hernia in 
his family. According to the evidence of his fellow 
workmen he complained of a sharp pain in the right groin 
but he continued his work for the rest of the day. Before 
he left the works he showed the place where he felt the pain 
to another workman who observed a lump of the size of a 




176 Thb La.vubt,] 


DR. DANYSZ'S EXPERIMENT. 


[Jan. 18,19C8. 


walnut in the right groin. Dr. Faguet found a small hernia 
scarcely projecting from the inguinal ring. The hernia was 
spontaneously reduced in the horizontal position. It again 
became visible only in the vertical position under the influ¬ 
ence of cough or effort. It was of the size of a walnut 
and was easily reduced but returned immediately. The 
pillars of the inguinal ring were separated and admitted 
the tip of the middle finger; the inguinal canal was 
short and had a direct course. Examination of the left 
side, inguinal canal, and ring showed manifest weakness 
of the abdominal wall in this position, so that there was 
not much difference between the two sides. Professor 
Weiss of Nancy has laid down the following conditions as 
necessary to prove that a hernia is due to accident: (1) the 
abdominal wall must be intact ; (2) an injury of the abdo¬ 
minal wall or a violent effort in a dangerous position must 
have occurred ; (3) symptoms of rupture of the abdominal 
wall—intense pains, ecchymoses, and so on—must suddenly 
appear. The French Government refuses to grant a pension 
to soldiers for hernia. On joining the army they are ascer¬ 
tained to be free from hernia. In the early days of service, 
under the influence of the exercises which they perform, 
hernia sometimes develops but the Government regards 
it as a disease and not as an accident. The conditions 
laid down by Professor Weiss were not all present in 
the case related by Dr. Faguet. He concluded that the 
hernia was the result of weakness (hernie de faiilesse) and 
that the accident was a secondary cause. Without the pre¬ 
disposition the effort would not have produced the hernia. 
However, the hernia would probably have slowly developed 
later under the influence of the man’s work or the efforts of 
cough or defascation. Even when wearing a truss the 
patient was not in a fit state to continue his arduous 
occupation without danger; his capacity was permanently 
diminished. Dr. Faguet assessed the compensation as 
10 per cent, of the man’s wages. This was accepted by both 
parties. _ 

DR. DANYSZ S EXPERIMENT. 

Our Australian correspondent writes ; 11 The report of Dr. 
Frank Tidswell, who was appointed by the Government to 
supervise the experiments conducted by Dr. Danysz in 
Broughton Island with the view of exterminating rabbits by 
disease, has been furnished to Parliament. Dr. Tidswell 
finds (1) that the efficiency of the virus as a destroyer of 
rabbits has not been demonstrated ; and (2) that although 
the microbe could be made to infect certain small animals 
there is no reason to apprehend danger from its 
practical use. Dr. Tidswell remarks that with regard 
to the introduction of the virus by subcutaneous inocula¬ 
tion he did not meet with any normal rabbit capable 
of resisting it administered in that way. As a general 
rule, animals so treated died within 24 hours. In 67 serial 
inoculations by Dr. Danysz, in which each rabbit was 
inoculated with blood of that one immediately before it, 41 
died in 24 hours, 11 in less, and 13 in longer periods of time. 
A fatal result followed even very small doses. The virus 
rubbed on a rabbit's skin denuded of fur killed the animal in 
from 24 to 48 hours. A drop or two of infected blood in 
bouillon culture placed inside the nostril killed in the course 
of a few days. Feeding with similar cultures was usually, 
but not invariably, fatal. When mixed with bait and fed to 
rabbits there were survivals. It is next pointed out that to 
be of any service the infection of rabbits most occur without 
artificial aid. Cage experiments showed that when the 
disease was once started the virus can spread to asso¬ 
ciated animals. In a second series of experiments rabbits 
were confined in outdoor yards one-third to one-half an acre 
in extent. Of 55 infected and 508 ‘contact’ rabbits em¬ 
ployed in this series, 49 infected and 391 ‘ contacts ’ perished, 


while six infected and 117 ‘contacts’ survived. Dr. 
Tidswell accepts from this evidence the fact that the virus 
can give rise to a fatal infectious disease under the conditions 
of the experiments. He is not of opinion that they prove 
that pasteurellosis of the rabbit is as contagions and spreads 
as surely in the open as in cages, which was claimed by Dr. 
Danysz. On the western side of the island extended experi¬ 
ments had been begun by Dr. Danysz and were continued by 
Dr. Tidswell. The injected rabbits initiated an outbreak on 
the island as a whole but nothing like the devastation of the 
cage experiments was forthcoming. Nearly 400 rabbits 
were shot or captured and examined, and in none of 
them was there the slightest sign of disease, nor could 
the microbe be obtained from them. Dr Tidswell says 
further that the identical microbe introduced by Dr. Danysz, 
or one indistinguishable from it, has been known on 
the mainland for many years in New South Wales, 
and a mild disease among rabbits due to its presence is a 
familiar phenomenon. Oomparative experiments have shown 
that this native virus is quite as potent as the imported 
variety. In spite of its existence and the fact that it has 
already caused epizootics rabbits go on 6teadily increasing 
in New South Wales. The virus, operating according to 
natural laws, has been unable apparently to check the 
increase. The Pastoralists’ Association, under the direction of 
which the whole scheme has been carried out and financed, is 
displeased at Dr. Tidswell’s finding. It is asserted that Dr. 
Tidswell was only asked to satisfy himself that there was no 
danger attaching to the project, and this it claims is 
abundantly proved in his own report. It is stated that the 
association will, if permitted, apply the virus to rabbit- 
infested districts.” _ 


THE INVENTOR, THE MAKER, AND THE 
SALESMAN. 

We have received recently a claim for the establishment 
of what would, we conceive, be an ill-assorted union between 
surgery and commercialism the circumstances of which are 
worth a little attention. Proprietorship of medicines would 
be universally condemned by the medical profession, but the 
Detroit Medical Journal for November contains a corre¬ 
spondence between Dr. Roswell Park of Buffalo, New York, 
and Mr. J. F. Hartz, President of the “American Surgical 
Trade Association,” in which both writers advocate the 
patenting, by surgeons, of any improvements in instru¬ 
ments which they may effect; and this proposal is 
supported by our contemporary in un article upon the sub¬ 
ject, from which we beg respectfully to express our entire 
dissent. The plea urged is certainly a specious one and 
is to the effect that, in the absence of a patent, there is no 
security for the accurate carrying out of the design of the 
inventor or for the actual attainment of the advantages 
which the invention was intended to secure. It is sug¬ 
gested that there are instruments on the market, described as 
Kelly’s catheters for the ureters, O’Dwyer’s intubation 
tubes, or Murphy’s buttons, which not only depart widely 
from the designs of those inventors but which could not 
I be used for the accomplishment of their presumed pur¬ 
poses and would be liable to entail disaster upon patients 
as well as discredit upon the operators employing them. 
The force of this argument seems to us to be appre¬ 
ciably weakened by the fact that the name of Mr. J. F. 
Hartz, the trade president who takes part in the corre¬ 
spondence, appears also upon the face of our contemporary 
in the capacity of “business manager," so that he may 
reasonably be supposed to have exerted some influence upon 
the judgment of his editoral colleague. We do not know 
the state of the American instrument market, but the 
leading instrument makers of the United Kingdom are, we 
do not hesitate to say, strictly careful with regard to the 




ThbLanobt,] HERPES OF THE BUTTOCK AFTER LUMBAR PUNCTURE.—HOSPITAL ABUSE. [Jan. 18,1908. 177 


patterns of any instruments to which the name of an 
inventor is attached. If they were asked for Kelly’s, or 
O'Dwyer’s, or Murphy’s instruments they would either supply 
them of correct pattern or they would frankly offer some 
departure from them of their own make, for which, in all 
probability, they would even claim some advantage. As a 
rule, a surgeon who designs a new instrument is materially 
aided by his instrument maker in perfecting his design ; 
and we cannot but regard Mr. Hartz’s claim as the 
expression of a desire on the part of the maker to 
monopolise a pattern to the usefulness of which he has 
contributed and thus to secure to himself or his firm the 
profits which may arise from its manufacture. Against this 
desire we have nothing to say, or at least should have 
nothing to say, if the instrument maker were himself the 
inventor. But it is trade and not surgery, and we do not 
believe it would be to the advantage of the profession to 
combine the two. As for the risks mentioned by Dr. Park 
and Mr. Hartz, they are, or ought to be, purely imaginary. 
A surgeon would scarcely buy an instrument until he knew 
how to use it and as soon as he possessed this knowledge 
he would see at a glance whether or not the instrument was 
calculated to fulfil the purpose for which it was professedly 
intended. The skill and knowledge of the purchaser should 
secure him against being supplied with an imperfect 
instrument, and if they were insufficient for this purpose 
they would certainly be equally insufficient either to secure 
the safety of the patient or to fulfil the requirements of the 
operation table. _ 

HERPES OF THE BUTTOCK AFTER LUMBAR 
PUNCTURE. 

In an annotation we have recently referred to a case of 
herpes of the face after the injection of stovaine into the 
spinal canal for the induction of ansesthesia, which was 
reported at the Socifitfi Mfdioale des Hopitaux of Paris. 1 
At a meeting of the society on Nov. 29th, 1907, M. Oh. Achard 
referred to a number of cases of interest in connexion with 
that case. He observed three cases of herpes of the face 
after intra-splnal injections. In two of them the substance 
injected was cocaine, while in the third it was eucaine. As in 
the case which we have described, the eruption was preceded 
by symptoms of meningeal irritation—headache and vomit¬ 
ing—but, contrary to that case, the herpes was bilateral. 
M. Achard also reported the following case in which herpes 
of the buttock followed, not the injection of any drug 
into the spinal canal, but simple lumbar puncture. A 
woman, aged 23 years, was admitted into hospital on 
June 29th, 1903, Buffering from weakness and headaches. 
Her hair had been falling for three months, there were 
pigmented spots on her body, and she reported that her 
husband had a large scar on the penis the result of an ulcer. 
Syphilis being suspected lumbar puncture was performed and 
yielded clear fluid devoid of leucocytes. Five days later the 
patient felt pains in the lumbar region and perceived that 
there were little swellings on the right buttock. A herpetic 
eruption, consisting of little vesicles surrounded by red 
aureolse, was found in this region. It extended for a 
distance of four inches obliquely outwards and downwards 
from the lower end of the sacrum and terminated at a 
distance of two and a half inches from the groove between 
the buttocks. The eruption was accompanied by slight 
swelling of the glands in the corresponding groin and 
recovery took place without any incidents. It is noteworthy 
that in this case of herpes, as in the cases of facial 
herpes following injection of anaesthetics into the spinal 
canal, there was an incubation period. This period 
amounted to 48 hours or more in the cases of facial 
herpes but in this case of herpes to five days. These 

1 The Lascet, Dec. 14th, 1907, p. 1703. 


cases are interesting not only as examples of the possible 
untoward consequences of intra-spinal injections, but they 
throw light on the pathology of herpes facialis (labialis) 
and herpes zoster. They tend to discredit the usually held 
view that these two forms of herpes are distinct diseases 
and to show that their pathology is identical. 


HOSPITAL ABUSE. 

Our Belfast correspondent tells in another column, under 
the title of “The Prevention of Hospital Abuse,” of the 
result of a conference between the lay supporters of the 
Victoria Hospital, Belfast, and the medical staff. One result 
of the conference has been to define the position towards the 
hospital enjoyed by regular subscribers of the working 
classes who have united in systematic support of the hos¬ 
pital. These subscribers, as will be seen by our corres¬ 
pondent’s communication, will enjoy considerable advantage 
over casual cases in the out-patient department of the 
hospital. In some circumstances this may be all right, but 
in others it may constitute a form of the very abuse which it 
is designed to prevent. The contributions from these work¬ 
men are sure to be extremely small, and the gift of 
pennies, even though systematically given and amounting 
in the aggregate to a large sum, ought not to confer 
a right to the service of the staff of a hospital. It is 
true that a notice is hung in a prominent place saying that 
treatment is only designed for those unable to pay for it, but 
in our opinion this will not in the least save the ont-patient 
department of the hospital from abuse. Workmen who pay 
large sums in the aggregate rarely see that they do not 
really contribute their just quota and are liable to demand as 
a purchased right what they do not pay for. There is, we 
think, also a fear that hospitals making such concessions to 
the working men may deprive the local practitioners of a 
reasonable source of income. 


THE PROPERTIES OF GREY OIL. 

The publication of several different formula; for the pre¬ 
paration of grey oil renders it desirable that a uniform 
standard of composition and physical properties should be 
adopted. This preparation is capable of producing very 
serious results when made by inexperienced persons. An 
excellent report on the subject has been published by 
M. Dumesnil in the Journal de Pharmacie et Ac Chime of 
Dec. 16th, 1907. Grey oil should be of fluid consistence 
and stable at ordinary temperatures and greyish-black in 
colour. If the consistence is that of an ointment it is quite 
unsuitable, as it is necessary to warm such a preparation 
when required for injection. But grey oil is decomposed 
by heat, a temperature of from 60° to 70° C. being sufficient 
to cause the minute particles of mercury to form larger 
aggregations, and after being warmed several times grey oil 
yields a large deposit of mercury. When properly prepared 
grey oil will remain perfectly homogeneous for several 
weeks. As regards strength it is desirable that a uniform 
standard should; be adopted ; the most generally accepted 
strength is 40 grammes of mercury in 100 cubic centimetres. 
Vegetable oils are unsuitable as a vehicle owing to their 
proneness to become rancid. The best results have been 
obtained with pure hydrocarbon oils combined with sterilised 
wool-fat. The latter iB the best agent for subdividing the 
mercury, and it has the additional advantage of rendering 
the oil more easily absorbable. The mercury should be so 
finely divided that on examining the oil under a microscope 
with a magnification of 480 diameters the particles of mercury 
should be no larger than the fine granules of sodium urate 
found in urinary sediments and magnified to the same degree. 
M. Dumesnil reports that in some specimens of grey oil which 
have been submitted to him the metallic particles were as 




The Lancet,] 


THE LANCET RELIEF FUND. 


[Jan. 18. 1908. 178 A 


THE LANCET RELIEF FUND. 

For Members of the Medical Profession and their Widows 
and Orphans when in Distress. 


-: 0 :- 


ALMONERS. 

THE PRESIDENT OF THE ROYAL COLLEGE OF PHYSICIANS OF LONDON. 

THE PRESIDENT OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND. 

THE PRESIDENT OF THE GENERAL MEDICAL COUNCIL. 

THOMAS WAKLEY, L.R.C.P. Lond. 

HON. AUDITOR. 

SIR THOMAS SMITH, Bart., K.C.V.O., F.R.C.S. Eng. 

-: 0 :- 

This Fund will be provided year by year in the month of January to the amount of at least £300 
solely by the Proprietors of The Lancet, and administered free of cost, for the purpose of affording 
immediate pecuniary assistance to Medical Men, or their Widows and Orphans, in cases of Acute Distress 
and Emergency, by the grant of money by way of loans free of interest, or gifts, as the circumstances 
of the various cases may require. 

Applicants must satisfy the Almoners of the Fund that they are qualified under the following 
regulation:— 

* *‘ The recipients shall be such persons as satisfy the Almoners that they possess one or other of the following 
qualifications—that is to say : (a) That the applicant holds a registered medical qualification, and that he 
has fallen into pressing need of immediate pecuniary relief; or (6) That they are persons who have been, 
previously to the date of application, legitimately dependent upon some person holding a registered medical 
qualification, and that they have pressing need of immediate pecuniary relief.” 

(7w the case of tVidims and Orphans , in order to come within the scope of the Fund, the death of the Husband or 
Father must have been of recent occurrence .) 

To ensure the utmost despatch, the “ Application Form ” upon the other side should be filled up and 
forwarded (in an envelope superscribed “The Lancet Belief Fund”) to the Secretary,.Mr. Charles 
Good, The Lancet Offices, Strand, London, W.C. 

The application must be accompanied by two separate Testimonials (originals, not copies)—one 
from the Clergyman of the Parish or other resident Minister of religion, and one from a registered 
Medical Practitioner. Each Testimonial must state—(l)that the application addressed to the Almoners 
has been read; (2) how long the writer has known the applicant; (3) that the writer believes the 
statements made by the applicant to be perfectly truthful, and such as may be acted upon without further 
inquiry; and (4) may state any other particulars that the writer desires to place before the Almoners. 

Testimonials written for the AJmoners of the Fund will in no case be returned. 



178 B The Lancet,] 


THE LANCET RELIEF FUND. 


[Jan. 18, 1908. 


Private and Confidential. 


APPLICATION FORM. 


To the Almoners of The Lancet Relief Fund. 

The’ applicant should here state shortly :— 

1 . The nature of the emergency that has arisen. 

(In the case of Widows and Orphans the fall names and date of death of the Husband or Father must be 
given .) 


2. The circumstances out of which it has arisen. 


3. The amount of the grant desired, and whether by way of loan (free of interest) or of gift. 


4. If b*' way of loan, state when the loan will be repaid; and from what source the funds to repay it are 
expected to be forthcoming. 






The Lancet,] 


THE LANCET RELIEF FUND. 


[Jan. 18, 1908. 178 0 


5. Whether the applicant is entitled or able in the circumstances which have arisen to look to any other source 
of assistance ; and if so, what is the expected nature and extent of such assistance. 


6 . Whether the applicant is receiving, or has received during the past six months, pecuniary aid from any 
Medical Charity. 


7. State how the applicant is qualified to receive assistance; vide regulation * on first page. 


8 . Particulars of: 

Applicant's age _ 

Number in family _ 

How many are self-supporting 
How many are partially dependent 

How many wholly dependent _ 

Applicant’s Signature ... 
Address __ 

Date ________ 






178 D ThbLancbi,] 


THE LANCET RELIEF FUND. 


[Jan. 18, 1908. 



THE LANCET RELIEF FUND 



Thb Lancet,] 


THE LANCHT RELIEF FUND. 


[Jan. 18, 1908. 179 


THE LANCET RELIEF FUND. 


mHIS Fund, which came into operation on the 1st of February, 1889, has for its Almoners the President of the Royal 
College of Physicians of London (Sir Richard Douglas Powell, Bart., K.O.V.O., M.D. Lond.), the President of the 
Royal College of Surgeons of England (Mr. Henry Morris), the President of the General Medical 
Almoners. Council (Dr. Donald MacAlister, M.D. Cantab., LL.D., D.C.L., F.R.C.P. Lond.), and Mr. Thomas 
Wakley, L.R.C.P. Lond. Sir Henry Pitman, M.D. Cantab., F.R.C.P. Lond., having resigned the 
position of Honorary Auditor, which he had held since the commencement of the Fund, Sir Thomas Smith, Bart., 
K.C.V.O., F.R.C.S. Eng., was appointed by the Almoners in his stead, and has kindly consented to act. 


\TlOR the guidance of those seeking assistance and of those desirous of recommending deserving cases, it may be 
A- useful to record that The Lancet Relief Fund is sustained solely by the Proprietors of The Lancet, who provide 
every January the sum of at least £300, which is administered free of cost, with the object of affording 
Scope of the immediate pecuniary assistance to registered medical practitioners, or to their widows and orphans, in 
Fund . cases of distress and emergency, by the grant of money by way of loans free of interest, or gifts, as the 

circumstances of the various cases may require. In the case of widows and orphans, in order to come 
within the scope of the Fund, the death of the Husband or Father must have been of recent occurrence. 


W HEN the Fund was inaugurated considerable misapprehension existed as to the precise objects for which it had 
been established, and, as a result, the majority of the earlier applications, being cases of chronic distress, and 
not coming, therefore, under the designation of emergency , could not be entertained. As the 
Chronic Cases Almoners still receive applications for assistance for cases which are obviously of a chronic 
ineligible . character, it is thought advisable to append a statement concerning cases of this nature which 

appeared in The Lancet of Feb. 16th, 1889:— 

"We are requested by the Almoners to state that, from the character of a number of tho applications received, both personally and by letter, 
tor relief, it is evident that in many cases the object for which this Fund has been established is not quite clearly understood ; and if relief had 
been afforded in the cases of those who suffer from chronic distress the Fund would have been completely exhausted within the first few days of 
Its existence. They would therefore be greatly obliged if those readers of The Laxcet who may bo asked to endorse applications would carefully 
peruse the Application Form and explain tho precise object of tho Fund to those applicants whose cases do not seem to come within the scope of 
the purpose for which the Fund has been established, which is to afford prompt aid to registered medical practitioners, or to the widows or 
orphans of members of the profession, who, in consequence of the supervention of some unexpected emergency, which is not likely to 
recur, have pressing need of immediate and temporary pecuniary relief ”— 

And who, it may be again pointed out, are likely to be benefited permanently thereby. 


Nineteenth Annual Report of the Almoners , 

For the year ending December 31, 1907. 


In presenting their Nineteenth Annual Report the 
Almoners have to record that the balance in hand on 
Dec. 31st, 1906, was £73 5«. 4 d., to which on Jan. 1st, 
1907, the Proprietors of The Lancet added the sum of 
£300, making, with £5 repaid on loans, a total sum of 
£378 5*. 4rZ. available for grants during the year 1907. 

The number of applications for assistance received 
by the Almoners during the year was 59, of which 
number 23 were rejected by the Secretary as quite 
outside the scope of the Fund; 11 were declined by 
the Almoners after due consideration; 8 Application 
Forms were not returned—doubtless owing to the applicants 
realising that their cases were not of a nature qualifying 
them to receive assistance from the Fund ; and 17 applicants 
were relieved by gifts or loans of money ranging from 
£5 to £50. The grant of the large and exceptional snm of 


£50 was made to meet exceptional circumstances. The 
relief of these 17 cases, a detailed list of which is given 
in the accompanying Statement of Accounts, involved the 
expenditure of the snm of £230. The total amount voted 
by the Almoners since the commencement of the Fond is 
£5873 6s. 3d. 

The Almoners continue to receive expressions of gratitude 
for the assistance which they have afforded to applicants— 
in some urgent cases the relief was given on the day on 
which the application was received. As in past years, the 
timely help of the Fund has enabled more than one applicant 
to keep his practice together when pressing claimB threatened 
to destroy his home and his means of livelihood ; and the 
widow and the orphan have also been helped at the moment 
of their greatest need. 

There are still far too many cases of “chronic” distress 




180 The Lancet, ] 


THE LANCET RELIEF FUND. 


[Jan 18, 1908. 


brought to the notice of the Almoners. Whilst sympathising 
with the applicants in their distress, the Almoners are 
quite unable to help them. The Fund at their disposal is 
not intended for such cases, and would be exhausted in the 
first month of the year were such claims to be met. The 
Almoners must again emphasise the fact that The Lancet 
Relief Fund exists to meet cases of sudden emergency : and 
they will be especially obliged if gentlemen giving testi¬ 
monials or recommending cases will bear this in mind. 

The Almoners regret to record the death of Mr. Thomas 
Henry Wakley, the Founder of the Fund and one of the 
Almoners since its commencement. From an extended 
experience of all the details of medical practice Mr. Wakley 
came to the conclusion that there existed a large class to 
whom a small gift or a loan bearing no interest, if granted 
immediately upon application, might be of the greatest 
service. He knew of sad breakdowns in men's careers where, 
if appearances could have been kept up for a few more weeks, 
the storm might have been weathered—now that he is dead 
there is no indiscretion in saying that he himself had not 
infrequently found the sum necessary for this purpose—and 
he decided to systematise this irregular form of generosity 
by means of The Lancet Relief Fund. He also decided 
that he would invite the cooperation of Almoners whose 
position in the medical world, both individually and officially, 
was such as to insure as far as possible that the grant 
of money, whether by gift or loan, reached worthy objects. 
From these intentions the Fund sprang. 


The veteran Sir Henry Pitman, M.D., F.R.C.P., the 
honorary auditor of the Fund since its inception, has inti¬ 
mated to the Almoners his desire to be relieved of the duties 
of his office by reason of advanced age. When it is re¬ 
membered that Sir Henry Pitman entered upon his 100th 
year on July 1st, 1907, the Almoners are bound to accept 
the sincerity of the plea and to place on record their 
admiration of the energy and the zeal with which he has 
discharged his labour of love for the Fund for the past 19 
years. It is surely a unique, as also a remarkable, fact that 
one who is in his 100th year should have had the physical 
and mental capacity to carry out the duties of his office as 
Sir Henry Pitman has done within the past few days. The 
Almoners are proud of their late colleague : they wish him 
continuance of the peace and happiness which he has so well 
earned. 

In conclusion, the Almoners would point out that they will 
at all times be glad to have their attention called to any 
cases of genuine distress coming within the scope of the 
Fund, but they trust that those recommending cases or 
giving testimonials will first take steps to satisfy themselves 
of the bona fides. as well as of the suitability, of such cases 
before endorsing them. In the administration of such a Fund 
as this the Almoners are of necessity largely guided in their 
decisions by the testimonials accompanying the applications. 

(Signed) R. Douglas Powf.ll. Henry Morris. 

Donald MauAlister. Thomas Wakley. 

Jan. 9th, 1908. 


THE LANCET RELIEF FUND. 


STATEMENT OF ACCOUNTS FOR THE YEAR ENDING DEC. 81st, 1907. 


Dr. 

To Balance at the London and West-1 
minster Bank, Limited (Westminster V 
Branch), Jan. 1st, 1907 . J 

„ Proprietors of The Lancet, Jan. 1st, 1907 

„ Repayment of Loan :— 

Case No. 690 . 


£ 

s. 

d. 

By Loans :— Cr. 

£ 

s. 

d. 




Case No. 734 . 

... 50 

0 

0 

73 

5 

4 

,, 745 . 

... 30 

0 

0 




,, 747 . 

... 15 

0 

0 

300 

0 

0 

By Gifts:— 







Case No. 703 . 

5 

0 

0 

5 

0 

0 

„ 710. 

... 10 

0 

0 




„ 711 . 

... 10 

0 

0 




,, 714 . 

... 10 

0 

0 




„ 717 . 

5 

0 

0 




„ 722 . 

... 10 

0 

0 




„ 725 . 

... 10 

0 

0 




„ 727 . 

... 10 

0 

0 




,, 728 . 

5 

0 

0 




„ 729 . 

... 15 

0 

0 




,, 742 . 

5 

0 

0 




,, 750 . 

... 20 

0 

0 




„ 751 . 

... 15 

0 

0 




752 . 

5 

0 

0 


,, Bink Charges. Cheque Biok 
Balance at Bank, Dec. SI, 1007 

£.378 5 4 


£ ». d. 


95 0 0 


135 0 0 
0 4 2 
148 1 2 

£378 5 4 


I find by the Bankers' Book that the actual Balance on Jan. 1st, 1907, to the credit of the Fund was £73 5 s. 4 d., to 
which the sum of £300 was added by the Proprietors of The Lancet on Jan. 1st, 1907. 

The balance at the Bank on Dec. 3lst, 1907, was the sum of £148 Is. 2 d. I have also checked the receipts for 
disbursements and find the above account strictly accurate. 

January 6th, 1908. 


Henry Pitman, Hon. Auditor. 













This Lancet,] THE NEW OPERATING THEATRES AT THE ROYAL FREE HOSPITAL. [Jan. 18, 1908. 181 


THE NEW OPERATING THEATRES AT THE 
ROYAL FREE HOSPITAL. 

On Deo. 3rd, 1907, tbe new operating theatres at the 
Royal Free Hospital were opened by H.R H. the Princess 
Christian, the President of the hospital. The theatres are 
placed on the top of the north wing, and they have been 
built and equipped on the most modern principles of con¬ 
struction and sanitation bo as to insure the high degree of 
perfection which is now demanded in a modern operating 
theatre. Access to them is obtained by a staircase and 
electric lift placed at the east end of the block. A wide 


ceilings are covered with adamant plastering which takes 
a very high polish and are finished by paintiDg with white 
ripolin. Thus they can be easily cleansed by a hose or 
washed as may be required. The doors are of polished teak 
and are flush with the wall those to the corridor being 
sliding and huDg on ball-bearing runners. All the rooms 
and tbe corridor are heated by hot-water swing radiators 
which will allow every part to be cleansed thoroughly. 

The theatres are 24 feet in length by 16 feet in width, with 
a height of 20 feet 9 inches to the apex of the roof ceiling. 
Each is lighted by a gable-end window 12 feet in width and 
19 feet in height, with polished p'ate glass panes. The 
frame is made of iron and two of the panes open outwards. 
A gauze screen is provided to fit the opened window, thus 


Fig. 1. 



Fig. 2. 



View of a new operating theatre at the Royal Free Hospital. 


corridor from which the various rooms are entered runs the 
whole length of the block on the south side. In the 
centre the sterilising room is placed. On each side of 
this is a theatre with doors leading directly from it. An 
anaesthetising room is attached to each theatre and at the 
west end of the block there are separate rooms for the 
surgeons and students. An emergency exit is also provided. 
The accompanying plan will make clear the general arrange¬ 
ment. The floors throughout are of fireproof construction, 
finished in terrazzo, those in the theatres being laid to falls 
with a draining channel along the north wall. The walls and 


preventing dust, entering the theatre from without. 
Around three sides of the theatre is a gallery for Btudents 
and visitors, with wrought-iron enamelled standards and 
handrail, marble panels being fitted between the standards 
to a height of 2 feet above the level of the gallery floor, 
forming a skirting to prevent any dirt falling into the 
area of the theatre. The floor of the gallery is laid 
with a fall and there is a separate entrance from the 
corridor, so that students and visitors need not enter the 
theatre. The fittings to each theatre comprise five 
lavatory basins, with a glass shelf between eaoh pair, a 




































182 The Lancet,] 


VITAL STATISTICS. 


[Jan. 18.1908. 


glazed fire-clay mackintosh sink and glass shelves 
for lotion jars, &c. t he basins are tinted with pedal taps 
and the hot and cold water are mixed in a chamber before 
passing through the delivery pipe over the basins. The 
waste pipes are all carried at once outside the external walls, 
no waste discharges being allowed within the theatres or 
adjuncts. The glass shelves are carried clear of the walls 
on gun-metal brackets. Artificial lighting is provided by 
means of two large swing brackets attached to the gallery, 
one on each side of the theatre. Each bracket carries a 
moveable arm which can be swung through an angle of 45°. 
To the ends of this arm the lamps are fixed at a height of 
6 feet 4 inches from the floor. The brackets are nickel- 
plated and so arranged that the light can be concentrated 
upon any part of the operating table, in whatever position it 
is placed. 

The sterilising room is fitted with sinks and a large 
lavatory basin. A large high-pressure steam steriliser is pro¬ 
vided for general use and there are two large rectangular 
copper boilers for sterilising bowls, dishes, and the like. There 
are also six large circular copper boilers, three to each theatre, 
for providing sterilised water, salt solution, and bo on. Each 
of these has a delivery pipe carried through the wall into the 
corresponding theatre. These pipes are easily detachable and 
can thus be sterilised as often as is necessary. These boilers 
are heated by steam pipes, as are also the small instrument 
sterilisers. The ansesthetising rooms have separate doors 
into the theatres and corridors. 

The work has been carried out under the direction of the 
architect, Mr. W. Harvey, F.R.I.B.A., and Mr. Albion T. 
Snell, M. Inst. C.E., consulting engineer. 


VITAL STATISTICS. 


HEALTH OP ENGLISH TOWNS. 

In 76 of the largest English towns 9105 births and 6018 
deaths were registered during the week ending Jan. 11th. 
The mean annual rate of mortality in these towns, which had 
been equal to 14'7 and 16-9 per 1000 in the two preceding 
weeks, further rose to 19 ■ 3 in the week under notice. During 
the 13 weeks of last quarter the death-rate in these towns 
averaged 15 5 per 1000, the rate during the same period 
not exceeding 14 ■ 9 in London. The lowest annual death-rates 
last week in the 76 towns were 10 1 in Hornsey, 11'4 in 
Wallasey and in West Hartlepool, and 11-5 in Hastings and 
in Beading; the rates in the other towns ranged upwards 
to 27 7 in Merthyr Tydfil, 29'3 in Swansea, 31 6 in Liver¬ 
pool, and 32 • 5 in Rhondda. The rate in London last week did 
not exceed 18 • 5. The 6018 deathB registered during the week 
under notice showed a further increase of 764 upon the num¬ 
bers returned in the two preceding weeks, mainly due to the 
late severely cold weather, and included 457 which were 
referred to the principal epidemic diseases, against 372 and 
393 in the two previous weeks; of these 141 resulted from 
measles, 127 from whooping-cough, 80 from diphtheria, 
57 from diarrhoea, 30 from scarlet fever, 22 from “ fever ” 
(principally enteric), but not one from small-pox. The 
deaths from these epidemic diseases in the 76 towns 
were equal to an annual rate of 1 ■ 5 per 1000, the rate from 
the same diseases in London not exceeding 1-2. Ho death 
from any of these epidemic diseases was registered last week 
in 12 of the smaller towns, including Brighton, Bourne¬ 
mouth, West Bromwich, and Warrington ; the annual 
death-rates from these diseases averaged upwards in the 
other towns to 4 6 in Willesden, 4 ■ 7 in Merthyr Tydfil, 
5'9 in Stockton, and 7-4 in Rhondda. The fatal cases of 
measles, which had been 104 and 103 in the two preceding 
weeks, rose to 141 last week; the highest annual death- 
rates from this disease were 2 8 in IpBwich, 2-9 in 
Stockton, 3-6 in York, and 4-6 in Willesden. The deaths 
from whooping-cough also further rose to 127 last week, 
from 89 and 92 in the two previous weeks ; the highest 
death-rate6 from this disease were 2 0 in Merthyr Tydfil 
and in Rhondda, 2 ■ 3 in Bootle, and 3 ’7 in Aston Manor. 
The 80 deaths referred to diphtheria exceeded the 
number in the previous week by five, and included 29 
in London, six in West Ham, four in Liverpool, and 
five in Salford. The 57 deaths attributed to diarrhoea 
also showed a further increase upon recent weekly 
numbers.; whereas the fatal cases of scarlet fever showed 
-a considerable decline. The deaths referred to “fever" 


(principally enteric) farther declined in the week under 
notice to 22, from 23 and 26 in the two preceding weeks ; 
the two fatal cases in Rotherham were equal to an annual 
rate of 1 ■ 6 per 1000. The number of scarlet fever patients 
under treatment in the Metropolitan Asylums Hospitals, 
which had declined from 5581 to 4684 in the five pre¬ 
ceding weeks, had further fallen to 4481 in the week ending 
Jan. 11th. No case of small-pox has recently been under 
treatment in these hospitals. The deaths in London referred 
to pneumonia and other diseases of the respiratory organs, 
which had been 317 and 333 in the two previous weeks, rose 
during the week under notice, influenced by the recent cold 
weather, to 460, and exceeded by 55 the corrected 
average number in the corresponding week of tbe five years 
1903-07. The causes of 72, or 1 -2 per cent., of the deaths 
registered in the 76 towns last week were not certified either 
by a registered medical practitioner or by a coroner. The 
proportion of these uncertified deaths in London did not 
exceed 0 2 per cent. All the causes of death were duly 
certified in West Ham, Bristol, Manchester, Bradford, and in 
20 other smaller towns ; 17 uncertified causes of death were, 
however, registered in Birmingham, 16 in Liverpool, and six 
in Sheffield. _ 


HEALTH OF SCOTCH TOWNS. 

The annual rate of mortality in eight of the principal 
Scotch towns, which bad been equal to 18 - 2 and 20'6 per 
1000 in the two previous weeks, further rose to 24 • 3 during 
the week ending Jan. 11th, and exceeded by 5 0 the mean rate 
during the same week in the 76 English towns. Among the 
eight Scotch towns the death-rates last week ranged from 
18'2 and 18 • 6 in Aberdeen and Edinburgh to 29 ■ 0 in Glasgow 
and 32 • 6 in Berth. The 855 deaths in these eight towns 
last week showed a further increase of 130 upon the number 
in the preceding week, and included 143 which were referred 
to tbe principal epidemic diseases, against 109 and 127 
in the two previous weeks ; of these, 84 resulted from 
measles, 23 from whooping-cough, 16 from diarrhoea, eight 
from diphtheria, eight from "fever,” and four from scarlet 
fever, but not one from small-pox. These 143 deaths were 
equal to an annual rate of 4 • 1 per 1000, which exceeded 
by no less than 2 - 6 the mean rate last week from 
the same diseases in the 76 English towns. The 
fatal cases of measles in these Scotch towns, which 
had been 53 and 65 in the two previous weeks, 
further rose last week to 84, of which 74 occurred 
in Glasgow, four in Greenock, and three in Paisley. The 23 
deaths from whooping-congh corresponded with the number 
in the previous week, and included ten in Glasgow and four 
each in Edinburgh, Leith, and Perth. Of tbe 16 deaths 
attributed to diarrhoea seven were returned in Glasgow, 
three in Aberdeen, and two both in Edinburgh and in 
Greenock. The eight fatal cases of diphtheria showed a 
decline, but included four in Paisley and two in Glasgow, 
The eight deaths referred to “fever” exceeded the numbers 
returned in the two preceding weeks, and included six fatal 
cases of cerebro-spinal meningitis and two of enteric fever ; 
four occurred in Glasgow and two in Greenock. Of the four 
deaths from scarlet fever three were registered in Glasgow. 
The deaths referred to diseases of the respiratory organs 
in these eight towns, which had been 127 and 128 in the 
two preceding weeks, further rose to 205 in the week under 
notice, under the influence of the recent severe weather, and 
exceeded by 19 the number from the same diseases in the 
corresponding week of last year. The causes of 39, or 4 • 6 
per cent., of the deaths in these towns last week were not 
certified or not stated; in the 76 English towns the pro¬ 
portion oi these uncertified deaths last week did not exceed 
1 • 2 per cent. _ 

HEALTH OF DUBLIN. 

The annual rate of mortality irr Dublin, which had been 
equal to 19 ■ 8 and 25 5 per 1000 in the two preceding weeks, 
further rose to 26'0 in the week ending Jan. 11th. During 
the 13 weeks of last quarter the death-rate in the city 
averaged 21 • 5 per 1000, the rates duriDg the same period 
being only 14 1 9 in London and 14 • 8 in Edinburgh. The 197 
deaths of Dublin residents registered last week showed a 
further increase of four upon the numbers returned in the 
two preceding weeks, and included four which were referred 
to the principal epidemic diseases, against five and ten in 
the two previous weeks ; of these, two were attributed to 
diarrhoea, one each to diphtheria and whooping-cough, bat 




{Specially compiled for Thb Lancet.) 


The Lancet,] 


VITAL STATISTICS OF LONDON DURING DECEMBER, 1907. 


[Jan. 18, 1908. 183 


S 

a* 


« 

W 

« 

S 

w 

u 

H 

Q 

s 

p 

Q 

Z 

O 


a 

z 


OQ 

03 

H 

z 

to 

o 


o 


GO 

(H 

P 

•0 

z 

H 


•«*viq oooi 

09 jwoa ouo jopun 

134 

CQ O 
CM CM 

CO 

H 

ro 

8 

c* 

UO 

s 

119 

3 

o 

CM 


c— 

oo 

8 

211 

185 

| 

CM 

«T 

2 

lO 

c- 

g 

ro 

CM 

o- 

TT 

OJ 

139 

CM 

s 

118 

140 

B'juvjU} # o BqjvoQ 































CM 

rO o 

ro 

p- 

X 

<3- 

00 

CO 

CM 

ro 

P 

ro 

CO 

OJ 

o 

rH 

P 

CM 

rH 

CM 

OO 

00 

©■ 

o 

CO 

CM 

p- 

■P T* a 

0001 aed 09*J-q9*©a 

IA 

rH 

«f «r 


CM 

CD 

ro 

cb 

oo 

cb 

U3 

O 

rH 

PM 

OO 

OO 

8 

r— 

CO 

CTJ 

P- 

pH 

in 

rH 

ro 

ro 

S 

rO 

cm ro 1 


•eosnwa 

N 

lO iO 

*T 

fO 

CM 

P 

3 

o 

a 

ro 


s 

It 

o 

00 

00 

c— 

P 

V 

00 

m 

r- 

p- 

co 

p- 

CO 

ss 

o 

O 

g 


ro 

s s , 


Il« taoaj sq;«oa 


i— •— 



1—1 


1-1 







** 







1—1 



LM 





•»n|A,i 

suosaad QOOI 

<=> 

pH CO 



CD 

fO 



ro 


m 

«r 

in 

p- 

CO 

CO 

t- 

CM 

oo 

co 

oo 

PH 

ro 

o 

ro 

CH 

o 

«■ oo • 


' 
















6 

CM 



b 









a®d 041 U ivnuuy 






























‘1*9 ox 
















«*• 

c- 

CM 


CD 

oo 

CO 







£ 

«•» 






rH 



r*J 













1-1 




































s3 

S 

•«aoqjj*ia 

lA 

rH ro 

1 

tT 

- 

- 

1 

1 


»r 

i 

in 


1 

1 

1 

H 

CO 

CM 

ro 

CM 

ro 

1 

CM 

ro 

- 

1 

- i i 

Q 































'BJ0A9J 





























o 

ponuftaoo aaq io 





























o 

X 

6 

• J9A9J D]J99U|S 

(M 

~ 1 

1 

1 

1 

1 

1 

1 

1 

l 

i 

CM 

- 

1 

1 

CM 

- 

- 

1 

1 

rH 

i 

l 

- 

l 

- 

rH 

i i i 

►J * 
◄ 

CL 

M 

•aOA 0 ; BnqdAx 

1 1 1 1 1 1 1 1 1 1 1 1 1 III 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 

K 

•qJSnoo 

a > 





























-»U|dooqAl 


















1-1 











a 

C 

fi 

.-BHsqmdia 

CO 

1 " 

- 

CM 

- 

1 

CM 

1 

- 

OJ 

7* 

c- 

1 

1 

1 

1 

1 

00 

m 

1 

- 

- 


ro 

CM 

- 

CM 

- i i 

CD 

a 

H 

'J0A0J 99[a«ag 

co 

CO 

1 1 

- 

*o 

- 

- 

CM 

1 

00 

CM 

i 

rO 

1 


1 

- 

- 

CM 

rH 

o 

ro 

CM 

ro 

- 

UJ 

1 

- 

- 

rH fO | 































Q 

■80I8V0H 

H 

o 

H 

lO lA 

CM 

«3- 

CO 

rH 

ro 

1 

OJ 

ro 

- 

CO 

1 

ro 

1 

o 

CM 

CM 

- 

CM 

rH 

ro 

CD 

CM 

1 

1 

1 

~ 1 1 


•xod-u^ms 

1 

1 1 

1 

1 

1 

1 

1 

1 

1 

l 

i 

1 

1 

l 

1 

1 

1 

1 

i 

1 

1 

i 

1 

1 

1 

1 

1 

1 1 1 


■Kuiah 
• nomad 0001 

»H 

-o p- 

O 


o 

CM 

LO 

CD 

LO 

CO 

m 

CO 

rH 

ro 

E- 

oo 

CM 

C" 

oo 

ro 


CM 


O 


CD 

CO 

LO CO | 


b> 










OJ 



in 


o 

rr 

rt 



rH 

oo 












rH 








i-H 





1-1 




1—1 










to 





3 






















8 g 1 


‘I*9°X 

CO 

CO 


UJ 

TT 


o- 

©■ 

!_> 

rH 

lO 

r*j 

«T 

CM 




CD 

'IT 

ro 

CD 


1 

i 





co 

w 

•sniSujueui 





























* 

I«uici8-oiqg490 






















B 







Q 

•ffBpdlflAjJJ 

iA 


ro 

CM 

CM 

CO 

s 

C" 

CM 

C- 

CM 


CM 

OJ 

ro 

H 

ro 

g 3 


rH 

CO 

ro 

a 


rH 


LO CO | 

P 






























i 

SiL 

-J0A9J [«j9daan j 

c- 

i - 

- 

- 

1 

1 

- 

1 

- 

CM 

1 

- 

1 

i 

l 

1 

l 

CM 

- 

1 

- 

1 

1 

ro 

1 

1 

1 

- - 1 































•SJ9A9J 

co 














m 

■R 













o 

penaijuoo aaqjQ 














U 

H 

N 













a> 

H 

0 L 

■ J9A0J 0fJ9jug 

ai 

l - 

ro 

Ch 

CM 

ro 

rH 






rH 




o 


2 

CH 

ro 

m 

CM 



m 

1 

<D | | 

© 









1 

■ 

B 

1 

■ 


i 

■ 














A 






























s 

‘J9A0J anqdAx 

i 

i i 

i 

1 

1 

i 

1 

1 

1 

l 

1 

1 

1 

i 

i 

i 

1 

1 

i 

1 

1 

i 

1 

1 

1 

i 

1 

1 1 1 

o 

55 

.•«H9qiqd|a 

o 

K 

S S3 

<3- 

iO 

*T. 

C— 

s 

OJ 

CO 

OJ 

s 

O 

OJ 

CM 

CO 

i 

CM 

lO 

CM 

CM 

t> 

co 

CM 

CM 

CO 

2 

O 

ro 

ro 

OJ 

m 

CM 

S S S m 1 



rH 

O CO 

S 

CO 


CM 





8 



CM 

CO 

OJ 

XJ 

ro 

ro 

OJ 

OO 

ro 

oo 

8 

CM 

o 

in 

8 S 1 


*J0A9J J9l4«Og 

3 

CM 







U.J 








CM 

2 









•xod-u*uig 

rH 

1 1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

- 

1 

1 

1 

1 

1 

1 

1 

i 

1 

1 

1 

i 

1 1 1 


'£061 

00 

CO 

a> cm 

is S 

rO 

ro 

CD 

c*- 

55 

00 

CD 

CM 

oo 

ro 

3 

C-H 

t«- 

o 

ro 

CO 

3 

CD 

ro 

CM 

ro 

o 

ro 

CM 

CO 

Co 

3 

a 

CD 

§ 

CO 

o 

3 

g 

s 

c~ 

OJ 

OJ 

e 

o 

o 

XJ 

1 

CM CQ 

3 S 

JO eippjai 0<n aj 

aoi 4 «indod p&wamssv 

oo 

lA 

CD rH 
Ct 00 

S 

s 

a 

CM 

c— 

o-’ 

CM 

(D 

cb 

a 

tH 

M" 

ro 

3 

Cvl 

ro 

CM 

2 

CO 

OJ 

O 

CM 

in 

g 

00 

s 

C- 

§ 

i 

CO 

rH 

ro 

oo 

S 

s 

CM 

co 

§ 2 §’ ' 



TJC 






























•: 

: : 

: 

i 


: 


: 

• 

• 

: 

: 

: 

3 


3 


5 

: 

3 

3 

3 

3 

3 

: 

1 

: 

: i : 


•n 

i 

: : 

: 

: 


: 

: 


: 

5 

3 

: 

3 

3 


3 

; 

3 

3 

3 

: 

3 

3 

3 

: 

3 

3 



h 






























p 

o 

s 

5 : : 

i 

3 

i 

: 

ao * 

: 

: 

3 

3 

3 


3 



3 

3 

i 

3 2 

3 


3 

3 


3 

3 

3 3 3 


o 

cq 

• 

o . . 

5 : : 

i 

: 

• 


© . 
»: : 


3 

• 

■ 

• 


• 


i! * 


: 

3 

« : 

: 

3 

! 

I 

! 

5 

• 

5 5: 


Q 

5 

s 

•0 

§ ; s 

: 

: 

: 

u 

9 

c 

§« 
h; 


: 

* 

a 

: 

1 : 
i : 

3 

: 

V 



3 

is 

_ 

3 

3 

3 

3 

3 

3 

3 

3 3 3 


£ 

g 

M 

5 

« 

O 

Q 

K 

O 

u : : 

£ 

a a 

1 1 & 
a a 

i i 
*s § 
£ x 

A 

1 

Q-. 

g 

g 

5 

a 

« 

XI 

"p 

f* 

«8 

1 

© 

XI 

o 

a 

o 

t» 

p 

5 

.18 
<4 J 

o 

s 

a 

Hi 

CQ 

*0 

£ 

t 

a 

as 

a 

3 

o 

a 

A 

CQ 

a 

© 

B 

‘3 

a 

© 

© 

| 

s 

& 

0 

M 

S 

n 

i; 

i 

'o 

B 

fr 

1 

£ 

o 

■© 

1 

© 

O 

r 

XI 

© 

! 

o 

£3 

90 

a 

1 

o 

*5 

c 

X 

• 

m 

to 

9 

a 

A 

2 

CQ 

! 

r 

i 

i 

5 

§ 

CD 

1 

a 

o 

a 

& 

CQ 

X 

® 

1 

S 

S 

1 

CQ 

X 

o 

IB 

T3 

P 

«8 

& 

3 

9 

l 

% 

a 

« 

o 

T2 

O 

l 

Q 

3 

a 

T 

a 

: ! § 

• ■§ 

B «i ■§ 

3 S S 

ll 1 


Including membnnoiu croup. 









184 Thb Lanoet,] 


VITAL STATISTICS.—THE SERVICES. 


[Jan. 18,1908. 


not one either to small-pox, measles, scarlet fever, or 
“ fever.” These four deaths were equal to an annual rate 
of O'5 per 1000, the death-rates from the same diseases last 
week being 1 • 2 in London and 1 • 3 in Edinburgh. The 
fatal cases both of diarrhoea and whooping-cough showed a 
decline from the numbers in recent weeks. The 197 
deaths from all causes in Dublin last week included 
41 of infants under one year of age and 58 of persons 
aged upwards of 60 years; these numbers differed but 
slightly from those in the previous week. Eight inquest 
cases and five deaths from violence were registered, and 78, 
or 39'7 per cent., of the deaths occurred in public institu¬ 
tions. The causes of eight, or 4'1 per cent., of the deaths 
in Dublin last week were not certified ; the proportion of 
these uncertified causes of death last week did not exceed 
0'2 per cent, in London but were equal to 7'2 percent 
in Edinburgh. _ 

VITAL STATISTICS OS' LONDON DURING DECEMBER, 1907. 

IN the accompanying table will be found summarised 
complete statistics relating to sickness and mortality in the 
City of London and in each of the metropolitan boroughs. 
With regard to the notified cases of infectious diseases it 
appears that the number of persons reported to be suffering 
from one or other of the nine diseases specified in the 
table was equal to an annual rate of 9'1 per 1000 of 
the population, estimated at 4,758,218 persons in the 
middle of last year ; in the three preceding months the rates 
were 11 -0, 13 • 6, and 11 • 4 per 1000 respectively. The lowest 
rates last month were recorded in Paddington, the City of 
Westminster, St. Marylebone, St. Pancras, Holborn, and 
Pinsbury ; and the highest rates in Hackney, Bethnal Green, 
Stepney, Poplar, Wandsworth, Deptford, and Woolwich. 
The notified cases of scarlet fever showed a marked decline 
from the unusually high numbers recorded in recent months ; 
this disease was proportionally most prevalent in Hackney, 
Shoreditch, Bethnal Green, Stepney, Poplar, Bermondsey, 
Deptford, and Woolwich. The Metropolitan Asylums 
hospitals contained 4956 scarlet fever cases at the end of 
last month, against 4293, 5395, and 5600 at the end of the 
three preceding months; the weekly admissions averaged 
458, against 654, 778, and 621 in the three preceding 
months. The prevalence of diphtheria showed a considerable 
decrease from that reported in the previous month ; among 
the several metropolitan boroughs diphtheria was proportion¬ 
ally most prevalent in Fulham, Hackney, Stepney, 
Wandsworth, Greenwich, Lewisham, and Woolwich. There 
were 1168 diphtheria patients under treatment in the 
Metropolitan Asylums hospitals at the end of last month, 
against 964, 1252, and 1277 at the end of the three 
preceding months ; the weekly admissions averaged 155, 
against 160, 199, and 179 in the three preceding 
months. Enteric fever was rather less prevalent in 
December than in the two preceding months; the 
greatest proportional prevalence of this disease was 
recorded in Fulham, St. Pancras, Bethnal Green, 
Poplar, Camberwell, Deptford, and Lewisham. The number 
of enteric fever patients under treatment in the Metro¬ 
politan Asylums hospitals, which had been 99, 123, and 128 
at the end of the three preceding months, had declined again 
to 119 at the end of last month; the weekly admissions 
averaged 18, against 2l, 20, and 18 in the three preceding 
months. Erysipelas was proportionally most prevalent in 
St. Marylebone, the City of London, Shoreditch, Stepney, 
Poplar, and Deptford. The 17 cases of puerperal fever 
notified during the month included three belonging to 
Wandsworth, two to Islington, two to Stepney, and one 
to each of ten other boroughs. Seven cases of cerebro¬ 
spinal meningitis were notified, of whioh two belonged to 
Southwark, and one each to Islington, Finsbury, Poplar, 
Lambeth, and Camberwell. 

The mortality statistics in the table relate to the deaths 
of persons actually belonging to the various boroughs, the 
deaths occurring in institutions having been distributed 
among the several boroughs in which the deceased persons 
had previously resided. During the four weeks ending 
Dec. 28th the deaths of 5532 persons belonging to London 
were registered, equal to an annual rate of 15 ■ 2 per 1000 ; 
in the three preceding months the rates were 12 ■ 0, 13 • 5, 
and 14 • 5 per 1000 respectively. The death-rates last month 
ranged from 8 6 in Hampstead, 10 - 0 in Stoke Newington, 
12 5 in Lewisham, 12'7 in Fulham, and 12'8 in Holborn, 
to 18 0 in the City of London, 18 9 in Finsbury, 19 1 in 
Poplar, 19 '5 in Chelsea, and 20 • 1 in Shoreditch. The 


5532 deaths from all causes included 354 which were 
referred to the principal infectious diseases; of these, 
101 resulted from measles, 66 from scarlet fever, 61 from 
diphtheria, 69 from whooping-cough, 12 from enteric fever, 
and 45 from diarrhoea. No death from any of these 
diseases was recorded last month in Hampstead ; among 
the other metropolitan boroughs they caused the lowest 
death-rates in Hammersmith, the City of Westminster, 
Stoke NewiDgton, Holborn, Camberwell, and Lewisham ; and 
the highest rates in Chelsea, St. Pancras, Hackney, Shore¬ 
ditch, Stepney, Poplar, and Battersea. The 101 deaths from 
measles were 69 below the corrected average number in 
the corresponding periods of the five preceding years ; 
this disease was proportionally most fatal last month in 
Chelsea, St. Pancras, Islington, Shoreditch, Stepney, and 
Battersea. The 66 fatal cases of scarlet fever were 25 in 
excess of the corrected average; among the various metro¬ 
politan boroughs this disease showed the greatest pro¬ 
portional mortality in Fulham, St. Pancras, Stepney, Poplar, 
Wandsworth, and Woolwich. The 61 deaths from diph¬ 
theria were 11 fewer than the average number in the 
corresponding periods of the five preceding years; the 
highest death-rates from this disease were recorded in 
Islington, Hackney, Stepney, Poplar, Battersea, and 
Greenwich. The 69 fatal cases of whooping-cough 
were 42 below the corrected average number; this disease 
was proportionally most fatal in Chelsea, St. Marylebone, 
Stepney, Poplar, Wandsworth, Greenwich, and Wool¬ 
wich. Only 12 deaths from “fever" were recorded last 
month, against an average of 33 in the corresponding periods 
of the five preceding years ; of these 12 deaths two belonged 
to Hackney, two to Shoreditch, and one to each of eight 
other boroughs. The 45 fatal cases of diarrhoea were 
23 fewer than the corrected average number ; this disease 
showed the highest proportional fatality in Kensington, 
Fulham, Hackney, Stepney, and Bermondsey. In conclusion, 
it may be stated that the aggregate mortality in London 
last month from the principal infectious diseases was 30 
per cent, below the average. 

Infant mortality, measured by the proportion of deaths 
among children under one year of age to registered births was 
equal to 134 per 1000. The lowest rates of infant mortality 
were recorded in St. Marylebone, Hampstead, Holborn, 
Bermondsey, Wandsworth, and Greenwich ; and the highest 
rates in Islington, Finsbury, the City of London, Shore¬ 
ditch, Bethnal Green, Poplar, and Southwark. 


THE SERVICES. 


Royal Navy Medical Service. 

In accordance with the provisions of Her late Majesty’s 
Order in Council of April 1st, 1881, Fleet-Surgeon George 
Despard Twigg has been placed on the Retired List, at his 
own request, with permission to assume the rank of Deputy 
Inspector-General of Hospitals and Fleets (dated Jan. 6th, 
1908). 

The following appointments are notified :—Staff-Surgeons : 
H. J. Chater, to the Cormorant , additional for Ascension 
Hospital ; P. H. M. Star to the forte ; and W. R. Center to 
the Vivid, additional, to be lent to the Skirmisher. 

Royal Army Medical Corps. 

Lieutenant William H. Gillatt is seconded for service with 
the Egyptian Army (dated Dec. 27th,, 1907). 

Major H. E. Staddon, from Mauritius, has been appointed 
for duty at the Curragh. Brevet Colonel R. D. Hodson has 
joined the London District for duty. Colonel D. Wardrop 
has been appointed Commandant and Director of Studies, 
Royal Army Medical Corps, vice Lieutenant-Colonel H. E. R. 
James. 

Volunteer Corps. 

Royal Garrison Artillery (Volunteers) : 1st Fifeshire: 
Surgeon-Major R. *B. Graham to be Surgeon-Lieutenant- 
Colonel (dated Dec. 17th, 1907). Ri/lo: 15th Middlesex 
(The Customs and the Docks) Volunteer Rifle Corps : 
William Cameron Macaulay to be Surgeon-Lieutenant (dated 
Dec. 13th, 1907). 

Royal Army Medical Corps (Volunteers). 

Northern Command: Leeds Companies : Major de B. 
Birch to be Lieutenant-Colonel (dated Dec. 18th, 1907). 
Scottish Command: Aberdeen Companies: Major J. S. 




The Lancet,] ANOMALOUS REACTIONS OBTAINED IN TESTING URINE FOR SUGAR. [Jan 18, 1908. 185 


Riddell, M.V.O., to be Lieutenant-Colonel (dated Dec. 18th, 
1907). Western Command : Manchester Companies : Surgeon- 
Captain Wilfred Morilz Steinthal, from the 3rd Volunteer 
Battalion, The Lancashire Fusiliers, to be Captain (dated 
Dec. 5th. 1907). William Robert Douglas to be Lieutenant 
(dated Dec. 12th, 1907). The Cheshire Bearer Company : 
Major G. W. Sidebotham to be Lieutenant-Colonel (dated 
Dec 4th, 1907). Eastern Command ; Maidstone Companies : 
Arthur Thomas Falwasser to be Lieutenant (dated Dec. 7th, 
1907). 

The Health op the Navy. 

The statistical report of the health of the Royal Navy for 
the year 1906, which has been issued as a blue book, opens 
with the satisfactory assurance that the returns for the total 
force for the year 1906 show a continuous improvement in 
the general health of the fleet as compared with that of pre¬ 
vious years. The total force, corrected for time, in the year 
under notice was 108,190, and the total number of cases of 
disease and injury entered on the sick list was 77,842. which is 
in the ratio of 719 ■ 49 per 1000, being a decrease of 119 • 3 per 
1000 as compared with the average ratio of the last nine 
years. The average number of men sick daily was 3144 ■ 77. 
giving a ratio of 29 ■ 06 per 1000, and showing a decrease 
of 6 • 00 in comparison with the last nine years’ average 
The total number of days’ sickness on board and in hospital 
was 1,147,843, which represents an average loss of service of 
10'6 days for each person, which is a decrease of 2 • 19 
in comparison with the average for the last nine years. 
The total number of persons invalided was 2436, which is in 
the ratio of 22 - 51 per 1000, and shows a decrease of 5 73 
per 1000 in comparison with the average of the last cine 
years. Of the above total 1721 persons were finally invalided 
from the service (78 of these refused surgical operations), 
giving a ratio of 15 • 9 per 1000 for the whole force, or 70 • 65 
per cent, of the number invalided, thus showing an increase 
of O'42 per 1000 when contrasted with 1905. Including 
marines invalided from headquarters, the total number in¬ 
valided out of the service was 1901. Of the 2436 invalided, 
2268, giving a ratio of 20'96 per 1000. were invalided for 
disease, and 168, giving a ratio of 1'55, for injury. The 
total number of deaths was 399, giving a ratio of 3'68 
per 1000, which shows a decrease of 1'46 per 1000 
as compared with the average ratio of the last nine years. 
Of this number 269. a ratio of 2'48 per 1000, were from 
disease, and 130, a ratio of 1'2 per 1000, from injury. 
Under the heading of general diseases 184 cases of enteric 
fever are recorded, with 24 invalidings and 32 deaths The 
case ratio per 1000 of strength shows a decrease of 0 '73, the 
invaliding of 0-17, and the death of 0'17, as compared with 
the last cine years’ ratios. These figures, the report states, 
must on the whole be considered satisfactory. The returns 
for the Home Station showed 59 cases; for the Mediterranean 
Station, 29; North America and West Indies and Particular 
Service Squadron, 26 ; Atlantic Fleet, 25 ; Channel Fleets. 
15; China Station, 13 ; Irregular List, 10 ; Cape of Good 
Hope Station, 5; and East Indies Station. 2 cases. The 
mean force for the Home Station was 45 930; for the 
Mediterranean Station, 12,130; for the North America and 
West Indies and Particular Service Squadron, 3690 ; 
for the Atlantic Fleet, 11,720; for the Channel Fleet, 
19,600; for the China Station, 5000 ; for the Irregular 
List, 3650 ; for the Cape of Good Hope Station, 1440 ; and 
for the East Indies Station, 1780. It will be seen, there¬ 
fore, that the morbidity with regard to enteric fever differs 
considerably among the different fleets, squadrons, and 
stations. It would, of course, not be difficult to suggest 
reasons for these variations, seeing that the conditions of 
climate, local control of the men, and other things must play 
an important part with regard to the incidence of the 
disease. This, no doubt, will explain the difference in 
morbidity between the home stations and the Channel Fleet-, 
where the percentages of cases work out at something 
like O'13 and O'08 respectively. Still, it is not satis¬ 
factory that the figures in the one case should be more 
than half as much again as those in the other. With 
regard to Mediterranean fever the returns show 216 cases 
with 134 invalidings and five deaths. These figures show 
a decline on the average ratios for the past nine years. 
The Mediterranean station gave 145 cases, the Home station 
53, the Channel Fleet five, the China Btation four. North 
America with Particular Service Squadron and Irregular List 
three each, and the Atlantic Fleet, the East India station, 
and Australia station one case each, but it seemB almost 
certain that all the cases owed their primary origin to the 


Mediterranean area. Under the heading of tubercle 290 cases 
with 216 invalidings and 39 deaths are recorded. Both as 
compared with last year and the last nine years the case and 
invaliding ratios show a satisfactory decrease. The death 
ratio is identical with that of last year but shows a decrease 
on the nine years' ratio. For the first time in these 
reports the cases of tuberculous disease have been classi¬ 
fied . The total number of recorded cases of venereal 
diseases is 13,193 There were 279 invalidiogs and six 
deaths. The total number of days’ loss of service from 
venereal disease was 316 631, while the average daily 
number ineffective from these diseases was 867 ■ 46. This 
enormous amount of sickness, says the report, shows very 
little sign of any diminution as years go on. A slight 
fluctuation is noticed year by year but the case ratio for the 
year under notice is practically identical with the average 
ratio of the last nine years. Nearly all other diseases show 
a steady decrease ; these remain in rtatu quo. Australia 
shows the highest case ratio. An appendix to the report 
contains a paper by Staff Surgeon H. C. Whiteside, R.N., 
on the work done in the laboratory at the Royal Naval 
Hospital, Malts, during the year 1906 ; a paper by Fleet 
Surgeon J. L. Birrington, R.N., on Traumatic Aneurysm of 
the Right Common Femoral, Ligature of the External Iliac 
Artery, Recovery; and a paper by 8taff Surgeon Oswald 
llees, R N., on Caisson Disease. 

Medical Service in the Territorial Force 

A meeting of members of the medical profession was held 
at University College, Bristol, on Jan. 10th to meet Colonel 
Russell, Deputy Assistant-Director General from the War 
Office, who in an interesting address explained the organisa¬ 
tion of the medical service of the Territorial Force. It was 
proposed that Bristol should furnish one of the three infantry 
field ambulances which are required for the group of counties 
in which Bristol is situated, and also that the city should 
provide a general hospital. A motion pledging the meet¬ 
ing to support the scheme was carried unanimously and it 
was further determined that the Faculty of Medicine of 
University College, Bristol, should be the committee to select 
the names of physicians and surgeons to be recommended to 
the Army Council to serve on the constitution of the proposed 
general hospital. 

The Naval Medical Supplemental Fund. 

At the quarterly meeting of the directors of the Naval 
Medical Supplemental Fund, held on Jan 14th., Sir J. N. 
Dick, K.C.B., in the chair, the sum of £65 was distributed 
among the several applicants. 


Comsponknrc. 


“Audi alteram partem.” 


ANOMALOUS REACTIONS GIVEN BY 
FEHLING’S SOLUTION IN TEST¬ 
ING URINE FOR SUGAR. 

To the Editor of The Lancet. 

Sir,—I n Dr. H. MacLean's excellent paper on the above 
subject he attributes the yellow precipitate given by many 
saccharine urines to the fine state of division in which the 
red cuprous oxide is precipitated owing to the presence of 
kreatinin. There can be little doubt that the colour-change 
is due to kreatinin; this was demonstrated in 1900 by 
Nenmayer. Dr. MacLean’s explanation, however, is debatable. 
Whilst admitting that the precipitate is in a fine state of 
division, not the utmost comminution will change the red of 
cuprous oxide to yellow. Roscoe and Schorlemmer directly 
contradict the conjecture in Vol. II., p. 330, of their treatise 
on Chemistry, where they state when describing cuprous 
oxide that “the more finely it is divided and the finer red 
does its colour become.” A trifling experiment will show 
that something more than the state of division is concerned. 
It is founded on the fact that cuprous oxide (Cu a O) does not 
oxidise on exposure to air when in the dry state ; cuprous 
hydroxide (4 Cu a O + H a O) does oxidise to cupric hydroxide 
on exposure in the dry state. If a little solution of glucose 
in water is added to boiling Fehling’s solution cuprous 
oxide is thrown down as a red precipitate. If a little 
diabetic urine which contains an average amount of 



186 The Lancet,] 


SIDELIGHTS ON NATURE’S OPSONIC METHODS. 


[Jan. 18,1908. 


kreatinin is added to another supply of boiling Fehling’s 
solution, the precipitate is yellow. If the contents 
of each tube are then poured on to a separate filter 
and left for some hours it will be found that the pre¬ 
cipitate of cuprous oxide will be as red as when first 
deposited, whilst the yellow precipitate will have changed 
to greenish-blue, the change commencing in a few minutes. 
On account of the fine state of division of the yellow pre¬ 
cipitate a considerable amount passes through the filter and 
collects at the bottom of the receptacle under the funnel, 
and, being protected from the air by the liquid over it, it 
retains its primitive yellow colour for an indefinite time. If 
the filter on which the yellow precipitate is collected be 
zjuickly dried the change of colour takes place with the dry 
deposit. The same results are obtained with cuprous oxide 
that has been prepared by adding sodium hydrate to cuprous 
chloride. However finely powdered cuprons oxide may be, it 
does not change in colour, if it be dry, by exposure to air. 

I venture to think that I have given good grounds for still 
thinking that the yellow precipitate produced by diabetic 
urine with Fehling’s solution is cuprous hydroxide. 

I am, Sirs, yours faithfully, 

Manchester, Jan. 14th, 19D8. J. DlXON MANN. 


SIDELIGHTS ON NATURE’S OPSONIC 
METHODS. 

To the Editor of The Lancet. 

8 iR,—Sir A. E. Wright’s recent addresses on the rationale 
of the cure of sinuses, lec , by increased opsonic flushing 
through the parts fully explain the good results occurring in 
the following cases in animals. These seem interesting, a9 
unexpected and unusual meanB attain the desired end. 

While experimenting with trypanosome camels in an out-of- 
the-way part of this State oue of the dogs used for inocula¬ 
tion purposes was deeply mauled in the side and round the 
sheath by another dog, or perhaps dingo. The wounds were 
very deep and burrowing and the dog was much injured. 
They soon became foul with extensive sloughing and reten¬ 
tion of discharge in the deep parts and, in spite of all atten¬ 
tion we could bestow, I feared a fatal result. At this stage 
the animal slept outside the tent at night near a nest of 
sugar ants, which had annoyed us by their nightly preda¬ 
tions on our meat and jams. In the morning we found that 
these little creatures had crawled all through the depths of 
the wounds and had removed the evil-smelling sloughs and 
pocketed discharge, leaving a clean slightly moist surface 
through which serum with fresh contents of opsonins could 
percolate freely. These ants seem rarely to bite and 
41 Punch ” allowed them to continue their operations without 
any attempt to lick them away, with the result that granula¬ 
tion and healing proceeded apace. During the day-time the 
dies hovering round the wound also much annoyed “Punch,” 
but his attention to them was also rendered unnecessary when 
a. long-tailed lizard perched on his side and caught them'. 

It seems to be a practice in some parts of Australia to cure 
•fistula in horses by deliberately “blowing” the sinus with 
dies. The opsonic theory here, again, explains the good 
results. The maggots eat away the indurated walls, leaving 
& new surface through which serum rich in opsonins can 
pass, and thus, as the larvae die or are washed out, cure 
follows.—I am, Sir, yours faithfully, 

J. Burton Clrland, M.D., Oh.M. Syd., 
Government Pathologist, Perth, Western Australia. 


HAMPSTEAD GENERAL HOSPITAL. 

To the Editor of The Lancet. 

Sir, — I shall be obliged if you will allow me space to offer 
a few remarks upon the present situation of the Hampstead 
Hospital question. I write to you because I do cot think 
that the readers of the leading article which appears in this 
week’s issue of The Lancet will be able to appreciate fully 
the motives which are actuating the medical staff in sending 
in their resignations, which latter I may inform you have 
been accepted by the council of the hospital. I am not con¬ 
cerned at this moment to discuss all the terms of the 
amalgamation scheme, but merely to assist in rescuing from 
the confusion which seems to be abroad the one perfectly 
clear issue which the staff and the local practitioners have 
before them. 

You will remember that the Hampstead General Hospital 
has been organised and developed from its inception by 


general practitioners, and that there has always been a con¬ 
sulting staff, which, I may add, for the information of your 
readers, no one has ever suggested should be abolished ; on 
the contrary, the present acting medical staff has recom¬ 
mended that it should be augmented. Within three months 
of our coming into the new hospital buildings the executive 
committee of the King Edward's Fund expressed the opinion 
in writing that . “the time has come when the Hamp¬ 

stead General Hospital should secure the services of an 
honorary medical staff of consulting surgeons and physicians 
in accordance with the general practice of other hospitals 
of like importance.” In the early part of 1907 the 
amalgamation scheme was pat forward by the same 
committee of the Fund and it was laid down as an un¬ 
alterable part of that scheme that general praotitioners 
should sooner or later cease to be in any way connected with 
the professional work of the hospital. 

Now, Sir, the perfectly clear and precise issue upon which 
the staff of the Hampstead General Hospital bas resigned 
is, “Shall or shall not general practice be a bar to the 
bolding of appointments in suburban hospitals } ” and I am 
quite sure that whatever may be the opinion of your journal 
on that point the time has come when it is right that it 
should be discussed {rankly and I hope in your editorial 
columns. I venture to submit the following points to you:— 

1. A very large proportion of the surgical and medical 
work in this country is done, and done successfully, in coontiy 
hospitals by general practitioners. 

2. With every year that goes by the medical man as turned 
out by the medical schools is more and more fitted to 
organise hospitals and do the work in them. 

3. As following upon No. 2, there is less difference now 
than formerly between the capacity of the consulting and the 
general praotitioner, more particularly when it comes to the 
practice of the profession. 

4. It is to the advantage of the public that as many as 
possible of the general practitioners Bhould have continued 
access to hospital practice. (I will add here, if you like, the 
converse, which I myself believe to be the solution of the 
struggle which is supposed to exist between consultants and 
general practitioners—viz., it is to the advantsge of the 
public that as many as possible of the consultants should do 
general practice openly in addition to consulting practice.) 

5. It is to the financial advantage of the hospitals (I do not 
refer to the 13 teaching hospitals) that general practitioners 
should he associated with them, seeing that as things are it 
can hardly be said that the medical profession as a whole is 
ardent in its support of hospitals. 

Well, Sir, we general practitioners in Hampstead have 
officered this hospital and have done so successfully, nor have 
we been called in question by anyone in respect either of the 
organisation or of the professional work done in it. That it is 
not complete is dne largely to the interference with its natural 
progress which has resulted from the discussions of the new 
scheme which have taken place during the last two years 
and for which we, as members of the staff, are in no wise 
responsible. I venture to submit that for the executive 
committee of the fund collected for the relief of the sick 
poor to dictate or even suggest who is to do the work in a 
voluntary hospital is a misuse of the power which is the 
possession of those with a long parse. That it should satisfy 
itself that the money is economically spent and the patients 
properly attended each year before it gives its grant is right 
and proper and it does that by means of its professional and 
lay visitors. The net result of its action in endeavouring to 
alter the constitution of this hospital for no other reason than 
that it is a different one to that of any other suburban hospital 
(witness, inter alia, its contributory 12s. beds open to any 
practitioner), the net result, I say, remains to be seen ; but I 
venture to think that an appreciable falling off in subscrip¬ 
tions and donations will oocur and I am certain that the 
executive committee will regret that. 

So far as the senior members of our staff are concerned 
perhaps we might be contented under the terms of amalgama¬ 
tion, but we are unable to sit by and calmly feather our own 
nests. We have felt that a vital principle is at stake in the 
matter and that we are only tolerated for our own individual 
personalities. That there are plenty of men as capable as, 
nay, more capable than, ourselves of staffing this hospital and 
who yet are in general practice we believe to be a fact, and 
we have resigned not so much because of our disbelief in the 
finance of the scheme (which disbelief is all but shared by 
some of our opponents) ; not because we object to amalgama¬ 
tion per ee with every other hospital in the north-west 
district if need be; not because we object to work with our 






The Lancet,] 


GIRDLE PAIN. 


[Jan. 18,1908. 187 


brother medical practitioners who live in the less salubrious 
districts in the West-end ; not becanse we object to the 
Hampstead Hospital serving the poor outside the borough of 
Hampstead, for it has always done that; hntand for the sole 
reason that by this scheme a blow is aimed at general 
practitioners as a class and they are told, and the public of 
London is told, and it is the executive committee of the 
King’s Fund who tells them, that they, the general practi¬ 
tioners, are incapable of satisfactorily managing a hospital 
and doing the work in it, which telling is directly contra¬ 
dicted by the very existence of the hospital-and by the facts 
of the hospital world as evidenced in the country towns of 
Eogland. 

I hope you will discuss this point and will give the valuable 
support of your journal to the cause of the general practi¬ 
tioners in this and other suburban districts. 

I am, Sir, yours faithfully, 

Hampstead, Jan. 12th, 1908. LEWIS G. GLOVER. 


To the Editor of The Lancet. 

Sir,—W ill you kindly allow me to correct the statement 
in your leading article that the wards of this hospital have 
been closed * • for lack of funds ” 1 

In July we were officially informed by the King’s Fond 
that the terms of amalgamation had been agreed to by the 
three contracting parlies. It was therefore reasonably 
assumed that the scheme would be carried through by 
Sept. 30th at the latest. So arrangements were made for 
gradually closing the wards in order to make inventories of 
our stock and put everything in readiness for the new riyime. 
At that time our debts were paid and our balance at the 
bank on current account was over £3000. Clearly your 
metaphor of the sinking ship is not quite appropriate 1 
My committee’s anxiety to promote the amalgamation is 
explained by the fact that they felt unequal to the financial 
liability of undertaking the rebuilding of this hospital which 
the King’s Fund had insisted upon. 

I am, Sir, yonr obedient servant, 

Alfred Craske, Secretary. 

North-West London Hospital, Kentish Town-road, 

Jan. 15th, 1908. 


GIRDLE PAIN. 

To the Editor of The Lancet. 

Sir,—T he abrupt dogmatism of the text-books in regarding 
girdle pain as a symptom pathognomonic of an affection of 
the spinal cord or posterior root ganglia would seem to 
exclude any question of its pathology and to imply that the 
subject rests upon a satisfactory basis. This attitude of 
certainty deterred me for a long time from submitting for 
publication the notes of a case with some comments thereon, 
which seem at variance with the generally accepted opinion 
that girdle pain is always a manifestation of disease of the 
central nervous system and as showing with a considerable 
amount of probability that it may sometimes be a valuable 
symptom of visceral disease. The enormous difficulty of the 
subject may be appreciated when practical physiologists 
after most elaborate and ingenious experiments are unable 
to make any definite pronouncement upon it. It is, however, 
of very considerable clinical importance, and especially so in 
view of the malingering which is sure to arise out of the 
recent extension of the Workmen’s Compensation Act. 

About a year ago I had under my treatment a case of 
cancer of the pancreas, verified by abdominal section, which 
presented many interesting phenomena, amongst which girdle 
pain was a most prominent and distressing symptom. Many 
other referred and irradiated pains were present, some probably 
due to extension of cancor to the stomach, under surface of 
the liver, and other adjacent structures, but the girdle pain 
predominated over all these in severity and distress to the 
patient. It was present from an early stage of the disease 
and was described as a painful sense of constriction as by 
a narrow band or rope encircling the body at a level between 
the umbilicus and ensiform cartilage in front and about the 
origin of the twelfth dorsal nerves posteriorly. WheD uncon¬ 
trolled by morphia the general nerve storm was so wide 
extending that it was at first difficult to outline the exact 
boundary of the constriction pain. Apparently it began in 
the left side and quickly increased in intensity until it became 
equally severe on both sides. In its early stage there 
appeared to be wide overlapping, but this was probably 


owing to confusion with other painful areas, for when 
it reached its highest point of intensity it was restricted 
to a band of skin about an inch in width. The 
tendon reflexes were normal and there was no history or 
evidence of syphilis, no perverted or delayed sensation in the 
skin, nor peripheral degeneration anywhere, as there would 
have been had the spinal cord been involved. Consequently, 
although there was no post-mortem examination, I think I 
may exclude the spinal cord and posterior nerve roots as, in 
this instance at all events, contributory to the pain, because, 
as I have already said, it was an early symptom, and if at an 
early stage cancer had attacked the spinal column or its 
contents destruction of these parts would have been so 
extensive as in a short time to leave no doubt of their 
implication. Hence the question arises as to its origin. 
This is very difficult to answer with any degree of certainty, 
but if I may draw an analogy from other visceral pains there 
is, I think, presumptive evidence in support of its being in 
the sympathetic system. 

The solar ganglia send fibres to all the abdominal viscera 
and although there is an absence of physiological evidence 
of the presence of sensory fibres running from these ganglia, 
clinical observation seems to support the existence of such 
fibres. For example, the heart and first portion of the aorta 
are supplied by post-ganglionic fibres from the inferior 
cervical and stellate ganglia, and aneurysm of the aorta, 
apart from any local pressure it may exert on surrounding 
structures, often gives rise to very acute pain. It is a well- 
known physiological fact that excessive pressure on the 
endocardium causes pain, and the vagus has not, I believe, 
hitherto been proved to contain pain fibres. The superior 
mesenteric artery is innervated by the superior mesenteric 
plexus, and calcareous degeneration and other diseases of 
this vessel are said to excite severe abdominal pain. 
Now as post-ganglionic fibres supply the blood-vessels and 
disease of these vessels may be accompanied by pain, there 
is, I think, reasonable presumptive evidence that some at 
least contain pain fibres. There are other afferent channels 
from the viscera into the central nervous system, but this fact 
does not interfere with my argument. In the discussion on 
acute pancreatitis at the recent meeting of the British 
Medical Association at Exeter mention was made of the 
frequency with which this affection was attended by pain in 
the right iliac region and the consequent danger of mistaking 
it for appendicitis. In the case about which I write there 
also was acute pain along the course of the right ilio¬ 
inguinal nerve accentuated at the flank and back of the 
scrotum and extending down the inner side of the thigh to 
the knee. 

In Schilfer’s “Physiology’’ Langley says that the preverte- 
bral ganglia send fibres to the thoraoic, abdominal, and pelvic 
viscera and ' ‘ the probability is great that the distribution of 
the grey rami is the same in its general plan as the cutaneous 
branches of successive spinal nerves.” This hypothesis is no 
doubt true, otherwise it seems difficult to explain why the 
right ilio-ingninal nerve should be affected in disease of the 
pancreas, as from clinical observation I assume it not infre¬ 
quently to be, unless it is through the grey rami of the solar 
ganglia. At all events, this appears to me to be the simplest 
and most feasible explanation and the probability of its 
being the correct one is increased when the anatomical posi¬ 
tion of the superior mesenteric ganglion which lies to the 
right of the plexus is taken into consideration, and 
thus its great liability to be excited in inflammatory 
conditions in and about the head of the pancreas. More¬ 
over, Langley says that cutaneous nerves seem not to 
be constituents of the afferent spinal roots which, in respect 
to muscular tone, are of chief importance ; therefore on this 
finding the pain would not be due to a twig from the ilio- 
ingninal to the pancreas. Finally, if conduction of pain was 
through a preganglionic fibre or white ramus only, owing to 
the wide distribution of these fibres in the sympathetic 
chain irradiation of pain would take place over an extensive 
area of the trunk. This, [in fact, was so, but in addition 
there was the limited girdle pain, and physiologists tell us 
that areas of skin innervated by successive grey rami overlap 
only a few millimetres. 

Recent experiments of Muller, Goltz, and others have 
transferred the deeply rooted theory of the spinal localisa¬ 
tion of the vesical and rectal centres to the sympathetic, 
and I have now a patient with rectal and bladder crises 
which seem outside the spinal cord. Other tabetic crises 
are cot improbably also of similar origin. 

I am not, however, so much concerned with physiology as 



188 Thb Lancet,] HYPERTROPHIC STENOSIS OF THE PYLORUS.—MIRROR-WRITING. [Jan. 18, 1908. 


in an effort to show that girdle p&in is Dot always character¬ 
istic of local lesions of the spinal cord or posterior root 
ganglia, and that it probably has its origin in some part of 
the sympathetic system and may sometimes occur in disease 
of the abdominal viscera, and the frequency with which it 
occurs at the girdle would suggest investigation of the solar 
ganglia as playing an important part in its production. 

I am. Sir, yours faithfully. 

Bournemouth, Jan. 5th, 1908. E. CURTIN, M.D. R U.I. 


HYPERTROPHIC STENOSIS OF THE 
PYLORUS. 

To the Editor of The Lancet. 

Sir,— In The Lancet of Jan. 11th Dr. W. H. Cooke 
raises doubts as to the possibility of palpating the enlarged 
pylorus when it is completely covered by the infantile liver 
and as to the accuracy of the statement that if lavage fail6 
the only recourse is to try operation. I believe it is possible 
to feel the enlarged pylorus in nearly every case, sometimes 
with absolute certainty, at others in such an uncertain way 
that one can only say it can be felt indefinitely. On the 
other hand, I am well aware that an enthusiast will feel it, 
although no enlargement is present. The liver is not a 
serious drawback, although it may be situated anteriorly 
to the pylorus. It is generally comparatively easy to 
press the fingers down and under the liver, even in a 
well-nourished child. The chief sources of difficulty are a 
rigidity of the muscles due to crying or straining, a dis¬ 
tended abdomen, and a crying child. The question as to 
the possibility of curing well-marked cases without opera¬ 
tion is still tub judice. Undoubtedly some of the milder 
degrees of the affection may be so cured, but one must bear 
in mind that the existence of the hypertrophy is often 
erroneously diagnosed. If I may be allowed to criticise 
Dr. Cooke’s cases on the basis of the few data which he 
gives in his letter I should suggest that the first case was 
a typical one of the affection and was inourable by medical 
treatment, and that the second was probably an instance of 
pyloric spasm. I cannot believe that it would be impossible 
to feel a hypertrophied pylorus, if present, in a baby which 
wasted down to three and a half pounds. 

I am. Sir, yours faithfully, 

Upper Brook-street, W., Jan. 11th, 1908. EDMUND CauTLKY. 


To the Editor of The Lancet. 

Sir,—Y our correspondent, Dr. W. H. Cooke, has raised an 
interesting point with regard to the palpation of the pylorus 
in this condition. There is no doubt as to the difficulty 
which is frequently met with in eliciting this sign, but from 
an impression formed from making post-mortem examina¬ 
tions in ten cases the position of the pylorus in relation to 
the liver is not, I think, the essential cause of tbe difficulty. 
The pylorus after death is usually found at ODly a slightly 
higher level than the lower edge of the liver in such a 
position as would render it fairly easily palpable through the 
abdominal wall of an emaciated infant as far as this matter 
is concerned. 

It would seem that a more important cause of the obscuring 
of the pyloric tumour is the relation which it usually bears to 
the rest of the stomach. In these cases the enlarged stomach 
tends to become bent upon itself so that the pylorus and the 
pyloric end of the stomach come to lie behind the rest of the 
viscus. If the pylorus be sought for by palpation of the 
abdomen in the region of the right rectus muBcle it will be 
seen that two layers of thickened gastric wall intervene 
between the band and the tumour so that the latter cannot be 
recognised. A more successful method is with the infant 
lying on his back to place the finger-tips well over into the 
right flank and to push inwards and slightly upwards below 
the liver towards the vertebral column. 

Further, it is well known that in any one case the pylorus 
is only intermittently palpable and is most easily found at 
those times when gastric peristalsis is proceeding. This ie 
usually explained by saying that when the pylorus is 
spasmodically contracted it becomes harder and so more 
easily felt. It would seem, however, that this is not the 
whole truth for the hypertrophied pylorus must be sufficiently 
firm to be palpable whether in spasm or relaxed. It is, I 
think, more probable that the explanation lies in the fact 
that during peristalsis tbe stomach tends to become 
straightened out so that the pylorus becomes not only 


more uncovered but is dragged nearer tbe surface. In 
addition, palpation of the pylorus is rendered difficult by the 
depth and mobility of the tumour, and, one may perhaps 
add, by the examiner's knowledge that any prolonged attempt 
to elicit this sign is apt to do harm by causing the child to 
vomit. 

In spite of these difficulties the pylorus usually becomes 
palpable in such cases as can be watched for a short period, 
although it is seldom felt at the first examination. In all 
cases recovering under lavage and dieting the pylorus may 
be felt from time to time throughout a period extending over 
many weeks.—I am, Sir, yours faithfully, 

Reginald Miller, 

Medical Registrar and Pathologist. 

HosDital for Sick Children. Great Ormond-street, W.C., 

Jan. 11th, 1908. 


MIRROR-WRITING. 

lo the Editor of The Lancet. 

Sir, —The case of mirror-writing given by Dr. Vaughan 
Fendred in The Lancet of Jan. 4th might perhaps be 
explained by assuming an abnormal activity of the nervous 
apparatus concerned in the right hemisphere. A statement 
as to the existence or not of a tendency to mancinism would 
have been instructive here. My own case seems worth 
putting on record, as it involves some points of psychological 
interest. Being originally '‘left-handed," when first taught 
to write in the usual fashion I was at that time able to write 
with the untaught left hand the reverse way and with more 
facility. This habit was early repressed and very soon given 
up and during seven subsequent years of schooling (ninth to 
sixteenth year) never indulged, quite unpractised ; indeed, 
almost forgotten. After beginning my medical education it 
occurred to me that the halting way with which thought 
followed pen when using the right hand—a fact always the 
bane of my school examinations, Ac., and which had 
distressed me much in view of a far readier faculty of 
expression in speech—led me to decide on a serious 
attempt with the left hand as before, "mirror-fashion.” 
The first time I experimented I succeeded, to my surprise, 
with a rapid, perfectly formed, neat, even elegant, writing, 
infinitely better than the clumsy right handed performance. 
I then found that thought followed pen far more easily, so as 
to change the writing of consecutive steps of an argument 
from a misery into a pleasure, though I could not read wbat 
I wrote, and bad to get help from a looking-glass. In Mark 
Twain’s phraBe, " the obstruction was removed.” I have 
continued for ten years nsing this unsought accomplishment, 
on transparent paper, and am still unable to read well the 
reversed words ; also there is no doubt that the vocabulary 
is more limited. But apparently during all those formative 
years the centres on the right side, though unused, were 
secretly profiting by the training given to the left. The 
manoinist no doubt succeeds in developing his right hemi¬ 
sphere by the educational system in many respects, but in 
writing, and even in reading, those very important factors in 
culture, he is probably at a grave disadvantage. 

I am, Sir, yours faithfully, 

Edmund Hughes, M.H.O.S. Eng., L.R.O.P. Lond. 

Liverpool, Jan. 5th, 1908. 


THE INFECTIVITY OF CANCER. 

To the Editor of The Lancet. 

Sir,— Under the above heading in The Lancet of Jan. 11th 
Dr. A. T. Brand writes : “ It was the resemblance between the 
mitosis of malignant cells and that of normal reproductive 
tissue cells which led to tbe enunciation by the director of 
tbe Imperial Cancer Research Fund of the famous analogical 
fallacy that malignant new growths are merely reproductive 
tissue in abnormal situations.” He also writes: "When 
Farm r, Moore, and Walker announced their interesting 

discovery . the director of the Imperial Cancer Research 

Institute hastened to emit the extraordinary declaration, 
ex cathedra , that ‘ malignant new growths were virtually 
reproductive tissue arising in abnormal situations.’ ” 

1 have nowhere expressed this opinion as having been 
formed by myself and have only mentioned it to combat its 
tenability. As Dr. Brand has inadvertently misrepresented 
my attitude by his manner of quoting what Dr. Murray and 
myself wrote, I ask yon to be good enough to print the 
passage In full. "From these observations the authors” 






The Lancet,] 


THE SPREAD OF CHOLERA: AN INFECTED HAJ. 


[Jan. 18, 1908. 189 


(Le., Farmer, Moore, and Walker) “concluded that malignant 
new growths were virtually reproductive tissue arising in 
abnormal situations and possessed of an independence and 
power of growth like that of testis in the mammalian body." 
To our original paper 1 we added a note emphasising that we 
did not accept this and other conclusions, as to the diagnostic 
value of the forms of cell-division in benign and malignant 
new growths, drawn by Farmer, Moore, and Walker. 

I am, Sir, yours faithfully, 

Jan. Uth, 1908. E. F. Bashford. 


A NEEDLE 12 DAYS IN THE ALIMENTARY 
CANAL OF A CHILD 15 MONTHS OLD. 

To the Editor of The Lancet. 

Sir,—T he clinical note on the case of an open safety-pin 
in the oesophagus of a child published in The Lancet of 
Jan. 4th makes me think that it might be of interest to 
mention a similar experience this last month in my own 
practice. A child 15 months old was playing with a 
needle one and a half inches long used for wool work and 
dot having a very sharp point, when she put it in her mouth 
and swallowed it. I advised that a skiagram should he 
taken and the child watched for any untoward symptoms, 
and that the food should be as solid as possible. The parents 
did not take the advice as regards the skiagram, but anxiously 
watched the child from day to day. Nothing happened till 
the twelfth day when on the usual washing and straining of 
the fasces the needle was found. 

I am, Sir, yours faithfully, 

Green-lanes, N., Jan. 8th, 1908. LEOPOLD G. HILL. 


THE COEFFICIENT OF DISINFECTANTS 
AS REGARDS THE PLAGUE 
BACILLUS. 

To the Editor of The Lancet. 

Sir, —My friend Dr. J. 0. Thresh in The Lancet of Jan. 4th 
points out that bacillus pestis gives unsatisfactory coefficients 
when tested in broth cultures, and suggests that other 
bacteriologists may care to repeat his experiments and con¬ 
firm or disprove his results. This is quite unnecessary, as 
Dr. Thresh’s experience is not new but in accord with 
Simpson and Hewlett’s work 2 who have shown that agar 
suspensions should be substituted for broth cnltures when 
testing disinfectants with this organism. 

I am, Sir, yours faithfully, 

• Samuel Rideal. 

Chemical Laboratory, Victoria-street, S.W., Jan. 9th, 1908. 

AMYL NITRITE IN HAEMOPTYSIS. 

To the Editor of The Lancet. 

Sir, —Dr. Reissmann has every right to traverse my views 
concerning the treatment of haemoptysis by nitrite of amyl, 
but he has no right to assume that my note of warning in the 
matter was based upon mere theory. In point of fact the 
passage from my lecture which Dr. Reissmann quotes was 
inspired by two cases of haemoptysis due to tubercle, in both 
of which the exhibition of the nitrite was immediately 
followed by death. I do not wish to lay too much stress 
upon these cases. One of the patients certainly, and the 
other possibly, would very shortly have died in any circum¬ 
stances, but in each case theywrf hoc was sufficiently striking 
to suggest the propter hoc, and thus to point a warning 
against the indiscriminate and routine use of the drug, 
which appears, amongst residents at any rate, to be the 
fashion of the moment. 

I am. Sir, yours faithfully, 

Tork-street, W„ Jan. Uth, 1908. LEONARD WILLIAMS. 


THE MORPHINE HABIT AT THE AGE OF 
87 YEARS. 

To the Editor of The Lancet. 

Sir,—A patient of mine, a lady, has just died from bron¬ 
chitis at the age of 87 years and 11 months. She enjoyed to 
within a few days of her death absolute clearness of mind 


1 ProceedlogB of the Royal Society, Jan. 21st, 1904. 
fi The Lancet, August 20th, 1904, p. 524. 


and acuteness of observation. Three years and a half ago 
she “ broke her hip,” with such subsequent pain that I was 
forced to administer hypodermically ,'jth of a grain of 
morphine. No relief followed find the dose was raised through 
jth, i, and £ grain to 1 grain twice daily. In spite of effort 
to the contrary on my part, larger doses followed, until for 
the past 18 months she has had (hypodermically) 2j and 
sometimes 3 grains twice daily. The tolerance of the drug 
at this extreme age must be interesting. The usual dis» 
tressing symptoms when waiting for the dote were present. 

1 am, 8ir, yours faithfully, 

Jsn. 11th, 1907. M.B. 


THE SPREAD OF CHOLERA: AN 
INFECTED HAJ. 

(From the British Delegate on the Constantinople 
Board op Health.) 


To those who have followed the recent course of the cholera 
epidemic in the Near East, as set forth in previous letters, it 
will not come as a surprise to learn that the pilgrimage to 
Mecca and Medina is already seriously infected with the 
disease. The pilgrimage culminates in the three days of 
Kurban Bairam, when the religious fetes at Arafat and Mina, 
•ear Mecca, take place ; those three days fall this year on Jan. 
13th, 14th, and 15th. It iB at that time, of course, that the 
number and density of the mass of pilgrims reach their highest 
point. But for several weeks before they accumulate, in con¬ 
stantly increasing numbers, both at Mecca and Medina, and 
the “ roads,” or rather the desert tracks between Medina find 
Yanbo on the one hand, between Jeddah and Mecca on the 
other, and finally those between Mecca and Medina, are 
being at the same time constantly traversed by unending 
streams of pilgrim caravans. Already both the holy cities of 
Islam, both the ports named, and two out of the three 
“roads” just mentioned are all seriously contaminated 
with the cholera infection. 

It is not at present known how the infection was introduced 
to Mecca or to Medina. In Mecca a Soudanese woman was 
found to be ill with symptoms of cholera on Dec. 13th; 
she was isolated and died on the next day. Microscopically 
bacilli resembling those of cholera were found in the 
intestinal contents. This woman was said to have come 
over from Suakim to Jeddah in a native boat, or “ sambouk,” 
at the beginning of the Moslem month of Ramazan (early in 
October) and to have reached Mecca at the end of that 
month. She is further said to have collected refuse of food 
left in the neighbourhood of a spot where some Indian 
pilgrims had camped in the Mesfelleh quarter of Mecca. 
This quarter is outside the walls of the town. On Dec. 17th 
another Soudanese, a male, fell ill and died. Then on the 
18th there were 4 fresh cases; on the 19th, 4 deaths 
and 2 cases isolated; and on the 20th, 3 deaths and 
1 case isolated. Up to this date it was stated that all the 
cases had oocurred in the same quarter and exclusively 
among Soudanese. The later telegrams are silent on this 
point, but it may be surmised that the epidemic is no longer 
confined to one race or to one quarter of the town. The further 
coarse of the outbreak in Mecca has been as follows :— 


Dec. 21st .. 

14 deaths 

1 case isolated. 


22 nd . 

■ 17 „ 

... 1 


23rd . 

. 21 „ 



24th . 

■ 18 „ 

6 ” 


25th . 

• 13 „ 

... 8 


26th . 

- 35 „ 

... 12 


27th . 

■ 25 „ 

... 15 


28th . 

• 25 „ 

... 15 


29th . 

■ 31 „ 

... 16 


30th . 

. 39 „ 

... 7 


31st 

• 36 „ 

... 15 


By the last day of the year the total number of registered 
deaths from cholera in Mecca had risen to 283. 

It is as yet uncertain whether Medina became infected by 
pilgrims from Mecca or by those coming from the north by 
way of Yanbo. The fact that cholera existed in Medina only 
became known by the arrival at Jeddah just before Christmas 
of a series of ships from Yanbo (the port for Medina) all 
seriously infected with the disease. But before describing 
these outbreaks mention should be made of a single case of 
cholera in the Abu-Saad lazaret close to Jeddah. As Btated 









190 The Lancet,] 


THE SPREAD OP CHOLERA: AN INFECTED HAJ. 


[Jan, 18, 1908. 


in my last letter, 1 cholera had broken oat on two ships 
undergoing quarantine at the Camaran lazaret; both these 
ships had to perform a supplementary quarantine of live days 
in the Abu-Saad lazaret before being given pratique at 
Jeddah. It was among the pilgrims from one of these ships 
that the case of cholera just mentioned occurred on Dec. 8th. 
There was bacterioscopic evidence that the case, which ended 
in death, was one of cholera. This case, however, could 
have had no connexion with the introduction of cholera to 
either Mecca or Medina, as in both these towns cases of the 
disease were seen before this ship's group of pilgrims had 
completed their 12 days’ quarantine in the Abu-Saad lazaret. 

On Dec. 21st a small ship, with 382 pilgrims, arrived at 
Jeddah and reported 4 deaths from fulminant cholera on the 
voyage. These pilgrims had come from Medina to Yanbo 
and they stated that about 100 cases of cholera had 
already occurred in Medina among Russian pilgrims, that 
they themselves had hastened their departure from Medina 
but their caravan had been ravaged by the disease on the 
road to Yanbo On the same day two other ships arrived at 
Jeddah from Yanbo ; on one 7 crises of cholera with 1 death 
had occurred and on the other 4 cases with 2 deaths. On the 
22nd a fourth ship arrived from the same source with 17 cases 
of the disease and 4 deaths. An attempt was made to send 
these ships on to Camaran to do their quarantine but the 
pilgrims revolted, as they feared they would in that case lose 
this year's Haj. They were therefore sent to the Abu-Saad 
(Jeddah) lazaret to undergo disinfection, a douche bath 
and five days’ quarantine. Between Dec. 2lst and 29th 128 
cases of cholera with 53 deaths occurred among these 
pilgrims interned in the lazaret; on the 30th there were 17 
more cases with 11 deaths, and on the 31st 2 more deaths. In 
the town of Jeddah itself an employee of the health offioe died 
from cholera after a few hours’ illness on Dec. 27th ; another 
fatal case occurred on the 29tb, 4 more deaths on the 30th, 
and 4 on the 31st. In the meantime it became known that 
cholera had existed in Yanbo since Dec. 19th; whether it was 
imported there from Medina is not clear. Between Dec. 20th 
and 24th 107 cases with 69 deaths were registered in Yanbo. 

The statements respecting the appearance of the disease 
in Medina are contradictory. It appears, however, that on 
Deo. 17th a caravan of 2000 pilgrims arrived there from 
Y'anbo and reported having lost by death from cholera a 
score of their number on the road. Then on the 18th there 
were 11 deaths and on the 19th 14 deaths from the disease in 
Medina. On the 19th a caravan of 3643 pilgrims arrived 
there by land from Mecca and reported that about 40 deaths 
from cholera had occurred among them on the journey. The 
march from Mecca to Medina takes about 12 or 13 days. 
On the 20th, in these different groups, as also among 
pilgrims who had come on foot from Damascus some ten 
days before, 11 deaths occurred, and on the 21st 18 deaths 
and 4 cases were isolated. Later news from Medina has 
been scanty, but it is known that on Dec. 24th 18 deaths 
from cholera occurred there among pilgrims and 2 among 
the native inhabitants. 

The very severe outbreak of cholera on a Russian pilgrim 
ship at the lazaret of Sinope described in my last letter did 
not come to an end before the total number of cases had 
reached the high figure of 73. of which 57 ended in death. 
The ship, with just under 2000 pilgrims on board, left the 
lazaret on Dec. 15th and proceeded to Jeddah. So far as is 
known no further cases of cholera occurred during her 
voyage, but on Dec. 30th news was received from Jeddah 
that this unfortunate ship had gone ashore some 40 miles 
from that port; her pilgrims have been saved but the ship 
has not been refloated. Another large pilgrim ship, flying 
the French flag, arrived from Sinope at the northern end of 
the Bosphorus on Dec. 24th ; one death from cholera and one 
from suspected cholera had occurred on board during the 
voyage ; the ship was allowed to continue her voyage 
en oontumace. Between Constantinople and Port Said 8 
more deaths are reported to have occurred on board, 7 of 
which were believed to have been due to cholera. She passed 
the Suez Canal in quarantine, landed two patients at the 
lazaret of Moses’s Wells, and proceeded on her voyage to 
Jeddah. 

It is very nearly six solar years, and exactly six Moslem 
years, since cholera was epidemic in the pilgrimage. In 
February, 1902, just before the Mecca fetes of that year, the 
disease appeared in Mecca, Medina, and on the road between 
the two. On that occasion it was believed to have been 


1 The Laxcet, Jan. 4tb, 1908, p. 52. 


imported to the Hedjaz from India. In the present instance 
there would appear to have been a double stream of infection, 
from the south and from the north. It is certain at least 
that the current of pilgrims coming to the Hedjaz by the 
Straits of Bab-el-Mandeb bad the cholera infection amongst 
them and that the current of Russian pilgrims from 
the north was also deeply infected. So far as is 
known at present the Hedjaz railway, whioh is now 
completed to within about 300 miles of Medina, has played 
no part in the introduction of cholera infection into the 
Hedjaz ; but it will offer a ready means of spread of the 
disease during the return of pilgrims and a scheme of 
sanitary defence of the line has been drawn up and will be at 
once put into execution. 

Now that cholera has become so seriously epidemic in the 
Haj the further progress of the disease in Russia is only of 
secondary interest. It will suffice, therefore, to give the 
following brief summary of the returns from the Russian 
Empire in completion of the figures published in my former 
letters :— 



From Nov. 7th 
to 13th. 

From Nov. 14th 
to 29th. 

Cases. 

Deaths. 

Cases. 

Deaths/* 

Samara (town) . 

1 

3 

— 

— 

Samara (government) . 

2 

1 

. 6 

2 

Karan (town). 

1 

— 

— 

— 

NIjni Novgorod (government.)... 

— 

1 

— 

— 

Penza (government) . 

19 

10 

71 

24 

Yaroslavl (town) . 

— 

— 

7 

7 

Yaroslavl (government) . 

5 

5 

— 

— 

Ekaterinoslav (town). 

— 

— 

10 

9 

Roatof on Don (town). 

6 

3 

6 

5 

Don Territory . 

— 

— 

9 

5 

Kief (town) . 

14 

4 

49 

5 

Kief (government) . 

2 

— 

12 

5 

Simbirsk (government) . 

— 

— 

6 

2 

Tchernigof (government). 

— 

— 

11 

1 

Orenburg (government) . 

— 

— 

1 

l 

Kuban Territory. 

— 

— 

8 

4 

Tomsk (government). 

9 

4 

32 

15 

Tobolsk (government) . 

4 

1 

— 

— 

Akraolinsk Territory. 

24 

18 

20 

13 


The above-mentioned dates are according to the Old Style. 
More recently the Russian Government has declared the 
following portions of the empire free from cholera: the 
governments of Astrakhan, Samara, Saratof, Tambof, Riazan, 
Vladimir, Viatka, Term, Ufa, Kursk, Bessarabia, Poltava, 
Volhynia, Podolia, Mogilef, Minsk, and Lublin in European 
Russia ; the governments of Stavropol, Baku, and Tiflis, the 
territory of Daghestan, and the towns and districts of 
Elisavetpol and Novorosiisk in the Caucasus and Trans¬ 
caucasia ; the territories of Uralsk and Semipalatinsk, the 
districts of Krasnovodsk and Mangyshliak in Transcaspia, 
that of Lepsinsk in the Semiretchinsk Territory—all in 
Russian Central Asia ; and the Transbaikal Territory in 
Siberia. The total number of cases registered in the 
Russian Empire from the beginning of the epidemic to 
Nov. 27th (Dec. 10th) was 11,934, and that of deaths 5706. 

Consranttnciplo, Jan. 2nd. 


Liverpool Medical Institution. — At the 
annual meeting held on Jan. 9th the following list of officers 
and members of council was adopted :—President: *T. H. 
Bickerton. Vice-presidents: F. Charles Larkin, R. W. 
Murray, ‘Hugh E. Jones, and *C. Thurstan Holland. 
Treasurer : Robert A. Bickersteth. General secretary : J E. 
McDougall. Secretary of ordinary meetings: *R. J. M. 
Buchanan. Secretary of pathological meetings : *D. Douglas- 
Crawford. Librarian: W. B. Warrington. Editor of the 
Jonmal : John Hay. Council: W. N. Clemmey, William 
Crooke, Charles A. Hill, W. B. Paterson, Thomas Stevenson, 
Joseph D. Wright, ‘Frank T. Paul, ‘John Ambrose Cooke, 
‘Henry Halton, *W. Blair Bell, ‘Joseph F. Blood, and 
‘Hubert Armstrong. Auditors: *G. P. Newbolt and ‘J. 
Lloyd Roberts. Those marked (*) did not hold the same 
office last year. 






The Lancet,] 


WOMEN HOME-WORKERS. 


[Jan. 18,1908. 191 


WOMEN HOME-WORKERS. 

(From a Correspondent.) 

That class of work commonly known as “ sweated labour ” 
is much occupying the attention of the public at the 
present time ; it mast always be of the greatest interest to 
medical men. Over 20 years ago Thk Lancet took up 
the matter, and indeed it was largely due to a report 
which appeared in this journal on May 3rd, 1884, that 
wide notice was first given to the subject in some of its more 
modern aspects. The report alluded to was made by a 
Special Commission appointed by The Lancet to inquire 
into the manner in which Polish Jew tailors lived and 
worked in the East-End of London. The conditions pre¬ 
vailing in this alien colony were graphically and closely 
described by our Commission, and it is not too much to 
say that the public conscience was so greatly aroused by 
the recital of the appalling state of affairs discovered in 
this poverty-stricken district that the Government was in¬ 
duced to appoint a House of Lords Commission to make a 
detailed and thorough inquiry into the circumstances of the 
situation. We are glad to remember that the result of this 
investigation was to confirm the statements of our Commis¬ 
sion in every important partionlar. The Lancet next sent a 
Special Commission to make investigations into the question 
of “sweated industries” in the provincial centres wherein 
such work was carried on. The commissioners visited Liver¬ 
pool, Manchester, Leeds, Birmingham, the Black Country, 
Edinburgh, and Glasgow and found the conditions were 
as bad in these towns as in the metropolis itself. Human 
beings were found to be existing and working amid surround¬ 
ings so insanitary as to be a menace to public health. Again 
the descriptions published in The Lancet aroused the 
Government to extend the scope of its inquiries and 
the House of Lords Commission traversed the ground 
covered by The Lancet representatives onoe more to 
confirm their findings. Thus it may be fairly claimed 
that The Lancet had much hand in the second great 
agitation against sweated industries which began more 
than 20 years ago and which lasted for several years. The 
main conclusion reached at that time was that home or 
outside work was productive of the greatest amount of 
suffering and was most inimical to the health of the workers 
themselves and to that of the community at large. For not 
only did the workers suffer but articles were made under 
suoh conditions as not infrequently to convey disease to the 
purchaser. Women and girl workers were the greatest victims 
of labour conducted in such circumstances. Another point 
clearly brought out by the House of Lords Commission was 
that clothes were the most common conveyers of infection. 
After sitting for 71 days and examining 291 witnesses the 
Special Committee appointed by the House of Lords in 
1890 gave tbe following verdict: “ These evils can hardly be 
exaggerated. The earnings of the lowest classes of workers 
are barely sufficient to sustain existence. The boors of 
labour are such as to make the lives of the workers periods of 
almost ceaseless toil, hard and often unhealthy. The 
sanitary conditions under which the work is conducted are 
not only injurions to the health of the persons employed, but 
are dangerous to the public, especially in the case of the 
trades concerned in making clothes, as infections diseases 
are spread by the sale of garments made in rooms inhabited 
by persons suffering from small-pox and other diseases.” 
The crnsade against sweated labonr in the ‘ 1 eighties ” was 
directed against that kind of work as a whole. I have for 
long been interested in the home-work of women only from 
the standpoint of health as regards the workers themselves 
rather than as regards the general public, and gladly avail 
myself of your invitation to give the results of visits to the 
homes of workers in certain distriots of London. These 
accounts may serve as a means ot comparison between the 
conditions described in The Lancet 20 years ago and those 
existing to day. 

In various parts of the country during the past six months 
exhibitions have been held at which women working at their 
underpaid trades have been present, serving as useful object- 
lessons to a public which is indifferent or hard to convince by 
any less obvious means than by the evidence of itB eyes, 
i attended a sweated industries exhibition which took place 
at the Bishopsgate Institute some two months ago, and then 
first witnessed exactly what was the work done by women 
home-workers in this country. I then understood better than 


ever before how badly paid were these tollers and how un¬ 
healthy a life of this kind must be under the conditions of 
abject poverty which too frequently prevail. Desiring to visit 
the homes of some of the great army of women home-workers 
in London and to judge for myself of the conditions that 
actually exist, I applied at the office of the Women’s 
Industrial Council, 7, John-street, Strand, where I was given 
a list of women home-workers in different districts of the 
metropolis. I have gone to the houses of these persons in 
the north, south, and east of London. 

The first district which I visited lay in that part 
of the East End of London where the evils of home¬ 
working amongst women in its most accentuated forms 
might be expected to occur. Amid the depressing 
and terribly Bqualid environment of this quarter I came 
across many instances of women toiling hard all day and 
oftt.imes far into the night, who were able to earn scarcely 
sufficient to keep body and soul together. The house which 
I first entered was one in that long street of mean dwellings 
known as the Old Ford-road. Tbe woman who lived here was 
a widow with four children and she worked at the laborious 
and badly paid trade of trouser-finishing. For this descrip¬ 
tion of work she was paid at the rate of 2». per dozen pairs, 
and was able to earn about lj(f. an hour ; thus working for a 
period of 13 hours dailyfor five days of the week her earnings 
amounted to 10*. She had to find her own machine and 
cotton. This woman hired two very small rooms at a weekly 
rent of 5*. It is needless to say that she found it impossible 
to support herself and four children upon such a wage and 
received parish relief to the amount of about 10*. Even with 
this aid she had to feed and clothe herself and four children 
on the sum of 15*. per week. The room in whioh she worked 
was small, untidy, and stuffy but not conspicuously dirty. 
A gas-stove was burning, a very common custom amongst 
home-workers, but one which does not make for purity of 
atmosphere. The woman looked pallid but fairly well and the 
children who came in from school whilst I was in the house 
appeared to be in excellent physical condition. Undoubtedly 
I chanced to light npon a very favourable specimen of a 
trouser-finisher, whose work is very badly paid and is both 
hard and monotonous. The next house to which I paid a 
visit was inhabited by an altogether different type of the 
home-worker, that of the woman who works to add to her 
husband's wages, and of these I met several in my journey- 
ings. In this particular instance the hnBband earned fair 
wages, as wages go, and their united earnings enabled them 
to live In comparative comfort. This person was paid 2d. 
a gross for matchboxes which she had made, and working 
on an average ten hours per day for five days of the 
week, was able to olaim a wage of about 7*. Here the 
family consisted of father, mother, and three children. In 
this house I was much impressed by the untidiness and 
dirtiness of the room which displayed an utter lack of 
housewifely care; but what margin of time is left for 
domestio amenities when working at such enormous 
stretches 1 In the same locality I interviewed a single 
woman who, together with her aged mother, occupied 
one small room. Tbe work in which they were engaged 
was that of sewing beads on shoes and for thiB form 
of labour, a great strain to the eyesight, the younger woman 
was able to earn from Id. to 1 id. per hour. In two days, 
with the assistance of her mother, she could earn 3*. The 
room in which they lived was ill ventilated and untidy. The 
condition of the room in the house whioh I visited next was 
disgusting ; it was filthy, hot, and stuffy and smelt offen¬ 
sively. Here the woman was married but her husband 
earned very small wages. She made blouses for which she 
was paid at the rate of 1*. per dozen. In one hour she conld 
make one blouse, and thus to earn 1*. sbe must work for 
12 hours. There were two or three children in the family 
but these I did not see, and was unable to observe if the 
probably insanitary state of the house had affected their 
health. 

I visited other houses in tbe neighbourhood and in the 
Bethnal Green district generally but I think the visits I 
have noted form fair examples of what I saw. Then I went 
to Woolwich, travelling through a neighbourhood in which 
the signs of depressed trade and poverty were most marked. 
The first names on my list were those of two old females who 
shared one small room in a dirty back street for wbicb a rent 
of 2*. 6d. weekly was charged. The younger of these women 
was 65 years of age and worked at home making army 
flannel shirts, for which she received pay at the rate of 
7 id. apiece. Ten of these were given oat to her in two 




192 The Lancet,] 


WOMEN HOME-WORKERS. 


[Jan. 18, 1908. 


weeks. Consequently, when able to procure work, she was 
given the opportunity of earning less than 8s. 6 d. per week. 
The other old lady, aged 75 years, had been refused outside 
work and was compelled to go to the factory to earn 
a pittance. These women received parish relief. I made 
many visits in Woolwich and Plumstead and obtained 
the following general impressions. Almost all these 
workers were abjectly poor and, with scarcely an excep¬ 
tion, lived and worked in a single room which, as 
a rule, appeared to me, at any rate, to be ill- 
ventilated and insanitary. Shirt-making and shirt-finishing 
were the trades which they followed. There was, how¬ 
ever, one case which is worthy of mention. On my list 
was the name of a woman who worked at covering tennis 
balls. When I questioned her I was surprised to hear that 
she was able to earn about 4 d. an hour. It may be said that 
at the present time trade is very bad in YVoolwich and 
in Plumstead, and I apprehend that in consequence of this 
far less home-work is given out than formerly. Indeed, I 
was informed that it is very difficult now to procure out 
work at all and owing to this distress is prevalent among 
home-workers and is likely to increase. 

The Old Kent-road, Peckham, Deptford, and Haggerston 
were the districts which I next visited. I found con¬ 
ditions there very similar. The majority of the women 
were married, had families, and worked because their 
husbands were either out of work or earned paltry wages. 
Some of these made a fair living. One was able to make 
4<f. an hour by sewing buttons on shirts and another earned 
about 3(7. an hour by making up men’s ties. The children 
whom I saw looked as healthy as slum children generally look. 
The other women whom I interrogated were unmarried or 
widows and were all existing in a state of the direst poverty, 
not one getting on an average more than 4«. per week and 
some even leBs. The rooms which they inhabited and their 
manner of living in respect of dirtiness and untidiness only 
differed in degree; the struggle for life was so keen with 
all of them that not a moment could be spared for mere 
cleaning. 

In one of these districts I met with a really conspicuous 
example of home-work being carried on under conditions 
which might be a menace to the public health. The worker 
in question placed the bristles in tooth-brushes. She 
was married, had borne many children, some of whom 
were in institutions, while the two youngest were at 
home. Her husband, who was suffering from pulmonary 
tuberculosis in a fairly advanced stage, was also at home. 
The home consisted of one small room in which lived during 
the night and for the greater part of the day the woman, 
her consumptive husband, and two young children. From 
Haggerston I went on to Hoxton, Hackney-road, Poplar, 
and Pentonville, returning to the Holborn district, and 
discovered the same state of squalid poverty and insanitary 
environment everywhere. 

This completed my short tour of investigation, which had 
led me to the homes of workers at trouser-finishing, match¬ 
box-making, bead-sewing, blouse-making, basket making, 
box-making, shirt-making and shirt-finishing, button-sewing, 
tennis-ball covering, and tooth-brush drawing. I saw sufficient 
of the condition under which the great mass of these 
workers lived to convince myself that it was unhealthy in a 
high degree. Readers of The Lancet may think it a little 
unnecessary to tell them so probable—nay, so obvious—a 
thing, but year by year goes by and our improvement in these 
matters is so slow that repetition of the well-known does no 
harm. In fact, it is the only way to keep the necessity 
for reform prominently before us. A speaker at the 
conference of women workers held in Manchester during 
last summer made the statement that in London alone 
there were between 300,000 and 400,000 people who lived 
in one-room tenements. According to Census report, 
1900, the proportion of one-roomed tenements per 1000 
population in London was 147. Of the persons whom 
I interviewed nearly two-thirds lived in one room, 
most of these being married women having children, 
while the husbands were either out of work or 
were paid too low wages to be able to support their 
families. Some of these employments are, from the nature 
of the work, if not actually unhealthy, very laborious. 
Trouser-finishing often means, for example, manipulating a 
sewing machine for from 10 to 12 hours daily. Then the work 
is not only hard but it is very irregular. There are times when 
work is very scarce, and I was told that in some of the trades 
for about half the year no outside employment can be 


obtained. From all these circumstances it will be clear 
that in the majority of instances home-work is detri¬ 
mental to the health of the worker herBelf. Long hours 
of confinement in the stuffy atmosphere of a room where 
cooking and sleeping also take place ; Bcanty wages allowing 
no proper food to refresh the tired body ; the torture of 
uncertain pay—these things weigh very hard on the luckless 
home-worker. I had heard it all often enough, but now I 
have seen it and I know it. 

As regards the offspring it is not so easy to say that the 
employment of their mothers in this way is especially inimical 
to their chances when it is remembered that in the absence 
of a father who can support the family, the mother must 
work abroad if she does not work at home. If the mother 
works in a factory she must leave her infant or young 
children at a creche or with a neighbour to be cared for 
during her absence. If she leaves them at a crfcche they will 
probably receive better attention than if she were at home, 
but if she places them in the charge of a neighbour the 
likelihood is that they will fare worse. But the regular 
factory worker earns a larger and more constant wage, 
as a rule, than the home-worker and therefore can buy 
more for her young children. I think that home-work, on 
the whole, has a more favourable infiaence upon infant 
mortality than factory work ; but the mothers who stay at 
home are largely in the majority, and the conditions of 
life induced by home-work are unhealthy, so that the high 
infant mortality that prevails in the poor districts of 
industrial towns can be associated with the life led by the 
home-working mother. If she went to a factory perhaps the 
state of the children might be worse—that is the one consoling 
thought. As for children over the age of five years, it 
probably makes little difference to their well-being whether 
their mothers gain their living at home or in the factory. 
In both cases they are usually neglected, and it is chiefly 
a question of how much the woman earns or is willing to 
spend for food and clothing that affects their physical 
welfare. Judging from my own observations, I should 
be inclined to say that while, of course, the product 
of the slumB is indebted for some of his poor physique to 
the state of poverty and to the insanitary conditions in 
which he is raised, home-work as a factor is secondary to 
some other causes. 

How greatly home-work is dangerous to the public 
health is another question which cannot be answered 
offhand. That under certain conditions infection may be 
spread by this means would seem to be clearly apparent. 
Clothes handled and left lying about in a small room 
in which measles, scarlet fever, or any other infectious 
disease was present might easily convey the disease to 
individuals outside. There would, I imagine, be little 
dissent from the view that home-work on clothes in some 
degree is a source of danger to the community. The only 
case I witnessed which could be said to be a menace to the 
public was that of the tooth-brush maker with the con¬ 
sumptive husband. On the other hand, I entered several 
rooms in which clothes were being handled and which I 
could understand might easily be the means of spreading 
infection. 

Miss Margaret Irwin in her report to the Scottish Council 
for Women’s Trades published some three months ago says : 
First, that home-work in Glasgow is frequently done under 
very insanitary conditions and that there is a great risk of 
the garments made becoming a medium for the dissemina¬ 
tion of dirt, disease, and vermin ; secondly, that home-work 
lends itself to long and irregular hours, and in some 
instances to the employment of juvenile labour, which is 
detrimental to health and tends to reduce wages. I saw 
little evidence of the employment of juvenile labour in 
London. I inquired as to this point in the houses in which 
children were and was assured that they gave no assistance. 
In one house I found a child of about 12 years aiding the 
mother, and it is possible that the Btate of affairs in this 
regard is in some ways similar in London to that described 
by Miss Irwin as occurring in Glasgow. 

The influence that home-work exerts on the public 
health must depend largely on the numbers engaged 
in it. Statistics bearing on the matter are very indefinite. 
The last Census returns show that the total number of 
persons returned as working at home in all industries to 
which the Faotory Act applies, excepting laundries, was 
447,480. During the examination of a skilled witness by the 
Select Committee of the House of Commons in June last it 
was brought out that the number returned by the local 





The Lancet,] 


THE ORGANISATION OF THE PROFESSION. 


[Jan. 18, 1908. 193 


authorities for England and Wales was only 50,000, and 
although the Home Office return only applies to the classes 
of industry which have been specified by the Secretary of 
State it is said to include all the chief home-work trades. 
The discrepancy of about 400,000 in the Census returns and 
those of the local authorities supplies convincing evidence 
that accurate information is lacking as to the number of 
English home-workers. Until trustworthy statistics are forth¬ 
coming in regard to this essential point it is obvious that it 
will be impossible to make any definite statements in respect 
to the part that home-work plays in the production of, and in 
the spread of, disease. I have little doubt that home¬ 
workers are far more numerous than is stated by the local 
authorities. 


THE ORGANISATION OF THE PRO¬ 
FESSION. 

(From our Special Commissioner.) 


The Bradford Practitioners were Organised Forty 
Years Ago.—Rents and Medical Fees.—The 

Clubs.—The Notification of Births Act.—United 
Action of the Profession against the Town 
Council.—Complete Success of the Movement. 

Bradford, Dec. let, 1907. 

Undoubtedly there is a hopeful tone prevailing in the 
ranks of the medical profession at Bradford. The tendency 
to complain, to say “ We ought to do this or that,” so 
often to be noted in different parte of the country, 
is not manifest at Bradford. “We have done this, 
and we have also done that, and we are now pre¬ 
paring for another effort,” is more the general style 
of the conversations likely to arise. It 1 b not a question that 
the profession ought to organise but if there is any differ¬ 
ence of opinion it is rather as to the historical origin of the 
organisation which actually exists. As for the battle of the 
clubs, why that was fought 30 or 40 years ago, though this 
will not prevent the necessity of having to fight it all over 
again. It was, I am assured, so far back as 1866 that a 
manifesto or declaration was drawn up and signed by a 
number of Bradford practitioners fixing the minimum fee 
for midwifery cases at 15*., to be paid within a month, 
or 1 guinea if paid later. Out of this arose the pro¬ 
posal to form a society of medical men which was called 
the Bradford Medico-Ethical Society. When once consti- 
tnted this society proceeded to make an assessment of all 
the houses in Bradford and fixed the minimum fee which the 
inhabitants should pay. This tariff has been modified from 
time to time and at present the following is the general 
principle. The minimum fee where the house rent is not 
above £25 per annum is 2 1 . 6 d. to 3s. 6 i. Above this rent 
and np to £50 the fee is from 3i. to St. Above this and 
np to £75 rent the fee is from 5s. to 7s. 6 d. The lowest 
charge for servants is Is. 6 d. and the highest 3s. 6 d., unless 
paid by the employer. Half a fee is charged for an addi¬ 
tional patient when seen in the same house. Midwifery fees 
were fixed at 15s. if the rent of the patient's house was under 
£ 10 . 

While a general understanding has thus been established 
as to medical fees the position in regard to contract work has 
still to be improved. So far back as the year 1870 it was 
declared that no club medical officer should accept less than 
4s. a year from each subscriber on his book. Several 
societies or clubs had reserves of money and were able to 
meet this demand without increasing the subscriptions paid 
by their members; others, on the contrary, had to make an 
augmentation. A considerable number of clubs, however, 
would not consent to pay even so small a sum as 4s. a year. 
They preferred to form a federation of friendly societies 
and to import a medical officer whom they retain in their 
service. This continues to this day though it is now reported 
to be working badly and it is said that a ceitain number of 
members of friendly societies only consult their medical officer 
for minor complaints. On the other hand, the medical practi¬ 
tioners of Bradford have completely failed in every attempt 
made to prevent the abuse of friendly societies. The more con¬ 
scientious of the well-to-do members of these bodies do pay 
their medical attendants ; but, as this is quite optional, many 
-do not scruple to avail themselves of medical aid at club 
rates. Yet at the hospitals something has been done to prevent 
abuse. A wage-limit is imposed and it is now proposed to 


appoint a scrutineer to make inquiries with the aid of the 
Charity Organisation Society so as to see that the wage-limit 
is observed. 

The work of organising the members of the profession was 
not always carried forward in a harmonious manner. There 
have been quarrels and dissensions. Indeed, at one time 
there was a regular split and a rival society was formed 
which was called the West Riding Medical Union. After 
differing for two years or more the parent body and the 
seceding body came together again and amalgamated. 
They then adopted the title of the Bradford and West Riding 
Medico-Ethical Union. It may be taken that the word union 
instead of society implies a desire for a strictly disciplined 
and energetic action in regard more especially to matters 
atfecting the economic interests of the profession. When 
the British Medical Association adopted its new con¬ 
stitution the question of absorption with the newly 
created Bradford division of the British Medical Asso¬ 
ciation arose. The proposal to merge the old organisa¬ 
tion with the new was not readily accepted. Some 
time elapsed before it was brought about but to-day the 
old Medico-Ethical Sooiety and Union are merged in 
the Bradford division of the British Medical Association. 
This division connts 153 members. At the committee meet¬ 
ings some six or seven members attend and at the general 
meetings perhaps there may not be more than 20 members 
present and yet it is considered to be one of the most active 
divisions. The majority of the members often do not know 
what has been going on ; nevertheless the division claims 
that it has done more economic work than was ever achieved 
in the past. Further, it maintains that it has dealt 
with questions which affect the whole country, while pre¬ 
viously the matters dealt with were mofe purely local. 
For instance, the division was very active when the 
Notification of Births Bill was before Parliament. It 
wrote and explained matters and appealed to 14 local 
members of Parliament and only one of these 14 voted in 
a manner that was opposed to the desires of the medical 
profession. The medical men at Bradford, or at least a con¬ 
siderable number among them, desired to be put on the same 
footing as other attendants on a woman who has given birth 
to a child. As a matter of fact, it is precisely those cssea 
where there is no medical attendant at all that generally 
stand in most need of notification followed by intervention 
on the part of the sanitary authority. On the other hand, 
there are cases, notably of illegitimate births, where the 
medical attendant would be committing a breach of 
confidence if he sect a notification. In spite of these 
and other objections made by some of the Bradford 
practitioners, it is almost certain that the health com¬ 
mittee of the Bradford council will vote in favour of 
applying the Act. As opposition would be useless none will 
be offered by the medical practitioners but efforts will be 
made to modify the methods of application. At Gateshead 
it has been agreed not to adopt the Act but to apply 
it voluntarily. It is thought that in notifying a birth the 
medical attendant should beable to state that there was no need 
of interference on the part of the sanitary authorities, as is 
actually the case in regard to infectious fever when the 
patient can be adequately isolated in bis own home. In a 
well-regulated home with a medical attendant in charge it 
is not necessary for a sanitary inspector to go round and 
give advice. 8uch interference, though useful in some cases, 
would be very much resented in others, and the practitioners 
at Bradford are anxious to devise means so that such 
unpleasantness shall not arise. 

Undoubtedly, however, the most important struggle in 
which the organised members of the profession have been 
engaged recently relates to the police surgeons. When the 
late chief police surgeon died the watch committee of the 
Bradford town council thought that it would establish a new 
regime. It proposed to employ a larger number of medical 
men but at a smaller scale of remuneration. There was to be 
one central police Burgeon living near the town hail who was 
to attend to all cases in the centre of the town and to receive 
£120 a year and court fees. Then there were to be three 
divisional surgeons at a salary of £50 each who were to 
attend to the police of their district and any accidents and 
in fact to be at the beck and call of the police. The small 
outside rural districts or villages were to be parcelled out 
between four subdivisional surgeons. These latter were to 
be paid for medical attendance at the rate of 10s. per 
annum for every policeman in the force in their district and 
no allowance was made for any other services which they 




194 The Lancet,] 


SOME ASPECTS OF MEDICINE IN CHINA. 


[JAN. 18, 1908, 


might he called upon to render, such a?, for instance, in 
cases of crime with violence or accidents. The objection to 
all these arrangements was that it consisted in a contract 
giving a limited or fixed pa? for an unknown and an 
unlimited amount of work. 

When it was known that these innovations were to be 
introduced the Bradford division of the British Medical 
Association was at once convoked. Several meetings were 
held in rapid succession. Then the situation was complicated 
by the fact that many medical men had already sent in 
applications for the new posts which were to be created. 
Indeed, a date had been fixed and it was said that applica¬ 
tions sent after that date would not be entertained. This 
had the effect of precipitating matters and brought the 
dispute rapidly to a crisis. It was discovered that no less 
than 50 applications had been made. The diviiion sent a 
deputation to the watch committee. The latter body offered, 
in response to the prot sts made by the deputation, to 
effect some insignificant concessions : these related for the 
most part to regulations in regard to the keeping of 
the books and such business details. Now and at the 
very last moment it became obvious that no compromise 
could be effected ; therefore, only the most energetic 
action could save the situation. All the 50 applicants had 
to be communicated with in the space of a few hours. In 
that brief time they had to be persuaded, as a matter of 
loyalty to their profession, to send at once to the watch 
committee and to withdraw their applications for the post of 
police surgeon. To the great honour of the Bradford medical 
profession it can be recorded that not one failed. The 
word of oommand was obeyed with unhesitating discipline. 
Every application was withdrawn. When the time came 
for the watch committee of the Bradford town council to 
carry out the new scheme and to appoint the police surgeons 
it was utterly uuable to do anything of the sort because it 
had cot a single candidate applying for the posts. The 
members of the medical profession in this instanoe bad most 
effectively shown what could be done by united action. 

The watch committee was forthwith obliged to modify its 
views and to accept the proposals of the medical profession. 
It certainly reduced the retaining fee to be paid to the 
three divisional surgeons from £50 to £45 each. For this the 
surgeons have to attend to the police in their district and to 
give them the ordinary medical certificates that may be 
needed. This, however, never constituted any difficulty ; the 
dispute related to the undefined amount cf Irregular work. 
Now this is clearly defined and will be paid for, and well paid. 
If a policeman calls for the assistance of a police surgeon at 
night the fee will be 10s. and in the daytime 5*. This 
applies to accidents or when the surgeon has to go to the 
police cells and so forth. Then, again, and this is of great 
practical importance, night has been advantageously defined. 
Night is to mean from 9 o’clock in the evening to 9 o'clock 
in the morning. Thus eight in the morning is to count as 
night, and therefore the police surgeon may rely upon it that 
if his rest is disturbed he will get the larger fee. But for 
some such financial check the surgeons would have been at 
the beck and call of every policeman. The four subdivisional 
surgeons are alto to get these fees besides the 10 j. per 
annum for every policeman in the force. 

Many other smaller matters have arisen in which united 
action was required and at Bradford the profession have 
stood well together. Nevertheless, in the various contests 
that have taken place both here and in different parts of the 
country the dispute over the Bradford police appointments 
is certainly one of the most noteworthy. What iB so striking 
is the fact that 50 medical men were persuaded, in the 
course of a few hours, to withdraw applications for posts 
which they all desired to obtain. Such self-sacrificing 
unanimity is really remarkable and reflects the highest credit 
on the Bradford members of the medical profession. 


Great Northern Central Hospital.— The 
attendance at the course of lectures which have recently 
been given at this hospital has fully justified the action of 
the medical staff in their attempt to utilise the clinical 
material at their disposal for teaching purposes. It is pro¬ 
posed to continue the series of lectures and demonstrations 
during the remainder of the winter months and it is hoped 
that it will be possible to arrange them more on the lines of 
actual clinical lectures than of set addresses. The time of 
the lectures has been altered from 3 o'clock to 3.30 P.M. in 
order to meet the wishes of those who attend these 
demonstra' ions. 


SOME ASPECTS OF MEDICINE IN 
CHINA. 

(From our own Correspondent.) 

Medicine and Surgery in General. 

China has of late years seen a steady growth in the demand 
for medical education. Not only in the treaty ports but 
inland have European hospitals and dispensaries been opened 
up, and the difference between scientific treatment and the 
rank charlatanism which prevails is so evident that the 
people are beginning to see that there is something radically 
wrong in the whole native system and that there is much to 
be gained by a closer acquaintance with foreign methods of 
rational treatment. So far as surgery is concerned there 
can be no comparison between the two ; Chinese “ doctors ” 
do not profess to be surgeons, and hitherto the knife of the 
nearest butcher has been the sword which has severed the 
Gordian knot in such caseB as in shaving off large tumours 
where the patients have reached the stage of being unable 
to endure their trouble any longer. Acupuncture, the 
drawing of teeth, cauterising, and the opening of abscesses 
are the surgical limits of Chinese practitioners. But 
in the domain of the practice of physic there is much 
to be said in China's favour. The experience of long 
ages of empiricism, coupled with patient observation, 
has made the Chinese physician capable of treating his 
clients better than would at first be imagined ; and though 
his methods may seem quaint he often uses remedies which 
are undoubtedly attended with benefit. Chinese medical 
practice is mainly homoeopathic, there being a large number 
of drugs in the pharmacopoeia, many of them useless, some of 
foreign origin ; and in the hope that it will prove acceptable 
to the readers of The Lancet I propose to draw especial 
attention from time to time to some of the remedies at present 
in use, in addition to sending the notes of foreign-treated 
cases. Before dealing with the manner in which the demand 
for medical education is being supplied it would be well to 
give a brief relume of Chinese medical knowledge at the 
present day. 

Anatomy and Phytiolaoy. 

As it is illegal to practise human dissection anatomy 
and physiology are fairly primitive sciences. There is 
no distinction between arterial and venous blood, nor 
between muscles and nerves. They recognise that blood 
runs in the vessels, and that there is a perpetual motion of 
circulation about 50 rounds every 24 hours. It has 
been claimed that the circulation of the blood has 
been known to Chinese physicians for 2000 years, but 
they have no idea of the physiology of circulation. 
The brain is a mysterious organ which communicates 
through the spine with the whole body, the spinal 
canal being a receptacle for marrow. The larynx goes 
through the lungs directly to the heart and the pharynx 
passes over it to the Btomacb, which is the seat of learning. 
The heart is the principal organ of the whole body, and 
there are three tubes which pass out of it going directly to 
the liver, spleen, and kidneys. The lungs are suspended 
from the spine. The liver has seven lobes and is the seat of 
the soul. The gall-bladder is the seat of passion : when it 
rises up and pushes into the liver the pereon becomes angry. 
The spleen assists digestion and lies between the stomach 
and the diaphragm. The pancreas is unknown. The small 
intestines communicate with the heart and urine passes 
from them into the bladder. The kidneys secrete the 
seminal fluid which passes from them to the testes, which are 
known by the name of the "outside kidneys ” Food ie 
separated from the urine at the caecum, from where it goes 
on through the large intestine. 

Osteology , Materia Medica, and Chemistry. 

Osteology is in a better state. All the bones are known 
and identified but the ligaments and joints are not taken 
much into account, and to Chinese would allow a native 
practitioner to reduce a dislocation if there were any foreign 
medical man available. Many works, some of great length, 
have been published on materia medica and plants. Though 
laborious, they are unscientific and are not studied by native 
• > doctors ” to any extent. Chemistry is little known—nearly 
all the chemical productions are u6ed in medicine, the best 
known being calomel, carbonates of sodium and potassium, 
saltpetre, alum, and the sulphates of iron and copper. Such, 
in brief, is the state of medical knowledge in China at the 
present day. 




The Lancet,] 


SOME ASPECTS OF MEDICINE IN CHINA.—MANCHESTER. 


[Jan. 18, 1908. 195 


The Teaching of Wettem Medicine. 

It will thus be seen that there is plenty of room for im¬ 
provement and a promising sign for the future is that so 
many Chinese youths are eager to take up scientific study 
and to go through a regular course falling not far short of 
the standard prescribed at home. There are three main diffi¬ 
culties which have yet to be overcome and none of them are 
insurmountable. First, the language question ; a foreigner 
caD, by steady application for two or three years, sufficiently 
master the colloquial to be able to teach in it and, 
with the aid of a dictionary, to translate Chinese into 
English; but it is an infinitely more difficult thing 
to translate English or any other European language 
into Chinese. There are about 48,000 words and only 
400 sounds to express these. It would be out of place here 
to explain how, to a certain extent, by means of different 
tones, prefixes, contexts, &c., this difficulty can be met. 
The fact remains that the introduction of scientific terms is 
a question which has been by no means satisfactorily settled 
yet in a language which has no alphabet and where each 
sound represents so many different words. In Shanghai a 
committee of medical missionaries has for some time past 
been at work on a system of medical nomenclature, invent¬ 
ing and adapting characters which are proving of great 
assistance to medical teachers and which will suffice, for the 
present at any rate, till Chinese medical men themselves are 
able to take the matter in hand. The second difficulty is 
that human dissection is not yet allowed ; it is sanctioned in 
Japan and it may be hoped that a few years hence will see the 
ban r< moved in China. Thirdly, with regard to the question 
of standardising examinations, it is at present unsatisfactory 
to think that any medical school can undertake to grant 
diplomas and degrees simply on a standard which it has 
itself set up. Sooner or later abuses will crop up. Some 
have already done so and it is highly necessary that the fair 
fame of foreign medical science should not be tarnished 
by graduates who have slipped through a course too easy 
to qualify them properly for practice as “ foreign-trained 
* doctors.'" 

Effort!for Progras. 

About a year ago the Imperial Government made the first 
step in this direction in sanctioning the despatch of offioial 
examiners from the Board of Education to hold examinations 
in the recently opened Union Medical College at Peking at 
the conclusion of each course “ for the issue of diplomas to 
such candidates as attain the prescribed standard certifying 
that they are entitled to practise medicine. ” This despatch 
concluded with a paragraph stating that “no other scholastic 
establishment whatsoever shall be permitted to bring forward 
this special privilege as a precedent.” The Union Medical 
College is an important step forward in the cause of medical 
education in China but it is useless to think that one school 
alone can adequately meet the demands of this vast empire. 
The competence of the official examiners to know if the 
students have reached the necessary standard is a douotful 
point; the important feature, however, is that official sanc¬ 
tion has been granted. Efforts are being made to get the 
Board of Education to elect a central examination board 
which would fix a common standard necessary for the pupils 
of any school to pass before they could be licensed to practise 
as “foreign-trained doctors.” Within the past few months 
the authorities of the Peking Imperial University, where inter¬ 
national law and arts are taught, have decided to enlarge 
their scope and to institute a medical department. Several 
Chinese medical men trained abroad have been appointed 
as teachers, and inducements, such as free food and tuition, 
have been held out to intending students but so far no 
actual work has been begun. There are at present two 
medical colleges at Tientsin, one of which is managed by 
an American-trained Chinese and instruction is given by 
Japanese medical men who teach through Chinese inter- 
peters. The other is in French hands and both colleges 
turn out medical men who are mostly employed in the 
navy and army. Their courses last three years but in the 
case of one college it is proposed to change this to five years. 
The example of Japan has aroused a spirit of emulation and 
the Chinese are not at all unwilling to invoke foreign aid to 
put them on the right path, which having reached they hope 
to follow successfully by themselves. At present Japan offers 
Bplendid educational facilities and has attracted large 
numbers of Chinese students, there being over 10,000 of them 
in Tokio alone ; but they have to study in Japanese and many 
of them return imbued with restless political ideas, which 


has not been unnoticed by Chinese statesmen, and it is to 
help to counteract this that China is endeavouring to meet the 
demand for education at home. The absence of all sickness 
and mortality rates makes it difficult to get any definite idea 
of the damage wrought by unchecked disease but if these 
rates can be judged by hospital practice they must be very 
high. Tuberculosis ravages the land, epidemics frequently 
break out, dysentery and diarrhoea are very common, as are 
also various infective conditions, such as boils and carbuncles, 
scabies, and the like. Intestinal parasites, to be enumerated 
later, infest the vast majority of Chinese, and among the 
widely Bpread class of opium-smokers a host of evils, the 
effect of dyspepsia, anaemia, habitual constipation, and ema¬ 
ciation, require to be dealt with. From all that can be 
gathered opium-smoking is on the decrease as a habit; the 
State is steadily making indulgence in opium more difficult. 
One great asset in China’s favour is the absence of alcoholism 
as a vice. Among the poorer classes intoxication is almost 
unknown. 


MANCHESTER. 

(From our own Correspondent.) 


The Manchettcr Infirmary. 

When the decision to remove the Manchester Infirmary 
from the Piccadilly site had, after years of discussion, been 
definitely determined on, the question of a central receiving 
ward at once obtained prominence. Some objected alto- 
getber to the removal, partly no doubt because they did 
not think it necessary, and partly because the infirmary had 
been so long on its present site and was associated with 
old names and old traditions. Thus a halo of sentiment— 
a difficult idea for many people to include in their con¬ 
ception of Manchester—had gradually been evolved, and it 
seemed something like sacrilege lor Piccadilly to know 
the respectable old building “black, though comely, no 
more. Those who held these views, whether influenced by 
sentiment or utilitarianism, wished to have a completely 
equipped but comparatively small hospital in a central 
position, preferably on the old site. Others, agreeing to the 
need of some provision for out-patients and the temporary or 
“first-aid” treatment of accidents or emergency cases that 
could not be at once removed to the new infirmary, con¬ 
sidered that it would not be necessary to have beds in the 
receiving house. In course of time the latter view became 
most prevalent. There was, however, Borne difficulty as to 
the site. By a resolution of the trustees passed in December, 
1904, it was to be within a certain area, but though the com¬ 
mittee of the board had the option of the purchase of 
certain plots of land none of them were within the 
area marked out by the resolution. Moreover, the unanimous 
opinion of the medical board had been expressed that it 
was inadvisable to incur a large outlay for the permanent 
establishment of a central branch before the public require¬ 
ments had been tested by experience after the opening of 
the new infirmary. The committee therefore communicated 
with the Lord Mayor of Manchester and the infirmary site 
committee of the corporation asking them to allow the 
infirmary to continue the occupation of the present out¬ 
patient department and dispensary as a central branch for 
such a time after the occupation of the new infirmary as 
would enable the best way of giving effect to the wishes of 
the trustees to be ascertained. At the last meeting of the 
board it was reported that the infirmary site committee 
of the corporation had most courteously acceded to this 
request and had made an arrangement subject to con- 
confirmation by the board for the occupation by the infirmary 
of the existing out-patient department and dispensary for 12 
months after the occupation of the new infirmary and there- 
after, subject to six months’ notice, at the nominal rent of a 
guinea a year. Mr. Oobbett, the chairman, proposed and 
it was carried unanimously, that the arrangement should be 
confirmed. Mr. Cobbett said again that the infirmary site 
committee had met them in a most courteous and handsome 
manner. In reply to a question the secretary estimated the 
upkeep of the central branch at about £2190. 
committee reported the receipt of a legacy of £6000 from 
the executors of the late Mr. H. Lewis Sal tarn of Southamp¬ 
ton. A donation of £25 from the directors of the Manchester 
Royal Exchange had a somewhat curious history, being the 
proceeds of the sale by tender of a bale of cotton pressed at 
Memphis by President Roosevelt, sent to Manchester entirely 


196 The Lancet,] 


MANCHESTER.—LIVERPOOL. 


[Jan. 18, 1908. 


by water free of charge, presented by the Merchant and 
Farmer Cotton Company of Memphis to the directors of the 
Royal Exchange, and by them sold for the benefit of the 
Manchester Infirmary. 

Manchester Epileptics. 

The desirability, or rather the need, for special provision 
of suitable schools and teaching for epileptics instead of the 
ordinary elementary schools has long been felt in Manchester 
and the education committee is appealing to the city 
council for the purchase of 20 acres of land at Warford, in 
Cheshire, for the purpose of a residential school for epileptic 
children. 

Supplying a Want. 

Gorton is a suburb of Manchester with a working-class 
population of 35,000 and with many large engineering and 
other works, but until now has not possessed a horse accident 
ambulance. On Jan. 5th this want was supplied by the 
presentation to the district council of a horse ambulance of 
the best construction at a cost of £135, raised by means of 
public subscription, a good instance of self-help. 

Compulsory Fireguards. 

Perhaps there may be a danger in recurring so often to the 
loss of life from burning in infants and children of pro¬ 
ducing weariness of the subject. But this painful death 
from fire is as prevalent as ever and cannot he put 
aside as of no consequence. Only so recently as Jan. 8th 
the Manchester coroner held the ninth burning case 
inquest within the week and said that he did not know 
“how it was going to be stopped. 1 ’ The same cry comes 
from other quarters. A Denbighshire coroner in holding an 
inquiry last week as to the death of a boy fire years old 
from his night-dress taking fire said, “ it was again that 
fatal flannelette.” For, in spite of Mr. W. Thomson’s 
experiments, it seems as inflammable as ever in the cottages 
of the poor, much more so than in the chemical laboratory. 
These two dangers—no fireguards and flannelette—stand out 
clearly as the principal causes of child mortality by burning. 
In the Welsh case both the coroner, Mr. H. Kenrick, and 
Dr. Rees, who gave evidence, condemned the use of 
flannelette most strongly. And yet it is well known 
that it can be rendered comparatively safe, as in 
that called “non-flam.” The necessary process might 
well be made compulsory. It is so cheap and warm 
that the poor will use it more and more, therefore the 
plea for its use being made safe is surely strong enough. 
In the last Manchester case, as the foreman of the 
jury said, it was the old story of flannelette and no fire¬ 
guard, and to the verdict of “ Accidental death” the jury 
added a rider that “the provision of fireguards should be 
compulsory,” and the wearing by children of “ inflammable 
flannelette material ” should be prohibited. The loss of life 
and the suffering and perhaps crippling of the many who 
survive seem to justify the rider added by the jury. 

Sunless Manchester. 

A little more than a week ago Dr. John Brown of Bacnp 
made a strong appeal in the local papers for more sunshine. 
In a return given by the Manchester Guardian it was stated, 
he said, that Manchester was the place of least sunshine 
in the summer months, the mean being less than three 
and three quarter hours per day. In Manchester there were 
340 compared with 533 hours in Blackpool. Through 
the thick screen of smoke and other solid matter which 
hangs over the city, the sun’s rays in winter often fail to 
penetrate. These foggy dark days are too costly to be 
endured patiently. It is difficult to estimate the amount of 
sickness and death caused by them and quite impossible to 
learn the loss to shopkeepers, manufacturers, and others by 
the damage done to goods and materials of fine texture and 
light colour ; bnt a draper dealing chiefly in men’s goods con¬ 
sidered the damage to his stock by one day's black fog to be 
£20, and his did not seem a very large business. Dr. Brown 
advocates a great extension in the use of gas for power and 
for domestic cooking and heating. Lancashire and Cheshire 
are getting blacker and blacker and it is quite time (o 
demand greater cleanliness of the air. 

Lancashire Field Hospitals. 

Colonel W. Coates, the indefatigable commander of the 
Manchester Companies of the Royal Army Medical Corps, 
addressed the men on the occasion of the prize-giving on 
Saturday night last. He dealt with the merging of the 
corps Into the Territorial Force, and showed that the condi¬ 
tions were more elastic under the new than the old scheme. 


“ The corps will be divided into a nursing section, a general 
duty section, a cooking section, and a clerical section. The 
cooking, clerking, and nursing sections will only be required 
to go to camp once in three years. The general duty 
men will be expected to go to camp three times out 
of four. If a man cannot go to camp he will be 
called on for eight days’ training in a military hos¬ 
pital or school of instruction.” Colonel Coates explained 
that the medical organisation for the East Lancashire 
Division was three field ambulances and a general hospital 
of 500 beds. 100 clever men specially trained in sanita¬ 
tion will also be needed. He said that in the Manchester 
corps there were officers and men enough to meet these 
special requirements, but there are to be three centres where 
there are bearing companies—Bolton, Burnley, and Bury— 
which will form one field ambulance, and the Manchester 
corps which will form the other two field ambulances. The 
sanitary detachment will also be formed in Manchester. 
The general hospital of 500 beds will only exist on mobilisa¬ 
tion and will consist of tents or huts. If the Eastern Force 
were mobilised it would probably be at Heaton Park. The 
medical staff has been arranged for. Practically all the 
physicians and surgeons at the Royal Infirmary and the 
Salford and Ancoats Hospitals have expressed their willing¬ 
ness to serve if the occasion should arise, and it is probable 
that Professor G. A. Wright will be appointed colonel in 
charge of the hospital administration. Probably also the 
Manchester Companies will be asked to furnish a special 
contingent for service abroad in war time. These men will 
be paid a retaining fee. All this foreshadows a good deal of 
work and also readiness for work but Manchester will not 
fall short of patriotic endeavour. 

Jan.14th, _ 


LIVERPOOL. 

(From our own Correspondent.) 


The Maintenance of Lunatics: Liverpool’s Contribution. 

The representatives of the Liverpool city council on the 
Lancashire asylums board have issued a report on the work 
and finances of the board. The board consists of 89 members, 
38 representing the county and 51 the county boroughs, 
Southport being the only county borough which has not 
joined the board. At the present time there are five asylums 
under the control of the board—Lancaster, Prestwich, 
Rainhill, Whittingham, and Winwick. The following 
statistics throw some light on the amount of work carried on 
by these institutions and the degree of success attending 
their efforts:— 


- 

Males. 

Females. 

1 

Total. 

In the asylums on Jan. 1st, 1906. 

5,079 

5.749 

10,828 

Total cases admitted during year ... 

972 

1,126 

2,098 

Total cases under care during year ... 

6,051 | 

6,875 

12,926 

Cases discharged. 



Recovered . 

Relieved ... 

Not improved . 

Died . 

Total cases discharged and died \ 

252 | 

81 

17 

500 

850 

412 

91 

31 

488 

1,022 

664 

172 

48 

988 

1,87£ 

during the year . S 

Remaining in asylums on Dec. 31st, i 
1906 .< 

5,201 

5,853 

11,054 


Taking as a basis the total number of cases under care during 
the year the number of deaths amounted to about 77 per 
1000, while the number of patients who have re¬ 
covered or been relieved works out at about 65 
per 1000. But, so far as recoveries are concerned, 
it should be pointed out that a large number of the 
cases were chronic and the patients had been inmates 
of the asylums for some considerable time, it being most 
improbable that the majority of them will ever be discharged 
as recovered. The percentage of 6'5 would therefore be 
materially increased if the number of curable cases were 
taken as the basis, and it should be observed that the per¬ 
centage of recoveries on admissions during the year works 
out at 31 ■ 65, and it will be seen that there were 226 more 
cases in the asylums at the end of 1906 than there were at 







The Lancet,] 


LIVERPOOL.—WALE8 AND WESTERN COUNTIES NOTES. 


[Jan. 18, 1908. 1S7 


the beginning. The board has purchased a piece of land 
at Whalley, near Clitheroe, on which another asylum is being 
erected. It costs from £400,000 to £500.000 to complete an 
asylum to accommodate Z000 patients, which generally occu¬ 
pies a period of five years in erection, and it is found in prac¬ 
tice that there appears to be a demand for another asylum 
at the end of every five years. The maintenance of the 
lunatics of the county involved an annual expenditure of 
about £260,000. The corporation of Liverpool paid £5261 
for the maintenance, &c., of vagrant luDatics, not 
chargeable to the Poor-rate, in 1906. About 2700 cases, 
or over one-fifth of the total number of 12,926 cases, have 
been sent from Liverpool, and the actual charge to the 
guardians was 8s. id. per head per week. The debt 
account of the board on April 1st. 1906, was £807,592; a 
further sum of £29,685 was borrowed during the year, and 
£63,291 were paid off, leaving a balance of £773,986 owing 
on April 1st, 1907. The interest on loans during the year 
1906 amounted to £26,470. The money required to be 
furnished during such year by the county council and the 
conncils of the county boroughs was £136,856, Liverpool’s 
contribution being £34,793. If contributions and repre¬ 
sentation are to be anything like correlative then, on 
the basis of Manchester and Salford rates, Liverpool’s 
representatives should be 13 instead of eight; if the basis 
taken be that of other councils Liverpool should increase its 
representatives by no less than 28. The question of with¬ 
drawing from the board and of Liverpool building its own 
asylum has, it appears, been discussed but it has been 
thought advisable not to pursue it. The representatives, 
however, thought that economy might be effected by the 
corporation providing accommodation for patients committed 
under detention orders and who could not be detained in 
the workhouse for a longer period than 17 days. 

Hospital Sunday. 

The collections on behalf of the Liverpool Hospital Sunday 
fund were taken on Sunday, Jan. 12th, in about 400 places of 
worship. Last year the combined effort, including £1056 
paid by 11 guarantors, resulted in £16,956 being distributed 
to the medical charities, or £2106 more than in 1906. Most 
of the guarantors have again generously offered to add 
10 per cent, on the increased collection ; indeed, some have 
magnanimously agreed to take the 19C6 collections as their 
basis. This offer turns out to be a fortunate one for the 
fund, as the advertised amounts collected last Sunday show 
considerable diminutions on the collection of 1907. 

Bootle Ictvti Council: Appointment of School Medical 
Ojfioeri. 

The recommendation of the education and joint (education 
and health) sub-committee was adopted by the Bootle town 
council last week to the effect that Mr. William Daley, the 
medical officer of health, should be appointed the school 
medical officer under the new Act at a salary of £25 per 
annum, to be paid by the education committee and that he 
should be held responsible for the supervision of such 
medical assistance as may be needed to carry out the 
medical inspection of children in the public elementary 
schools. It was further agreed that Mr. Joseph Beard 
should be appointed a school medical officer to act under 
the supervision of the medical officer of health and the 
control of the education committee, the conditions being 
that he shall relinquish his position sis resident medical 
superintendent at Linacre infectious hospital, that he 
shall retain his present appointment of assistant medical 
officer and surgeon to the police force and fire brigade, 
and that he shall be paid a salary of £300 per annum, 
such sum to be allocated as follows: education committee, 
£150 ; health committee, £50 ; and watch and fire brigade 
committees jointly, £100. 

Liverpool Royal Infirmary. 

Mr. Robert E. Kelly has been appointed an assistant 
surgeon in the room of Mr. Robert A. Bickersteth. 

Jan. 13th._ 


WALES AND WESTERN COUNTIES NOTES. 

(From our own Correspondents.) 

Booting at Merthyr Tydvil. 

Although the newly formed corporation of Merthyr has 
shown commendable activity in dealing with the provision of 
better houses a great deal remains to be done in this 
direction. In a recent report to the health committee it was 


stated that in a part of the town between Dowlais and 
Merthyr town there were in occupation cellar dwellings 
beneath upper floors. The rents of these cellars were 11s. 
per month and they were occupied by families of five or six 
persons. At the Merthyr police court on Jan. 9th a lodging- 
house keeper was fined 20s. and costs for contravening the 
by-law which provides for the separation of the sexes in 
registered common lodging-houses. Evidence was given that 
there were sleeping in the same room and without any form 
of curtain or screen not only married couples but children 
and single women. The question of providing a municipal 
lodging house is one which might very well be considered by 
the Merthyr corporation. 

An Accident Ambulance Wagon in the Rhondda. 

An accident ambulance wagon has been provided in con¬ 
nexion with the St. John Ambulance Corps of the great 
Rhondda Valley. It is to be stationed at a point where a 
telephone is available and a driver and constable will be in 
charge of it. There are an increasing number of the work¬ 
men employed in the Rhondda collieries becoming interested 
in the work of the corps, and in one colliery where over 2000 
men are employed nearly 200 of them are qualified to give 
first-aid. The ambulance wagon will be sent round to the 
various collieries in the district so that the certificated men 
may be instructed how to make use of it. 

Swansea Hoipital. 

During the three years that Dr. Florence M. 'S. Price 
has been on the resident staff of the Swansea Hospital she 
has given up a great deal of time to bacteriological work 
connected with the institution. Upon her resigning her 
appointment to practise in the town the honorary staff were 
desirous of retaining her services as bacteriologist and she has 
now consented to continue as such for six months without 
remuneration. 

Creamery Butter and Factory Butter. 

A case of some interest came before the stipendiary magis¬ 
trate at Cardiff on Jan. 8th in connexion with the trade in 
Irish butter. A large quantity of creamery butter was 
advertised for sale in Cardiff and upon a portion of it being 
examined by an inspector of the Board of Agriculture of 
Ireland he came to the conclusion that it should have been 
called “ factory butter” and not ‘‘creamery butter.” The 
magistrate took the same view and imposed a fine 
of £5, with 25 guineas costs, upon the firm who sold the 
butter. Notice of appeal against this decision waB given. 

Workmen's Dwellings in Newport. 

A committee of the Newport corporation has had under 
consideration the erection of workmen's cottages upon an 
estate of 40 acres situated on the outskirts of the town. The 
borough engineer is reporting upon a scheme for building 
on this land to the extent of about 15 houses per acre at a 
cost of £180 per house. In an interesting report issued last 
year the medical officer of health (Dr. J. Howard-Jones) gave 
the result of a local census which he had made in 45 streets 
containing 992 houses. In 34 per cent, of the houses there 
were two families in occupation and lodgers were taken in 
15 per cent. The average number of persons per house was 
found to be 6 • 6 and the average rental was 8*. 8 d. weekly. 

The Duties of Poor-law Medical Officers. 

At a meeting of the Bridgwater board of guardians held 
on Jan. 7th a complaint was made against a medical officer 
who it was alleged had refused to attend a woman in her 
confinement until a midwife had attended the woman 
although the guardians had given an order for medical 
attendance upon the case. The medical officer, who was 
present, explained that he had not refused to attend the 
woman but contended that it was unreasonable to expect a 
medical man to attend a woman perhaps a considerable time 
before the confinement, whereas if a midwife was employed 
she would be able to summon the medical officer in case of 
urgency. After considerable discussion it was resolved to 
send the correspondence to the Local Government Board for 
its opinion upon the matter. 

Drunk or Dying? 

An inquiry was held at Taunton on Jan. 9th relative to 
the death of a well-known Somerset sculptor which took 
place on Jan. 4th. Evidence showed that the deceased 
had intended to travel from Ilminster to Taunton on 
Dec. 27th, 1907, but he was found in the lavatory at 
Ilminster station a few minutes after the departure of 
the train. He was unconscious and as the station- 
master thought that he was under the influence of 




198 Thb Lancet 


SCOTLAND. 


[Jan. 18,1908. 


alcohol he was removed to the waiting-room where 
he remained on the floor nntil the next morning 
when medical aid was summoned. Medical evidence 
showed that death was due to cerebral haemorrhage 
and the jury returned a verdict ol "accidental death.” 
A rider was added to the effect that medical help 
should have been procured earlier. The representative of 
the Great Western Railway Company, in expressing regret 
at the treatment of the deceased, stated that the company 
issued instructions to the station masters in cases such as 
this to send for a medical man and to advise the police. 

Jan. 13th. 


SCOTLAND. 

(From our own Correspondents.) 


Resignation of Dr. T. S. Clouston. 

There have been rumours for some time that Dr. Olouston, 
the eminent superintendent of the Royal Asylum, Morning- 
side. Edinburgh, contemplated resigning his post in that 
institution. The official announcement that the resignation 
has been tendered and accepted comes somewhat as a shoes. 
Dr. Clouston graduated at the University of Edinburgh in 
1861 and has devoted his entire professional life to the 
department of medicine with which his name is so intimately 
associated. For the first three years of medical life he 
acted as assistant at Morningside Asylum to Dr. Skae. In 
1863 he was appointed medical superintendent of the 
Cumberland and Westmorland Asylum, near Carlisle, and 
ten years later, 1873, he returned to Morningside as successor 
to his former chief. For 34 years he has occupied that 
position. In that time the extent to whioh he has altered 
and added to the asylum may be gauged by the fact that the 
board has spent £180,000 in that period on these objects. 
At the beginning of that period the income from the better 
class of private patients was £8600 per annum ; it has risen 
to £35.000. Although Dr. Olouston has resigned the super - 
intendentship of the asylum it is understood that he does 
not propose to resign his lectureship in the university. 

Edinburgh Royal In firmary: Annual Meeting. 

The annual meeting of the general court of contributors 
of this institution was held on Jan. 6th. The attend¬ 
ance was small and the chair was occupied by Mr. 
W. B. Blaikie in the absence of the Lord Provost. The 
expenditure on ordinary working for the year had been 
£53,479, making the total cost per bed £54 5s. 6 id. This 
was larger than last year by £2 3*. 2 id. and was due to the 
increased cost of everything used in the infirmary. The 
ordinary income amounted to £35,707. From capital £17,772 
had been taken to make up the deficiency in ordinary 
income. Notwithstanding this the institution was richer 
by £3562 than it was in the previous year. It was hoped to 
undertake the reconstruction of the medical out-patient 
department during the year. It was mentioned that the 
managers had a scheme for the provision of wards for the 
treatment of mental cases as soon as the money was forth¬ 
coming ; it was to be remembered that it would cost £1600 
per annum. A committee was appointed to report on the 
annual statement to an adjourned meeting. 

The Local Government Board and Medical Officers of Health. 

Owing to the resignation of Dr. T. G. Nasmyth as medical 
officer of health of the counties of Fife, Kinross, and Clack¬ 
mannan the question of dividing Fife into districts with a 
medical officer for each district has been considered, but it 
is satisfactory to know that the authorities in Fife have 
loyally acquiesced in the strong representations made by tbe 
Local Government Board to the effect that the district 
should not be divided and that a medical officer should be 
appointed who should devote his whole time to public health 
matters as Dr. Nasmyth had done. 

Statistics of Scottish Universities. 

The Universities of Edinburgh and Glasgow have just 
published statements of the number of matriculated students 
attending at each University. At Edinburgh the total 
number of students matriculated for the year is 2688 as 
compared with 2736 in the previous year. The number of 
medical students is 1423 as compared with 1465 in 1906 and 
2026 in 1889. At the University of Glasgow the number of 
students matriculated in all faculties for 1907 is 1924 as 
cnmpmd with 1859 in 1906. The number of medical 


students is 622 in 1907 as compared with 626 in the previous 
year and 818 in the year 1889. In considering these figures 
it must be borne in mind that they do not in the case of 
either University include women students. Also the 
diminution in the number of medical students this year as 
compared with 1889 is not so great as might at first sight 
appear, as the Faculty of Science was only constituted in 
1893. and it now includes many students who formerly were 
included in the Faculty of Medicine. 

Examinership in Vital Statistic) at the University of 
Glasgow. 

Dr. A. K. Chalmers, the medical officer of health of 
Glasgow, has reported to the health committee that he has 
received an intimation that the University Court has offered 
to him the recently instituted examinership in vital statistics, 
Ac., in connexion with the public health degree of the Univer¬ 
sity of Glasgow. The committee, appreciating the honour 
conferred upon the medical officer and his office, has recom¬ 
mended that so far as the examinership is concerned the 
resolution of the corporation prohibiting officials from 
accepting any position which would entail absence from work 
during business hours should be BUBpended In bis case. 

Greenock Combination Hospital. 

A new combination fever hospital was opened at Greenock 
last week to serve the burghs of Greenock. Port Glasgow, 
and Gourock. The site, which extends to 10 acres, is an 
excellent one for the purpose. There are 12 different blocks 
of buildings, each intended to serve a specific purpose. 
Abundant provision is made for the observation of doubtful 
cases and for the isolation of cases of double infection, and 
a block is reserved for the special treatment of patients a 
few days prior to their being discharged. At present tbe 
hospital provides accommodation for 118 adult beds, which 
can be considerably increased in the case of children. Pro¬ 
vision is made for a further extension of the scarlet fever 
wards to the extent of 44 beds, so that the completed hospital 
will be able to accommodate 162 cases. The buildings are of 
brick and rough cast on face and the floors of the two-storey 
blocks are fireproof. In the wards, which are airy and well- 
lighted, a novel feature is tbe introduction of circular 
instead of square ends. At the end of each ward is a 
balcony with an escape stair. All the wards are 
connected by means of covered ways, and the heating of 
the buildings is on the Reck system, a radiator being placed 
at each window, with a direct air inlet which can be regu¬ 
lated as desired. Throughout the buildings, fittings, and 
furnishings have been kept perfectly plain and the total 
cost of the hospital will be about £400 per bed. 

Epidemic of Measles in Glasgow. 

A widespread epidemic of measles has occurred in Glasgow 
during the last few weeks and on that account it was recom¬ 
mended by the medical officer of health that the schools 
should be kept closed at Uhristmastide for a week longer 
than usual. In the fever hospitals of the city there are at 
present 628 cases of measles, as compared with 326, the 
largest number accommodated in the hospitals in any 
previous epidemic. 

Aberdeen Royal Infirmary: Hospital Sunday. 

Special collections on behalf of the funds of the Royal 
Infirmary are made annually on the first Sunday of the year 
in most of the Aberdeen churches. This year the total 
sum received amounted to £916 (excluding Queen's Cross 
U. F. Church), compared with £1044 last year. Last 
year the collection of Queen’s Cross U. F. Church amounted 
to £120, so that with a similar contribution this year the 
total sum collected by the churches will be pretty nearly the 
same as last year. St. Clement’s Established Church, with 
£114, gave the largest contribution. 

King seat Asylum. 

Kingseat Asylum up to date has cost £132,998. During 
the last month payments amounting to £563 have been made 
to various contractors. 

Aberdeen University Medical Society: Lecture by Sir 
11 illiam Japp Sinclair. 

At a meeting of the Aberdeen University Medical Society 
on Jan. 10th an interesting lecture on the Clinical Teaching 
of Midwifery was delivered by 8ir William J. Sinclair of 
Victoria University, Manchester. He first described the 
progress of midwifery in this country and on the continent 
and then referred to the deficiencies of the present-day 




The lancet,] 


IRELAND.—PARIS. 


[Jax. 18, 1908. 199 


teaching in this conntry. Professor J. T. Cash, Professor W. 
Stephenson, and Dr. G. M. Edmond added remarks. 

Jan. 14th. 


IRELAND. 

(From our own Correspondent.) 

The Treatment of Cerebro-spinal Fever. 

At a meeting of the Ulster Medical Society held on 
Jan. 9th Dr. A. G. Robb gave a most interesting account of 
the employment of a new serum which he had obtained from 
Dr. Flexner, pathologist to the Rockefeller Institute of New 
York, and bad used in the treatment of cerebro-spinal fever 
in the wards of the Purdysburn fever hospital, Belfast. It 
has been tried during the last four months of 1907 in 30 
cases, and of these 22 have recovered, giving a death-rate of 
26-6 per cent. Previously to the adoption of this treatment 
275 cases bad been treated in the hospital with 199 deaths, 
givtog a death-rate of 72 per cent., which is very much 
the same as that which prevails in Glasgow and other centres 
where the disease has occurred. It may be, of course, that 
the type of the disease was milder in the Purdysburn 
cases but evidence hardly shows it. In June, July, 
and August, before the serum was used, the death- 
rate in the hospital was 80 per cent. Further, in the 
last four months of 1907 there were 34 cases in the city of 
Belfast which did not come to the municipal fever hospital 
and were not given the serum, and among these there 
were 29 deaths, or a death-rate of 87 per cent., while at 
the same time the death-rate in the fever hospital was 
26 ■ 6 per cent. Too much, of course, must not be based 
upon the results but they are very interesting. I am sorry to 
say that cases of cerebro-spinal fever are still appearing in 
Belfast but no scientific evidence of any kind as to the 
lnfectiousness of the disease is available and the theory of 
intermediaries carrying the disease is not supported by those 
who have had special experience with the epidemic. 

The Purdysburn Fever Uoipital. 

A curious situation has arisen in reference to the registra¬ 
tion of deaths at Purdysburn fever hospital. This institution 
is situated outside the Belfast area in a district over which 
the Lisburn guardians have authority. But the registrar of 
deaths. Dr. Gawin Orr, was so overrun at his dispensary and 
the extern patients there objected so much to friends of 
patients who had died at the fever hospital coming to 
register their deaths there that the registrar has resigned. 
The Lisburn guardians urged the Registrar-General to make 
the chief resident officer of the hospital the registrar, but he 
declined and urged them to appoint someone in place of Dr. 
Orr. The Lisburn guardians have, however, refused to do 
so, as they urge that registration under the specified condi¬ 
tions would open up a serious mode of conveying infection to 
the whole division from the Belfast infectious diseases hos¬ 
pital. “ Having,” as they put it, “ some regard for the lives 
and safety of the inhabitants of the whole division they 
respectfully submit that the Registrar-General should make 
the infectious diseases hospital of Belfast a separate area 
from the division of Bally lesson.” 

The Prevention of Hospital Abuse. 

On July 3rd, 1907, the board of management of the Royal 
Victoria Hospital, Belfast, appointed a committee of lay 
members and of the medical staff to go into the whole ques¬ 
tion of the treatment of patients in the extern department. 
This committee met on five different occasions and several 
recommendations proposed by it have sow been adopted by 
the board of management. The substance of those recommen¬ 
dations is as follows. The by-laws have been altered so that 
under the heading of “ Privileges of Subscribers other than 
the Working Classes,” they now contain the words “ Annual 
subscribers of £1 can recommend for admission—1 intern and 
2 extern necessitous patients,” and so on to the end of the 
paragraph. The alteration consists in the word "necessitous” 
being added to the former rule. The "Rules for Admission 
of Patients” have also been altered by inserting the words 
"of the working classes” after the word "patients.” The 
honorary secretary of the hospital has issued a circular in which 
the working men and women of the city and neighbourhood, in 
their shops, mills, factories, and other places of employ¬ 
ment, are invited to nnite in the regular and systematic 
support of the Royal Victoria Hospital by weekly, monthly, 
or quarterly contributions. The circular goes on to state 


that in all cases suitable for hospital treatment, and pro¬ 
vided there is room in the hospital, other than cases of 
infections disease, delirium tremens, or consumption, the 
board of management is prepared to offer the following 
advantages to all works where a weekly or other contribution, 
to be agreed upon by the board and the employees of any 
firm, is regularly made: (1) Every subscriber of the working 
classes employed in the works will be admitted free as an 
intern patient; (2) any member of a family (not being a 
wage-earner) whose father is a subscriber will be admitted 
free; (3) any youth who is a subscriber, and who is the 
support of his mother or other members of the family, will 
be entitled to the same advantages for them as if he were 
the head of the family; and (4) every subscriber (of the 
working classes) or member of his family (not being a 
wage-earner) will be eligible for extern medical advice 
or surgical treatment free of charge A notice is to 
be hung prominently in the extern department stating 
that the medical and surgical treatment given in the 
hospital is only intended for those who are unable to 
pay for it elsewhere, and that it is desirable that patients 
should come to the hospital provided with either a sub¬ 
scriber's tioket or a note from their usual medical attendant. 
For use in doubtful cases a form of letter has been drafted 
by which the honorary medical officers of the hospital may 
apply to the patient's usual medical attendant inquiring 
whether be considers the patient to be “ a suitable case for 
treatment at a charitable institution.” The visiting staff is 
also to have the power to refer patients coming from another 
hospital or practitioner back to that hospital or practitioner 
for further treatment when they think that that course is for 
the benefit of the patient. 

Jan. 14th. 


PARIS. 

(From our own Correspondent.) 


The Treatment of Pulmonary Tuberculosis by Sea- Water. 

For the last two years M. Mongour has been studying the 
therapeutic effects of isotonic “sea-serum” in pulmonary 
tuberculosis. On Dec. 31st, 1907. he gave some results which 
he had obtained in a paper read before the Academy of Medi¬ 
cine. According to this paper injections of isotonic sea¬ 
water, even in small doses of from 10 to 30 cubic centimetres, 
bring about rises of temperature in any patient with pul¬ 
monary tuberculosis at whatever period of his disease he may 
be. The injections also seem to favour the production of 
haemoptysis. Variations in weight and in desire for food 
may be noted during the treatment but there are no definite 
amelioration of the symptoms and no staying of the pul¬ 
monary lesion. 

“ Dromethcrapy." 

At a meeting of the Therapeutical Society held during 
the month of December M. Burlureaux read a paper upon 
the great therapeutical value of a systematised running 
exercise, which he calls " dromotherapy.” He has already 
treated 180 patients in this way. He says that the treat¬ 
ment is eminently suitable for that class of patient who has 
no organic lesion but who is, nevertheless, valetudinarian. 
The distance of the runs is to be increased gradually and 
the pace at first is to be Blow. 

-I Strike of Medical Men. 

The medical men of the department of the Somme have 
struck owing to the new tariff brought out by the Assistance 
Mf-dicale and owing to the decision taken by the authorities 
to reduce the fees of the medical officers of the Assistance if 
the total expenses exceed 256.000 francs per annum. AH 
the medical men concerned have sent in their resignations; 
they have given notice that they will attend poor people 
gratuitously up to May 1st, but the department of the 
Assistance will not be able to be carried on officially and 
no one knows what will happen to the free distribntion of 
drugs or to the issue of hospital letters, for the medical men 
will sign no more requisitions. 

The Hygiene of Barracks and Epidemics Therein. 

At a meeting of the Academy of Medicine held on 
Dec. 17tb, 1907, M. Delorme read a paper in which he said 
that it was well known that the state of health as regards 
any particular barrack was only a reflection of the general 
sanitary condition of the garrison town. An urban district 



’200 The Lancet,] 


BERLIN.—BUDAPEST. 


[Jan. 18,1908. 


plays a great part in the origin and spread of epidemics and, 
like any other district where human beings are massed 
together, a barrack is favourable to the development of epi¬ 
demic diseases. The number, the frequency, and the variety 
of the epidemics occurring in barracks are no argument for 
the pulling down and rebuilding of such places. The eruptive 
fevers and such diseases as influenza and broncho-pneumonia, 
diseases which altogether form four-fifths of the epidemics 
which break out in the army, are a strong argument for some 
modification of the barrack system (deserrement du caterne- 
vtent).. Air and sunlight are the two most simple measures 
for disinfection and the windows of barrack rooms should be 
open'all day long, 

Bemi-resectwn of the Elbow for an Irreducible Dislocation of 
Doth Danes of the Forearm. 

On Dec. 18th, 1907, at the Surgical Society M. Loison 
showed a young soldier on whom he had performed this 
operation six months previously. The accident had been 
caused by. a fall on the elbow, the radius and ulna being 
thereby dislocated upwards and backwards. M. Loison 
resected the lower extremity of the humerus through a 
single internal incision. On the whole, the result is very 
satisfactory, as flexion of the arm on the forearm can be 
accomplished to nearly a right angle, although extension 
cannot yet be perfectly performed. 

A Revolver Bullet apparently Lodged in the Apex of a Heart. 

At the same society on Jan. 8th M. Guinard showed a 
man, aged 26 years, who received a bullet from a revolver 
in his back at the beginning of last July. He was seized at 
once with violent dyspnoea, with cough and sanious expectora¬ 
tion, and was removed without delay to hospital. Here the 
diagnosis of a wound of some abdominal viscus was made, 
chiefly owing to the marked rigidity of the abdominal 
wall, and on the next day a laparotomy was done but no 
trace of blood was found. After the operation the 
patient continued to spit blood occasionally in small 
quantities, after which he left the hospital, with no symptom 
except sometimes a little dyspnoea on walking, profuse 
nocturnal sweats, and tenderness on pressure over the 
prse cordial region. These symptoms did not give him much 
trouble at first but grew worse as he continued to work, and 
■he finally had to re enter the hospital. A skiagram was 
made which showed a ballet inside the thorax and several 
centimetres behind the ribs. 

Jan. 14th. 


BERLIN. 

(From our own Correspondent.) 


Obituary. 

During the past fortnight the Berlin medical profession 
nas sustained a severe loss by the death of not less than 
four eminent medical men, of whom three were of wide 
renown. Professor Adalbert von Tobold, the oldest of 
the German laryngologists, died on Dec. 22nd, 1907, in his 
eighty-first year. He was born in Berlin, where he also 
received his professional education, and subsequently became 
an assistant to the late Professor von Langenbeck, so cele- 
brated as a surgeon. He then went to Vienna, as it was at 
that time the custom for young German medical men to 
spend some time abroad in order to learn new methods of 
treatment. In Vienna laryngology was undergoing rapid 
development,. for the laryngoscope invented by the late 
JUanuel Garcia was being widely introduced as a means 
diagnosis by the Vienna laryngologists, Turk and 
Czermak. Young Dr. Tobold recognised the great value 
of the new instrument and after his return to Berlin he 
devoted himself entirely to the study of laryngology 
and as one of the earliest laryngologists he had a very large 
practice. He published many valuable communications on 
laryngeal matters and also wrote a text-book on laryngology. 
Professor Tobold was known as one of the medical men who 
were consulted in connexion with the Emperor Frederick’s 
tatal illness previously to the late Sir Morell Mackenzie. He 
was much liked by the present Emperor who knighted him 
a few months ago on the occasion of his eightieth birthday. 

Professor Oscar Lassar, one of the most popular members 
of the medical profession in Berlin, died on the day 
before that of Professor von Tobold’s death. Professor 
tassar s name cannot fail to be known to those readers 
of The Lancet who have attended any of the numerous 


medical congresses held in Berlin, and especially tie 
last congress on hygiene and demography, for he had 
always a prominent position in the committee of con¬ 
gresses because of his talent for organisation, his social 
gifts, and his great linguistic powers which enabled him to 
deliver addresses in several languages. Professor Lassar 
was born at Hamburg in 1849 and studied medicine at 
Heidelberg, Leipsic, and Berlin. His medical curriculum 
was interrupted by the Franco-German War. Being an 
excellent horseman he served in the war as a private in the 
Hussars and received a decoration for bravery. Subsequently 
he became a captain of the reserve of his regiment. For a 
medical man to be given such a position in the combatant 
grades was an unprecedented event, because qualified 
medical men naturally join the medical corps of the reserve. 
He first became an assistant to the late Professor Cohnheim 
of Leipsic, the celebrated pathologist. He then devoted 
himself to the study of dermatology and settled in Berlin ; 
in 1880 he was recognised as privat-docent, in 1892 he 
received the title of professor, and in 1902 became extra¬ 
ordinary professor in the Berlin Medical Faculty. He soon 
acquired a large and international practice, his patients 
including royal personages and the nobility of nearly every 
country of Europe. He devised many new methods of treat¬ 
ment and had much to do with the introduction of the x rays 
and radium into dermatological therapeutics. He also took 
much interest in the welfare of the poorer classes whom he 
benefited by originating the German society for public baths 
which enabled poor people to have a warm bath for the 
moderate price of 10 pfennig (Id.). He was a general 
favourite in Berlin and, apart from his high professional 
standing, he entered freely into the social life of the capital. 
His death was due to an accident. An automobile came 
into collision with his carriage and he was thrown out. 
He escaped with only a slight injury of the head and 
contusion of the ribs but the result was septicaemia which 
proved fatal. 

Professor Hoffa died on Dec. 31st, 1907. Like Professor 
Lassar, he was very popular in Berlin and had a world¬ 
wide reputation. He was born in 1858 at Richmond in 
Cape Colony where his father had settled as an emigrant 
from Germany. He was brought up in Germany and 
received his medical training at Freiburg. He then 
became an assistant to a surgeon, the late Professor Maas, 
and eventually devoted himself exclusively to orthopaedic 
surgery. In Wurzburg, where he established himself, he 
ounded an orthopaedic institute which was soon patronised 
by patients of many nationalities. He was recognised as 
privatdooenl and then as extraordinary professor, and in 
1902, on the death of Dr. Julies Wolff, professor of ortho¬ 
paedic surgery in the University of Berlin, he was called to 
be his successor. Professor Hoffa occupied this chair until 
his death. It was said that the number of private patients 
who followed him from his orthopaedic clinic at Wurzburg to 
Berlin was so great that he engaged a special train to bring 
them with him; his practice, of course, still increased 
in the metropolis. He was the leading orthopaedic surgeon 
of Germany and the president of the German Orthopaedic 
Association. His work included nearly every branch of 
orthopaedic surgery but his name will be connected especially 
with the treatment of congenital dislocation of the hip-joint. 
He has published, among other works, a text-book on 
fractures and dislocations and especially a handbook of 
orthopaedic surgery which bas been translated into several 
languages. He died from angina pectoris in Cologne on his 
way home from Antwerp where he had been called to perform 
an operation. 

Dr. Julius Becker, president of the Berlin Medical 
Chamber and the Berlin Medical Court of Honour since the 
establishment of both these institutions, died in that city on 
Dec. 20th, 1907. He was, moreover, vice-president of the 
Society for Internal Medicine and one of the most frequently 
consulted Berlin physicians. 

Jan. 13th. 


BUDAPEST. 

(From our own Correspondent.) 

Gonorrhoeal Inoculation of Ryes 'affected with Pannus. 

At a recent meeting of the Budapest Royal Medical Society 
Dr. William Goldzieher, professor of ophthalmology at the 
university, delivered an address on the revival of the 
inoculation of the eye with gonorrhoeal matter for the 




The Lancet,] 


BUDAPEST.—OBITUARY. 


[Jan. 18, 1908 201 


treatment of pannus. He said that in the ophthalmic 
department of the St. Rochns Hospital, which iB the largest 
one in Budapest, incurable cases of this kind were admitted, 
although they were excluded from most private and public 
hospitals. He had therefore to deal with the most inveterate 
and desperate cases of trachoma and the consequent pannus. 
With these patients he tried every kind of treatment—local, 
general, internal, and surgical, but all in vain. This was so 
great a disappointment to him that he felt himself justified 
in reviving the above-mentioned long disused method of 
treatment. It naturally appeared to be dangerous, but 
as the patients were already to all intents and pur¬ 
poses hopelessly blind there did not seem to be any 
objection to making an attempt to give them relief. 
On the other hand, this method has been described 
to be fairly effective by the best ophthalmologists of the 
middle of the nineteenth century—namely, Jaeger, Arlt, and 
Stellwag. Dr. Goldzieher began bis experiments with this 
method on a soldier who had for three years been suffering 
from severe pannus crassus and had been treated in two 
military hospitals and one civil hospital in every imaginable 
way but without the least benefit. When he was admitted 
to Dr. Goldzieher’s clinic his visual power was almost nil. 
On Sept. 12th, 3907, he inoculated this patient’s left eye 
with the secretion from the eye of an infant suffering from 
gonorrhoeal ophthalmia. The disease broke out in the man’s 
eye after three days and lasted for three weeks or so. The 
patient was afterwards sent home to await there the clearing 
up of his cornea. He presented himself again at the 
beginning of December and the result was found to be 
surprising. The cornea had become quite clear ; even the 
conjunctival tract had regained its soundness and the visual 
power reached about 4 . Emboldened by this success, Dr. 
Goldzieher then inoculated the patient’s right eye and 
the result will, seemingly, be as good as in the left eye. 
From these favourable results Dr. Goldzieher’drew the con¬ 
clusion that inoculation of the eye with gonorrhoea might 
be tried as a last resource in cases of apparently hopeless 
pannus crassus. 

The Decline of Medical Detearch. 

The last meeting of the year is always a festivity in the 
Royal Medical Society of Budapest. In 1907 the presidential 
address was delivered at this meeting by Dr. Arpad Bokay, 
professor of pharmacology at the University of Budapest'. 
He called attention to the fact that the papers embodying 
the results of original research had been falling off for the 
last three or four years. The prizes offered for such contribu¬ 
tions represented a not inconsiderable sum, but some of them 
had recently been withheld in consequence of the inadequate 
competition. He attributed this decline in medical research 
to the necessity imposed on practitioners of working so hard 
for their livelihood that they had no inclination to commence 
scientific investigations after the fatigue of the day. The 
staff of the clinic received so little remuneration that after 
finishing their heavy work in the wards these gentlemen 
endeavoured to increase their income by attending private 
patients. Only such members of the staff as were financially 
independent could devote their time to scientific research 
The salaries of the clinical staff would, however, in course of 
time be considerably raised and they would then be in a 
better position for undertaking original work. The society 
held 24 meetings in 1907. There were 25 lectures delivered, 
the subjects being theoretical medical science, general patho¬ 
logy, clinical medicine, surgery, psychiatry, neurology, 
paediatrics, obstetrics, gynaecology, forensic medicine, der¬ 
matology, and roentgenology. At the meetings 41 medical 
men exhibited 57 patients The society had also a jubilee 
meeting, when the festival address was delivered by Professor 
Hugo Preis on the subject of Virulence and Therapeutics. 

Jan. 4th. 


Medical Inspection of School Children.— 
The question of the medical inspection of school children 
was discussed at a recent meeting of the Warmley 
(Gloucestershire) out-relief union and the chairman 
remarked that he hoped that the local district officers 
would be selected for the work.—A conference between the 
district medical officers of Wiltshire and the county 
education committee was held at Trowbridge on Jan. 10th. 
The questions discussed were how far the district medicai 
officers would undertake the duties of inspecting the children 
and what fees would be charged. 




PATRICK CUMIN SCOTT, B.A., M.B. CANTAB, 
M.R.C. 8 . Eng. 

The death is announced on Jan. 10th of Dr. P. C. Scott of 
the High House, Old Charlton, Kent. Dr. Scott, who was in 
his fifty-first year, was educated at Winchester College, 
St. John's College. Cambridge, and St. Georges Hospital. 
He qualified in 1885. graduating as M.B., and taking his 
diploma as Member of the Royal College of Surgeons of 
England in that year. After holding various appointments 
at St. George's Hospital he was elected a house physician to 
the Hospital for Consumption and Diseases of the Cliest at 
Brompton, and he afterwards settled down in practice at 
Blackheatb, in which place he resided nearly the whole of his 
life. Soon after settling in practice there he was elected 
as physician to the Miller Hospital, Greenwich, and he 
was also one of the honorary surgeons to the Royal Kent 
Dispensary. For some time before his death he had been 
troubled with vague pains in his external auditory meatus 
and on examination a very small, dry and quite superficial 
sequestrum was found which was removed. The sequestrum 
was quite loose and came away perfectly easily. There were 
no signs of anything septic, no factor, and no sign of any 
recent inflammation. On the night of Jan. 8 th he expressed 
himself as feeling very comfortable and much relieved, but 
on Thursday night he developed partial paralysis of the right 
arm with extreme rigidity of mnscles at the back of the 
neck. Shortly afterwards he became comatose and death 
occurred early on Friday morning. The suddenness of his 
death will come as a shock to his many friends and is 
rendered all the more sad by the fact that his wife had been 
confined only a day or two before his death. 


GEORGE THOMAS KEELE, M.R.C.S. Kno., L.S.A. 

By the death of Mr. G. T. Keele Highbury loses one of its 
oldest and most respected practitioners. He was bora 
in Holloway in 1833, and was a son of the late 
George St. John Keele, principal accountant of the Inland 
Revenue Office, Somerset House. His grandfather, uncle, 
and cousins have been in practice in Southampton for 
more than 100 years. Mr. Keele was educated at 
Stockwell Grammar School and was apprenticed in 1348 
to Mr. W. Henloch, resident apothecary, Royal South 
London Dispensary, Southwark. He entered St. Thomas’s 
Hospital Medical School in the Borough in October, 
1851, and became clinical clerk to Dr. J. A. Barker 
and dresser to Mr. S. Solly. After taking the double 
qualification and passing the examination of the Navy 
Board he received his commission as assistant surgeon 
in the Royal Navy on July 1st, 1854. He served 
in H.M.8. Calcutta, guardship at Plymouth, for nine 
months, and thereafter in Her Majesty’s steamship Pyladct, 
employed in the Baltic during the Russian war, for nine 
months. He then resigned his commission in the navy and 
was assistant for six months to Mr. Walter Chapman of 
Lower Tooting to learn the ways of private practice. In 
August, 1856, he began practice in St. Paul's-road, Canon- 
bury, where he continued until his death on Monday last. 
For about 46 years he was one of the most active and busy 
general practitioners in Islington, doing every kind of 
general practice, including a large amount of midwifery work. 
For seven years he was parish medical officer for Highbury 
and Canonbury wards. For a short time he was medical 
officer of the Holloway and North Islington Dispensary and 
on his resignation was elected to serve on the committee, 
which he did very usefully for 34 years. Mr. Keele was 
one of the oldest members, not to say founders, of the 
Islington Medical Society which still flourishes. He also 
found time to take a share in the municipal and political life 
of Islington, in doing which and stoutly maintaining his 
principles he gained the respect of all his colleagues. His 
illnesB had been of some years' duration, disabling him from 
practice. It often entailed anginous and other pain but he 
was never heard to complain, and he died peacefully from 
bronchitis contracted a fortnight ago. Mr. Keele was twice 
married and leaves one daughter by the first marriage and 
four sons and one daughter by the second. 



202 The Lancet,] 


OBITUARY.—MEDICAL NEWS. 


[Jan. 18, 1908. 


WILLIAM ROSS JORDAN, M.R.C.8. Eng., L.S.A. 

Mr. William Roes Jordan of Birmingham died at his 
residence in Eisj-row in that city on Jan. 2nd, after several 
months’ indisposition. He belonged to a family well known 
for the number of medical practitioners which it has pro¬ 
duced. He was the son of a medical man and was born in 
August, 1832, at Masham in North Yorkshire. As it was 
intended that he should enter the medical profession he 
became apprentice to his father who was at that time 
practising in Birmingham, bnt circumstances which sub¬ 
sequently arose led to his spending three years in a merchant's 
office in Bradford. He then returned to Birmingham and 
after completing his medical curriculum at Queen’s College 
he took the diploma of M R.C.8. Eng. in 1858 and that of 
L.S.A. in 1867. The whole of his professional life was 
passed at various addresses in Birmingham where he was 
very popular and had a large practice. He took great 
interest in the Birmingham and Midland Hospital for 
Women, which was established in 1871, being one of the 
original founders, one of the surgeons for several years, and 
latterly consulting surgeon. His other appointments included 
that of examiner of lunatics for the Birmingham magistrates 
and board of guardians. He was also an ex-president of the 
Midland Medical Society, the Midland Arts Club, and the 
Birmingham Literary and Dramatic Society. His principal 
contribution< to medical literature were on gynaecological 
subjects. Mr. Jordan's health was a freqnent source of 
anxiety, and in 1880, after suffering a great deal with one of 
his knees, he was compelled to submit to amputation of the 
leg. This misfortune, however, caused only a temporary 
interruption in the work of his busy life. 


WILLIAM SPALDING, M.D. Edin., M.R.C.S. Enc.. 

The death of Dr. William Spalding, of Gorebridge, Edin¬ 
burgh, in his seventieth year, is announced. He was born in 
America and became qualified to practise in 1861, taking the 
degree of M D Edin. and the diploma of M.K C.S, Encr. in 
that year. He practised in the Gorebridge and Gala Water 
districts for 38 years. Dr. Spalding’s services were so appre¬ 
ciated in the locality that a handsome presentation waB 
made to him on his retirement. 


Deaths of Eminent Foreign Medical Men.— The 
deaths of the following eminent foreign medical men are 
announced :—Dr. J. von Mering. professor of clinical 
medicine in the University of Halle.—Dr. Adolf Vogt, 
formerly professor of hygiene and medical statistics in the 
University of Barne.—Dr. Cotholendy, formerly director of 
the medical service of the French Marine. 


Spiral Itttos. 


Examining Board in England nr the Royal 
Colleges ok Physicians of London and Surgeons of 
England —At the second professional examination of the 
Examining Board in England in Anatomy and Physiology 
held on Jan. 2nd, 3rd, 6th, and 7th, 77 candidates presented 
themselves, of whom 49 were approved and 28 were rejected. 
The following are the names of the successful candidates :— 

PhirozBhaw Rustomjee Bhaya, Bombay University and Middlesex 
Hospital ; Gordon Xormauby Jirandon, St. Thomas's Hospital; 
Juan Manuel Brito Salazar, M.D. Caracas. Caracas University 
and Middlesex Hospital; Ivo Gelkie Cobb, St Thomas’s Hos¬ 
pital ; William Lewis Cowurdin, St. Mary’s Hospital; Manekjee 
Jiatanjee Dalai, Bombay University and Middlesex Hospital; 
William John Dearden, Manehes'-er University; Henry William 
Doll, Guv s Hospital; Sandbrook Falkner, London Hospital; 
Ivor Stanley Gabe, Loudon Hospital; Robert Lionel Glass 
Bengal Medical College and London Hospital; Wilfrid Montague 
Gleuister. St. Bartholomew’s Hospital ; Henry James Hacker, 
St. Bartholomew's Hospital; Walter Parker Harrison, C Oaring Cross 
Hospital; Augustus Joseph Hickey, Westminster and King’s College 
Hospital; Willi .ra Henry Stewart Hodge, St. Bartholomew's and 
King's College Hospitals ; William Henry Hootan, Leeds University ; 
Rupert Llewellyn Jones, London Hospital; Joseph Bagnall Jordan, 
Birmingham University; Chbaganlal Hurgovindas Kantawala. 
Grant Medical College, Bombay; Ruston Darashaw Kapadia, 
L.M. & S. Bombiy, Bombay University and Middlesex Hospital; 
William Slocks Lacey, Guy's Hospital; William Ewart Latham. 
Liverpool University ; David Charles Lloyd, Guy's Hosnilal ; 
William Gordon Masefield. Middlesex Hospital; Albert Ernest 
Moore, London Hospital; Mar wood M Intern Munden, Guy’s Hos¬ 
pital; Bandla Ra j ago pal Naldu, Madras Medical College; Naranji 
Itanchhodji Naik Bombay University and Kings College Hos¬ 
pital; Allred l'hillp X’lcolle, London Hospital; Georg Xatanael 


Palmaer, London Hospital ; Adrian Charles Paterson, St. 
Thomas’s Hospital; Edward Austen Penny, Guy’s Hospital; .James 
Powell, University College. Cardiff; Thomas Bennion Bourne Price, 
London Hospital; John Pryce-Davies, Guy’s Hospital: Iskander 
Kihan. B.A , M.D., Syrian Protestant College. Beirut, M.D. Con 
stantinople. Beirut, Constantinople and St. Bartholomew's 
Hospital ; Henry Edwin Scargill. Leeds University; Sumner Hugh 
Smith, King's College Hospital; Harry Stobfe. St. Thomas's 
Hospital; Alan Herapath Todd. Guy's Hospital; Richard Herbert 
Vercoe, B.A. Cantab.. Cambridge University; Llewellyn Rhys 
Warburton, St. Thomas's Hospital ; Edward Parker W&llman 
Wedd, B.A. Cantab . Cambridge University and King's College 
Hospital ; Arthur White. St. Thomas’s Hospital ; Russell Facey 
Wilkinson. St. Mary's Hospital; Esmond Tetley Willans. B.A. 
Cantab.. Cambridge University ; John Wilson Williams. Cardiff 
and Guy’s Hospital; and Reginald Joseph Wooster, St. Mary's 
Hospital. 

University of Cambridge.—T he following 

have been examined and approved for the Diploma of 
Tropical Medicine and Hygiene :— 

H. L. Deck. W. R. Gibson, A. L. A. Webb, and F. A. Wille. 

—Mr. T. Manners-Smith, M.B , Downing, has been reappointed 
demonstrator of anatomy for five years.—Mr W. M. Fletcher, 
M.A., Trinity, ha9 been appointed an additional member of 
the Special Board for Biology and Geology. 

University of Liverpool.— The following 

have gained the diploma in Tropical Medicine :— 

J. B. Davey, M B. Lond.. MH.O.S, L.11C.P.; T. W. F. Gann, 
M.R.C.S . L.tt.C.P ; G. J. Kenne. M.D. Liverpool. D.P.fl. ; 
C. Mackey, M.B., Ch.B. Viet ; aud C. T. ltaikes, M.B. Oxon. 

Society of Apothecaries of London.—A t the 
primary examination held recently the following candidates 
passed in the subjects indicated :— 

Part I. 

Biology. —S. B. Webster, Sheffield. 

Chemistry. —A. J. C&rdelU Charing Cross Hospital; and E. Carter, 
Durham. 

Part II. 

Anatomy.— B. G. Carrol, London Hospital; J. B. Holmes, Man¬ 
chester; W. H. Hooton, Leeds; C. W. Jenner, London Hospital; 
L. M. Potter, Royal Free Hospital; and H. Wether bee, Loudon 
Hospital. 

Physiology.— C. B. Hawthorne. Cambridge and Birmingham; W. H. 
Ilootou. Leeds; G. F. Malden and L. M Potter, Royal Free 
Hospital; and H. Wetherbee, London Hospital. 

Foreign University Intelligence.— 

Amsterdam : Dr. H. Timmer has been recognised as privat- 
docent of Orthopaedic Sorgery.— Berlin : A Department for 
Affections of Speech is being established in the University 
Policlinic ; Dr. H. Gutzmann, a son of the well-known 
instructor of the deaf and dumb, will take charge of it. Dr. 
August Hildebrandt, Assistant in the Surgical Clinic of the 
Charity, and Dr. F. von Kuester of Charlottenburg, who was 
for many years Assistant to Professor von Bergmann, have 
been granted the title of Professor. Dr. YY f olienberg has 
been recognised as privat-docent of Orthopadics.— Breslau : 
Dr. Georg Gottstein, privat docent of Surgery, has been 
granted the title of Professor. Dr. Alexander Bittorf has 
been recognised as privat-docent of Medicine, Dr. Franz 
Kramer as privat docent of Psychiatry and Neurology, and 
Dr. Wilhelm Danielsen as privat-docent of Surgery.— 
Erlangen: Dr. Hermann Koaiger ha-* been recognised as 
privat docent of Medicine.— Halle: Dr. Isemer has been 
recognised as privat docent of Otology.— Heidelberg: Dr. 
Bender has been recognised as privat‘docent of Anatomy.— 
Kazan : Dr. D. TimoNP.eff, Extraordinary Professor of 
Histology, has been promoted to be Ordinary Professor.— 
Lille: Dr. Oui, agregi, has been appointed Professor of 
Midwifery and of the Hygiene of Young Infants. Dr. 
Carrie re, agrbgk, has been appointed Professor of Thera¬ 
peutics. Dr. Patoir, agrige , has been appointed Professor 
of Forensic Medicine in place of the late M. Cistiaux.— 
Marburg: Dr. Friedrich Kutscher of the Physiological Insti¬ 
tute has been appointed Extraordinary Professor of PnyBi¬ 
ology.— Michigan ( Ann Arbor University): Dr. George L. 
Streeter of the University of Pennsylvania has been appointed 
Extraordinary Professor of Anatomy in succession to Dr. 
J. P. McMurrich.— Nancy: Dr. Ancel, agrege , of the Lyons 
University, ha* been appointed Professor of Anatomy, in 
succession to M. Nicolas. Dr. Bouin, of the Algiers School 
of Medicine, has been appointed Professor of Histology in 
succession to M. Prenant.— Paris: Dr. Pierre Marie, agrege , 
has been appointed Professor of Pathological Anatomy in 
succession to M. Gornil.— Rostock : Dr. Adolf Bennecke has 
been recognise! as privat-docent of Midwifery and Gynae¬ 
cology.— St. Petersburg ( Military Medical Academy') : Dr. 
A. Drzbevetski has been recognised as privat docent of 



The Lancet,] 


MEDICAL NEWS. 


[JAN. 18,1908. 203 


Medicine.— Warsaw: Miss Stephanovski, who was for many 
years in the Physiological Institute at Brussels, has been 
appointed to a professorship. — Wurzburg: Dr. Liidke has 
been recognised as privat-doeent of Medicine. 

Royal College of Surgeons in Ireland.— 
The annual College dinner will take place on Saturday, 
Feb. 1st. 

Donations and Bequests— By his will the late 
Mr. George Hall of Norton Lees, Sheffield, bequeathed £5000 
to the Jessop Hospital for Women, Sheffield. 

Apothecaries’ Hall of Ireland.— At a special 

examination held on Jan. 3rd Edward Magennis, M.D. 
R.U.I., D.P.H., was admitted a Licentiate of the Apothe¬ 
caries’ Hall. 

University of London : University College. 
— On Wednesday, Jan. 22nd, at 5 P.st., Dr. C. Spearman, 
reader in experimental psychology, will deliver an inaugural 
lecture on “ Experimental Psychology and its Relation to 
Education.” The chairman will be Professor Adams. 

Inoculation for the Plague.— As was 
recorded in The Lancet of Dec. 21st, 1907, p. 1774, the 
new Governor of Bombay, Sir George Clarke, soon after his 
arrival in the Presidency issued an earnest appeal to the 
vernacular press to come to the aid of the authorities in the 
campaign against plague. The appeal met with a sympathetic 
response and His Excellency then issued an invitation to the 
editors of the vernacular papers to inspect for themselves the 
plague research laboratory at Parel in order to see the work 
carried on there and to have it explained to them. About 50 
from all parts of the Presidency accepted the invitation 
and met Sir George Clarke at the laboratory on 
Dec. 20th. 1907, the whole party being received by 
Captain W. G. Liston, I.M.S., acting head of the 
institution, who exhibited the numerous processes through 
which the plague prophylactic passes in the course 
of its manufacture and explained why inoculation provided 
the beet means for contending against plague. As it had 
been said that the advocates of the system only talked and 
did not act he submitted himself there and then for 
inoculation. This was the fifth time, he said, that he had been 
inoculated and the operation was both simple and painless. 
He also brought forward several witnesses who had been 
Inoculated several times without their constitutions having in 
any way suffered by it. Before the assembly broke up Sir 
George Clarke delivered an address, in the course of which 
he expressed the hope that his hearers would go away with 
a full knowledge as to how the serum was prepared and the 
great skill that was brought to bear on its preparation. After 
referring to the perfect method of sterilisation at high 
temperature and by the addition of carbolio acid, the 
Governor said they must have noticed the care taken 
to see that there might not be any contamination from 
any outside sources. He would not have invited them 
there unless he had been fully satisfied as to the 
great care taken in the preparation of the serum. He 
had written to them because be was absolutely convinced, 
after much deliberate study, that inoculation was the only 
way which provided the maximum immunity from plague 
with the minimum of inconvenience. Inoculation, as they 
had just seen, was simple and painless and its discomfort 
was of a very brief duration. There were other modes of 
combating plague, snch as the destruction of rats and rat 
fleas and evacuation, but those methods interfered with the 
feelings and habits of the people. If there should be an 
outbreak of plague this cold season he exhorted his 
hearers to advocate inoculation as the one thing 
needful to secure immunity. It had been alleged that 
frequent inoculation told upon the health and constitutions 
of people, hut this contention bad been successfully refuted. 
The servants at Government House were frequently inocu¬ 
lated without being any the worse for it. If they carried 
out inoculation on a large scale they could stamp out plague 
altogether. The Timet of India reports that Mr. Stuart 
Fraser, the British Resident, and the municipal commis¬ 
sioners of Bangalore on Dec. 19tb, 1907, held a large public 
meeting in the market-place to popularise anti-plague 
Inoculation. The Resident announced that on the following 
Saturday the authorities would inaugurate a new measure— 
namely, inoculations on the principle of vaccinations—with 
this difference : that nobody would be bound to submit to 
the operation. For the better classes of Indian women a 


lady inoculator would be at call. Mr. Fraser’s speech was 
translated into two vernaculars and then three leading 
Hindoo and three Mahomedan citizens came forward anrl 
offered their six residences as depots at which their friends 
and neighbours might be invited to undergo the operation. 
In this way street by street is to be taken np. For the 
more respectable classes already 11,000 inoculations have 
taken place without any untoward result and over two lakhs 
of rats have been slain. After the speeches many 
street-farers were inoculated and compensated for the 
possible loss of a day's wages by private benevolence. 

Royal Sanitary Institute.— We are informed 
that the Right Hon. the Earl of Plymouth, P.C., C.B., 
D.L., J.P., Lord-Lieutenant of Glamorganshire, has con¬ 
sented to act as President of the Twenty-fourth Annual 
Congress and Exhibition of the Royal Sanitary Institute to 
be held at Cardiff from July 13th to 22nd. The public 
meeting to inaugurate arrangements for the congress will be 
held at the City Hall, Cardiff, on Thursday, Feb. 6th; the 
Right Hon. the Lord Mayor will take the chair at 3 30 P.M. 

Imitation Cheese.— A Greek merchant, named 

Socrates Ambatellos, was summoned at Cardiff on Jan. 7th 
at the instance of the Customs authorities for importing into 
the United Kingdom “margarine cheese” which had not 
been conspicuously marked. This was the first prosecution in 
the town under the Butter and Margarine Act which came 
into force on Jan. 1st. The defendant was fined £2 and 
costs (amounting to £5) or one month’s imprisonment. 

Poisoning by Yew Leaves.— An inquest was 
held at Devonport on Dec. 23rd, 1907, relative to the death 
of a man aged 30 years. Medical evidence showed that 
death was due to poisoning by taxine, which was contained in 
the yew leaves, and the post-mortem examination showed a 
considerable amount of yew leaves in the stomach. Other 
evidence showed that deceased had recently been very 
depressed. The jury returned a verdict of “suicide whilst of 
unsound mind.” 

Longevity.— Mr. R. Hughes died recently at 

Llangollen in his 102nd year. The local press states that be 
was engaged in superintending the work on his farm until a 
few weeks ago.—It is stated that Mrs. Thomas B’a-.k died at 
Kilmarnock on Jan. 14th in her 105th year. She was born 
in Dumfriesshire on May 10th, 1803. She had seven ohildren, 
of whom only one survives.—Robert Phillips, an inmate 
of Swansea workhouse, celebrated the hundreth anniversary 
of bis birthday on Dec. 26tb, 1907. 

Salaries of Poor-Law Medical Officers.— 

At a meeting of the Pontefract board of guardians 
held on Jan. 11th Dr. W. Kemp and Mr. G. B. Hillman 
of Castleford reported that their visits to patients and 
supplies of medicine, Ao., during the six months which 
had elapsed since their appointment in place of the 
late Dr. E. Kemp had numbered over 3700, and that their 
salaries of £30 per annum each worked out on this basis 
at the rate of lid. per visit with supply of medicine. 
They asked that their salaries might be increased and 
suggested that £100 a year for each would not be an 
excessive remuneration. The matter was referred to the 
finance committee for consideration. 

Society for the Relief of Widows and 
Orphans of Medical Men. —A quarterly court of the above 
society was held on Jan. 8th, Dr. G. F. Blandford, the Presi¬ 
dent, being in the chair. 12 members of the court were present. 
Applications for membership were received from five medical 
men and they were duly elected members of the society. 
Since the last court one of the annuitants of the society, aged 
91 years, had died ; she had been in receipt of grants since 
1866 and had received £2824 from the society. Her husband 
had paid in subscriptions £27 6«. Three letters had been 
received from widows of medical men asking for relief, 
but this had to be refused as their husbands had not 
been members of the society. £534 were distributed 
as a special Christmas present amongst the annuitants 
of the charity in December, each widow receiving £10, each 
orphan £3, and those in receipt of grants under the Copeland 
Fund £5 each. The sum of £1267 10». was voted for the 
payment of the half-yearly grants to the 48 widows and 16 
orphans on the books of the society. Relief is only given to 
the widows or orphans of deceased members. Membership 
is open to any registered medical practitioner who at the 
time of his election is residing within a 20-mile radius of 




204 The Lancet,] 


BOOKS, ETC., RECEIVED.—APPOINTMENTS.—VACANOIE8. 


[Jan. 18,1928. 


Charing Cross. Full particulars and application forms may 
be obtained from the secretary at the offices of the society, 
11, Chandos-street, Cavendish-square, W. 

Presentations to Medical Practitioners.— 

Mr. F. J. Henry, M.B., Ch.B. Glasg., who is leaving Glasgow 
on his appointment as medical superintendent of High field 
Infirmary, Liverpool, was on Dec. 30th, 1907, entertained 
to dinner by his medical confreres and his friends when he 
was presented with a gold watch and chain.—On the 
occasion of his retiring from the practice of his pro¬ 
fession, Dr. George Petrie-Hay of Forres has been made 
the recipient of public testimonials from his patients and 
friends in Forres. Dr. Petrie-Hay has been in practice 
in Forres for the past 30 years. He was medical 
officer of Forres and some of the neighbouring parishes. 
In November last he received a gold watch from the St. 
Lawrence Lodge of Oddfellows, and he has now been 
presented with a silver rose bowl together with 120 guineas 
by the inhabitants of Forres and district. 


BOOKS, ETC., RECEIVED. 


Bailliere, Tindall, and Cox, 8. Henrietta-street, Covent Garden, 
London. W.C. 

Medical Laboratory Methods and Tests. By Herbert French, 
MA, M.D.Oxou., F.R.-C.P. Lond., Assistant Physician, Guy’s 
Hospital, &c. Second edition. Price 5s. net. 

Hernia, its Etiology, Symptoms, and Treatment. By W. McAdam 
Eccles, M S. Lond., F.R.C.S. Eng , Assistant Surgeon to, and 
Demonstrator of Operative Surgery at. St. Bartholomew’s Hos¬ 
pital ; Examiner in Surgery to the Society of Apothecaries; 
Examiner in Anatomy for the Fellowship of the Royal College of 
Surgeons of England. Third edition. Price 7s. 6d. net. 

Black, Adam and Charles Soho-equare, London, W. 

The Writers’ and Artists’ Year-book. 1908. A Directory for 
Writers, Artists, and Photographers. Price Is. net. 

Chatto and Windus, 111. St. Martin’B-lane, London, W.C. 

Herbert Fry’s Royal Guide to the London Charities. Edited by 
Johu Lane. Price Is. fid. 

Churchill, J. and A., 7, Great Marlborough-street, London. W. 

A Manual of Prescribing. For Students and Practitioners of 
Medicine. By C. R. Marshall, M.D., Professor of Materia 
Medica and Therapeutics in the University of St. Andrews, 
Assistant Physician to the Dundee Royal Infirmary. Price 5s. 
net. 

Plant Anatomy from the Standpoint of the Development and 
Functions of the Tissues and Handbook of Micro-Technic. By 
William Chase Stevens, Professor of Botany in the University of 
Kansas. Pricel0s.6d.net. 

The Theory and Practice of Hygiene (Notter and Firth). Revised 
and largely rewritten by R. H. Firth, Lieut.-Colonel, Royal Army 
Medical Corps, formerly Professor of Hygiene in the Royal Army 
Medical College, now Officer in Charge of the School of Army 
Sanitation, Aldershot, and Sanitary Officer to the Aldershot 
Command; Fellow of the Royal College of Surgeons of England ; 
Fellow of the Royal Society of Medicine. Third edition. Price 
21s. net. 

Guy’s Hospital Reports. Edited by F. J. Steward, M.S., and 
Herbert French, M.D. Vol. LXL, being Vol. XLVI. of the Third 
Series. Price not Btated. 

Fbow t de, Henry, and Hoddeb and Stoughton, 20, Warwick-square. 
London, E.C. 

Oxford Medical Publications. Rotunda Practical Midwifery. By 
E. Hastings Tweedy, M.D., F.R C.P.I., Master of the Rotunda 
Hospital, and G. T. Wrench, M.D., late Assistant Master. Price 
16s. net. 

Garden City Association, 602-3, Birkbeck Bank Chambers, Holborn, 
Lmdon, W.C. 

Town Planning in Theory and Practice. Price la. net. 

Gbafton Press, The, New York. 

Syphilis in its Medical. Medico-legal, and Sociological Aspeots. By 
A. llavogli, M.D., Professor of Dermatology and Syphilology in 
the Medical College of Ohio, Medical Department oi Cincinnati 
University; Dermatologist to City Hospital of Cincinnati; 
Member of the Ohio State Board of Medical Registration and 
Examination. Price not stated. 

Green, William, and Son9, Edinburgh and London. 

Arterial Ilypertonua. Sclerosis, and Blood-Pressure. By William 
Russell, M.D., F.R.C.P. Edin., Pnysician to, and Lecturer on 
Clinical Medicine in, the Royal Infirmary, Edinburgh; Lecturer 
on Practice ol Medicine, formerly Lecturer on Pathology, School 
of Medicine, Edinburgh. Price Is. 6 d. net. 

Gbiffin, Charles, and Company, Limited, Exeter-street, Strand, 
London, W.C. 

The Year-book of the Scientific and Learned Societies of Great 
Britain and Ireland. Twenty-fourth annual issue. Price Is. 6 d. 

Keener, W. T., and Co., 90, Wabash-avenue, Chicago. 

The Commoner Diseases of the Eye. How to Detect and How to 
Treat Thom. Fer Students of Medicine. By Casey A Wood, 
M. L)., V.M., D.C.L , Professor of Ophthalmology, Northwestern 
University; Ophthalmic Surgeon to St. Luke's Hospital and 
Wesley Hospital, Chicago; and Thomas A. Woodruff, M.D., 
C.M., LK OF. Lond., Ophthalmic Surgeon, St. Luke’s Hub- 
pital, and St Anthony de Padua Hospital, Chicago. Third, 
edition, enlarged and improved, with Index. Price §2 50 net. 


King, Sell, and Olding, Limited, 27, Chancery-lane, London, W.C. 

The Science Year Book, Diary, Directory, and Scientific Summary 
1908. Price 5s. net. 

Lewis, H. K., 136, Gower-street, London, W.C. 

Studies in Blood-Pressure. Physiological and Clinical. By George 
Oliver, M.D. Lond., F.R.C.P. Second edition, enlarged. Price 
4*. net. 

An Essay upon Disease, its Cause and Prevention. By G. E. 
Richmond, M D. Hons , B.Sc.. B.S., B.A Hons. London, D P II. 
Camb., late House Surgeon, Guy’s Hospital; late Demonstrator 
of Hvgieue. University College, London. Priced, net- 

The Doctor in the Schools. Being Notes on the Medical Inspection 
of Public Elementary School Children under the Education 
(Administrative Provisions) Act, 1907. By Hackworth Stuart, 
M.D. Lond., F.R.C.S K.. D.P.H. Cantab.. Medical Officer to 
llauley Education Committee; Medical Officer to the Stafford¬ 
shire Industrial School. Warrington. Price 1# net. 

Marshall Brothers, Limited, Keswick House, Paternoster-row. 
London, E.C. 

Christian Sanity. Bv A T. Schofield, M.D. With a Preface by 
Dr. Handley Moule (Bishop of Durham). Price not stated. 

Pentlasd. Young J., Edinburgh and London. 

The Edinburgh Medical Journal. Edited by Alexis Thomson, 
M.D., F.R.CS Ed., and Harvey Littlejohn, M.B., F.R C.S. Ed. 
New Series. Vol. XXII. Price not stated. 

Rkbman, Limited, 129, Shaftesbury-avenue, London, W.C. 

Guide to Diagnosis in Diseases of the Throat, Nose, and Ear. By 
Dan McKenzie, M.D Glasg., C.M., Assistant Surgeon to the 
Central London Throat and Ear Hospital. Price 5s. net. 

A Manual of Orthopedic Surgery. By August us Thorndike, M.D., 
Assistant in Orthopedics at the Harvard Medical School ; 
Visiting Surgeon to the House of the Good Samaritan; Assist¬ 
ant Orthopedic Surgeon to the Children’s Hospital, Boston. 
Price * 0s. 6 d. net. 

Royal Anthropological Institute, 3, Hanover-square, London, W. 
Nutt. David, 57-59, Long Acre, London. (For the Folk-Lore 
Society.) 

Bibliography of Anthropology and Folk-Lore. 1906. Containing 
Works published within the British Empire. Compiled by 
Northc »te W. Thomas. M A., F.R.A.I., Member of the F.L.S. 
First Annual Issue. Price 2s. net. 

Sands and Co., London and Edinburgh. 

The Nurse’s Day and Night Report Book. Price 6d. net. 

Sanitary Publishing Co , Limited, 5, Fetter-lane, London, E.C. 

The Sanitary Record Year Book and Diary, 1908. Price not stated. 




Successful applicants for Vacancies, Secretaries of Public Institutions , 
and others possessing informatioti suitable for this column, are 
invited to forward to The Lancet Office, directed to the Sub- 
Editor, not later than 9 o'clock on the Thursday morning of each 
week, such information for gratuitous publication. 

Browne, C. R., M.D. Durh., has been appointed Certifying Surgeon 
under the Factory ami Workshop Act for the Falmouth District of 
the county of Cornwall. 

Gibvax, nuoH, M.D.Giasg., has been appointed Certifying Surgeon 
under the Factory and Workshop Act for the Maybole District of 
the county of Ayr. 

Harkf.b, T. H., M.D. Lond.. has been appointed Certifying Surgeon 
under the Factory and Workshop Act for the Harwich District of 
the county of Essex. 

Hudson, Bernard. M.D.Cantab., M.R.C.P. Lond.. M It.C.S., has been 
appointed Pathologist and Registrar to the East London Hospital 
for Children, Shadw 11, E. 

Hutchinson, J. R . M B., Ch B., DP.H.Vict., has been appointed 
Assistant Medical Officer of Health of Manchester. 

James. William Morgan. B.A. Cantab., L.R C.P. Lond., M.R.C.S., has 
been appointed Medical Officer for the St. Woolos District by the 
Newport Mon ) Board of Guardians. 

Lapage, C. P.. M.D.Viet, has been appointed Medical Registrar to 
the Manchester Royal Infirmary. 

MacMahon, E J Ryan, L.R.C.P. & S. Irel., has been re-appointed 
Medical Officer of Health for the Northleach Rural District of 
Cheltenham. 

Price, Ernest Henry. L.S.A. Lond., has been appointed Resident 
Assistant Medical Officer to the Cardill Workhouse. 

Renton, John W„ M.B., Cb.B. Glasg., has been appointed Anaesthetist 
to the Incorporated Glasgow' Deutal Hospital. 




For f urther information regarding each vacancy reference should be 
made to the advertisement (see Index). 


Bangor, Carnarvonshire and Anglesey Infirmary. — House 
Surgeon. Salary £80 per annum, with board, washing, and 
lodging. 

Belgraye Hospital for Childrf.n, Clapham-road, S.W.—House 
Surgeon for six months. Salary at rate of £20 per auuum, with 
board and lodging. 

Birmingham. City- of.— Medical Officer (female) for Notification of 
Births Act. Salary £200 per annum. 

Brecon and Radnor Joint Counties Asylum, Talgarth, R.S.O., 
Breconshire. - Assistant Medical Officer, unmarried. Salary £170 
per annum, with apartments, board, washing, and attendance. 





The Lancet,] 


VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS. 


[Jan. 18, 1908 2 05 


Brighton, Susskx County - Hospital.— Second House Surgeon, un¬ 
married. Salary £60 per annum, with board and residence. 

Brighton Throat and Ear Hospital, Church-street, Queen’s-road. 
—Non-resident House Surgeon for six months, renewable. Salary 
at rate of £75 per annum. 

Bristol, University College.— Demonstrator of Physiology. 

Cambridgeshire, &.C., Asylum, Fulbourn.—Second Assistant Medical 
Officer, unmarried. Salary £120, rising to £150 per annum, with 
hoard, lodging, and attendance. 

Cancer Hospital, Fulham-road, London, S.W.—House Surgeon for 
six months. Salary £70. 

Carmarthen. Joint Counties Lunatic Asylum.— Assistant Medical 
Officer. Salary £200 per annum, with board, lodging, washing, and 
attendance. 

Chesterfield and North Derbyshire Hospital.— Junior House 
Surgeon. Salary £60 per annum, with board, apartments, and 
laundry. 

Colchester, Essex and Colchester General Hospital.— House 
Physician. Salary £S0 per annum, with hoard, residence, and 
washing. 

Eastbourne, Borough or.— Assistant to the Medical Officer of Health. 
Salary at rate of £150 per annum. 

Edinburgh, Royal Edinburgh Asylum for the Insane.— 
Phy sician-Superintendent. 

Hull, Royal Infirmary.— House Physician-in-Charge, unmarried. 
Salary £105 per annum, with board and apartments. 

Kidderminster Infirmary and Children’s Hospital.— House 
Surgeon, unmarried. Salary £100 per annum and board. 

Leeds Tuberculosis Association Sanatorium, Gateforth. near 
Selby.—Resident Medical Officer. Salary at rate of £100 per 
annum, with board, lodging, and washing. 

Liverpool Hebrew Tontine Society.—S urgeon. 

London Fever Hospital, Liverpool-road, N.— Resident Medical 
Officer. Salary £250 per annum, with board and residence. 

Maidstone, Kent County Asylum.— Fourth Assistant Medical 
Officer, unmarried. Salary £175 per annum, with quarters, attend¬ 
ance, coal, gaa, Ac. 

Montgomery County Council.— Medical Officer of Health. Salary 
£75 per annum. 

Mount Vernon Hospital for Consumption and Diseases of the 
Chest, Hampstead and Northwood, Middlesex.—Junior Resident 
Medical Officer. Salary £50 per annum, with board, lodging, Ac 

New Hospital for Women, Buston-road.—Clinical Assistant ilemale). 

Northampton, Berry Wood Asylum.— Junior Assistant Medical 
Officer, unmarried. Salary £150, increasing to £200, with board, 
lodging, and washing. 

Poplar Hospital for Accidents, Poplar, E.-Assistant House 
Surgeon for six months. Salary at rate of £80 per annum, with 
board and residence. 

Public Dispensary, 122. Drury-lane.—Physician. 

fix. Giles, Camberwell, Infirmary and Workhouse.— Assistant 
Medical Superintendent. Salary £180 per annum, with apartments, 
board, and washing. 

St. Pancras Infirmary and Workhouse, Pancras-road.—Junior 
Assistant Medical Superintendent and Medical Officer (female). 
Joint salary £80 per annum, with board, apartments, and washing. 

Seamen's Hospital Society.— Surgeon at Branch Hospital. 

South Lambeth, Stockwell. and North Bhixton Dispensary, Albert 
square, Clapbam-road.—Vacancy in the Visiting Medical St-ff. 

Staffordshire Education Committee.— Senior Medical Inspector of 
School Children. Salary £300, rising to £400. 

Stroud General Hospital.— House Surgeon. Salary £100 per 
annum, with board, lodging, and washing. 

Tiverton, Devonshire, Infirmary and Dispensary.— House Surgeon 
and Dispenser. Salary £80 and all found. 

Tkntnor, Royal National Hospital for Consumption and Diseases 
of the Chest on the Separate Principle.—Two Assistant 
Resident Medical Officers, unmarried. Salary £100 per annum, with 
board and lodging. 

Victoria Hospital for Children, Tite-street, Chelsea, S.W.—Senior 
Resident Medical Officer. Salary £105 per annum, with board, 
residence, and washing. 

Warrington Union Workhouse.— Medical Officer, non-resident. 
Salary £100 per annum Also Assistant Resident Medical Officer, 
unmarried. Salary £100 per annum, with apartments, rations, and 
allowances. 

West-End Hospital for Diseases of the Nervous System, 
Paralysis, and Epilepsy, 73, Welbeck-street, London, W.— 
Physician to Out-patients. 

Western General Dispensary, Marylebone-road, N.W.—Honorary 
Surgeon. _ 

The Chief Inspector of Factories, Home Office, S.W., gives notice of 
a vacancy as Certifying Surgeon under the Factory and Work¬ 
shop Act at Hayle, in the county of Cornwall. 


JJtarriap, anir $eat(}8. 


BIRTHS. 

Bandilands.— On Jan. 10th, at Bonvile, Winchester, the wife of John 
E. Saudi lands, M.D..of a daughter. 

Wilkinson.— On Jan. 10th, at Lahore, the wife of Major Edmund 
Wilkinson, I.M.S., of a daughter. 


DEATHS 

Bainbridgf..— On Jan. 11th, at Clevedon, Somersetshire, aged 89 years, 
Frederick Bainbridge, M.R.C.S., son of the late G. C. Bainbridge, of 
Gattonside House. Roxburghshire. 

Dhuiti.—O n Jan. 7th, at Mentone, Victoria, Australia, Lionel 
Druitt, M.D., youngest son of the late Robert Druitt, M.D., 
F.H.C.P., F.R.C.S., aged 53 years. 


N.B.—A fee of 6t. is charged for the insertion of Notices of Births, 
Marriages , and Deaths. 


Stotts, j%rt Comments, anh Jnstoers 
to Cormpitonts. 

A QUESTION IN ETHICS. 

To the Editor of The Lancet. 

Sir.—A recently took into partnership B, an excellent all-round man 
and first-rate surgeon. Some weeks later Mrs. C, a patient of long 
standing, consulted Area lump in the breast and was told by him that 
it was a simple tumour which could be removed without risk, though 
there was no immediate necessity for operation. Partly through an 
attack of “ nerves” and partly through a chill Mrs. C was confined to 
bed and was visited by A and B alternately for several days. She fre¬ 
quently discussed the question of operation with A and B, expressing 
entire confidence in both and agreeing to A’s suggestion that B should 
perform the operation on account of his wide surgical experience. She 
rapidly Improved and at the end of a week her husband informed A by 
telephone that she had gone away for a day or two. Nothing more was 
heard for six days and then A received a letter from Mr. C thanking 
him for his kindness to Mrs. C and stating that he had called in D (one 
of the senior medical practitioners in the town) to see his wife on the 
previous day. D confirmed the diagnosis, advised immediate operation, 
and was thereupon requested by C to operate next day. This he did with¬ 
out notifying A and B in any way of what had been or was going to be 
done, though fully aware that there had been no breach of friendly 
relations between A and C. When asked by A for an explanation of his 
conduct D admitted that he knew A and B had been in attendance only 
a few days previously, and said C had told him he had asked A not to 
call again *• in the meantime.” D also stated that Mrs. C had said that 
she would not be operated upon by a comparative stranger, however 
capable, and further took credit to himself for having prompted C to 
write and inform A of what had been done. 

W r as D’s line of conduct correct morally or ethically? If not, 
what should be have done? 1 am, Sir, yours faithfully, 

M.B. 

* # * On the information before us we should say that D should not have 
operated before informing A And B that the case had been handed 
over to him. There does not appear to have been any urgency about 
the case and D should, in our opinion, have notified A and B previously 
to operating.—E d. L. 

A COUNTESS’S CURE FOR SMALL POX. 

Amongst the papers of the Earl of Ancaster preserved at Grimsthorpe 
and just reported upon by the Historical Manuscripts Commission is 
a letter addressed in 1648 by “ Monsieur J. G.” to John Pridgeon, 
bear-leader to the young Lord Willoughby of that day, inclosing 
directions for preparing and taking certain physic, a number of 
recipes for purges and cooling drinks, and what is described as “ the 
Countesse of Holdernesse’s receipt for the small-pox.” Subjoined is 
the text of the latter : — 

If the partie should have the small-pox, which you may guessc 
by his heavines, burninge and cough, lette him lie warme in his 
bed but moderately, keeping his throate pretty coole, givinge him 
burnt wine with saffron till you see there will no more come 
forth Take fresh butter, a quarter of a pound, and melt It on the 
fire, as much refined searved (?) through tiffeny or lawne, and beate 
it with a spoone till it come to be so thlcke as Pomato; then take 
a fine feather (when it Is melted) and dip it in (being luke warme) 
and annoynt his face and handes twenty times in a day & 
night, nott Bufferinge the party to scratch himselfe nor rubb 
them too hard against his pillow or anythinge else, nor 
to clippe them or the like, keepings the places still anoynted 
till you see them shill off, alwayes beinge extreame carefull 
to keepe him in a temperate heate, but rather warme than 
cold, by all meanes, for if be should take cold it would endanger 
his life ; now if he should have them in his eyes or throate, take a 
little breat mllke, a little saffron, and a little white sugar-candy, 
melt them together in a saucer, and lett him swallow a little of 
this att a time, being warme, for his throate when you see them 
first appear ; then take a feather and dip it in the same and draw 
it through his eyes lidds, and by the grace of God it will preserve 
his sight. 

To take aw ay the holes in the face: Take the quantity of a pound 
of veale and putt it in some corner in a seller where it may best 
putrifie and breede maggotts; then take those maggotts, beinge 
well growne, put them on a wire and rost them before the fire, 
haviuge somethinge to preserve the drippinges of them, which you 
must take and annoynt the party’s pitta in his face, and it will 
take away the holes therein. Given by an Italian. 

X RAY AND ELECTRO-MEDICAL APPARATUS. 

We have received a we’l-illustrated catalogue of x ray and electro- 
medical apparatus from Messrs. Siemens Brothers and Co., 
Limited, of Queen Anno’s-chambers, Broadway, Weslzqinster- 
From an inspection of some of tbeir apparatus on view at 
the recent exhibition held under the auspices of the Electro 
Therapeutical Section of the Royal Society of Medicine we can speak 
favourably of what they offer. Messrs. Siemens have succeeded 





206 The Lancet,] NOTES, SHORT COMMENTS, AND ANSWERS TO CORRESPONDENTS. [Jan. 18, 1908. 


in obtaining the rare metal tantalum in comparatively large 
quantities, and on account of its high melting point—2300° C. as com¬ 
pared with 1600° for platinum—have successfully employed it in the 
construction of the anodes of x ray tubes. These can be worked at a 
bright-red heat, almost to incandescence, without injuryto the metal 
parts. A noteworthy feature is a compressor apparatus and examin¬ 
ing table which have been constructed on lines laid down by Dr. 
Albers-Schonberg. With this outfit any part of the body can be 
radiographed without disturbing the patient or exposing any part 
to the rays other than that immediately under examination. 
This firm make a speciality of portable x ray outfits for civil and 
military purposes and have designed a very ingenious contrivance 
for using the power of a horse or mule to generate the necessary 
current—in our opinion a far better arrangement for military 
service than that wherein a tandem bicycle figured and about which 
we heard so much some years ago but with which so very little 
useful work was done. There is also a large selection of protective 
and measuring devices which merit attention, as well as rectifiers 
and accessories of all kinds. Those who are interested in this 
branch of medical science will find the catalogue useful to them. 

THE TREATMENT OF PILES. 

To the Editor of The Lancet. 

Sir,—M any years ago Sir A. Gar-rod showed the great remedial value 
of sulphur In the treatment of piles, detailing a number of cases of 
cure by its internal administration In the form of a compound sulphur 
lozenge of his own prescription, continued over a period of three 
months. I think his greatest success was with retlrod army officers. 
I have used the same with decided advantage in women, in the reduc¬ 
tion In size of the piles and great consequent relief from bremorrhage. 
If patients can be Induced to persevere with them, taking one or 
perhaps two daily for a few months at a time, they will certainly gain 
relief. I should add that the lozenge of bis prescription is now on the 
market, bearing his name. 

I am. Sir, yours faithfully, 

Jan. 14th, 1908. W. J. V. Hable. 

THE HOLDERS OF MIDWIFERY LICENCES. 

A correspondent writing on this subject points out that the Irish 
Royal Colleges still grant midwifery licences to registered persons 
after examination. Our annotation referred mainly, as will be seen 
by the opening lines, to •• Licentiates in Midwifery possessing no 
other or registrable qualification." 


Disgusted .—The medical men mentioned have clearly had no hand in 
the publicity which offends our correspondent. We agree with him 
that the paragraphs are very unfortunate but the same may be said 
of the whole column. The compiler is evidently not in touch with 
the medical world. 

Inquirer.—Our correspondent is not a medical roan. If he pursues the 
usual course and consults his medical adviser he will be told whether 
the assistance of any special consulting physician or Burgeon is 
required, and be recommended to the selected man in the usual 
manner. 

T. B. B .—Medical opinion is'neither unanimous nor conclusive. The 
special circumstances of interment have to be taken into account. 
The slight “growth" commonly observed is due to shrinkage of 
the Bkin. 

Communications not noticed in our present issue will receive attention 
in our next. 


Iftfbical Iliarir for tljc ensuing 

OPERATIONS. 

METROPOLITAN HOSPITALS. 

MONDAY (20th). —London (2 p.m.), St. Bartholomew’s (1.30 P.M.), St. 
Thomas’s (3.30 p.m.), St. George’s (2 p.m.), St. Mary’s (2.30 p.m.), 
Middlesex (1.30 p.m.), Westminster (2 p.m.), Chelsea (2 p.m.), 
Samaritan (Gynecological, by Physicians, 2 p.m ), Soho-square 
(2 p.m.). City Orthopedic (4 p.m.), Gt. Northern Central (2.30 p.m.). 
West London (2.30 p.m.), London Throat (9.30 a.m.), Royal Free 
(2 p.m.), Guy’s (1.30 p.m.), Children, Gt. Ormond-street (3 p.m.). 
St. Mark’s (2.30 p.m.). 

TUESDAY (21st). —London (2 p/m.), St. Bartholomew’s (1.30 p.m.), St. 
Thomas’s (3.30 p.m.), Guy’s (1.30 p.m.). Middlesex (1.30 p.m.), West¬ 
minster (2 p.m.), West London (2.30 p.m.). University College 
(2 p.m.), St. George's (1 p.m.), St. Mary’s (1 p.m.), St. Mark’s 
(2.30 p.m.), Cancer (2 p.m.). Metropolitan (2.30 p.m.), Loudon Throat 
(9.30 a.m.), Samaritan (9.30 a.m. and 2.30 p.m.), Throat, Golden- 
square (9.30 a.m.), Soho-square (2 p.m.), ChcUea (2 p.m.), Central 
Ixmdon Throat and Ear (2 p.m.), Children, Gt. Ormond-street 
(2 p.m., Ophthalmic, 2.15 p.m.), Tottenham (2.30 p.m.). 

WEDNESDAY (22nd).—St. Bartholomew’s (1.30 p.m.), University College 
(2 p.m.), Royal Free (2 p.m.), Middlesex (1.30 p.m.), Charing Cross 
(3 p.m.), St. Thomas’s (2 p.m.), London (2 p.m.), King’s College 
(2 p.m.), St. George’s (Ophthalmic, 1 p.m.), St. Mary s (2 p.m.), 
National Orthopedic (10 a.m.), St. Peter’s (2 p.m.), Samaritan 
(9.30 a.m. and 2.30 p.m.), Gt. Northern Central (2.30 p.m.), West¬ 
minster (2 p.m.), Metropolitan (2.30 p.m.), London Throat (9.30 a.m.), 
Cancer (2 p.m.), Throat, Golden square (9.30 a.m.), Guy’s (1.30 p.m.), 
Royal Ear (2 p.m.). Royal Orthopedic (3 p.m.), Children, Gt. 
Ormond-street (9.30 a.m., Dental, 2 p.m.), Tottenham (Ophthalmic, 
2.30 p.m.). 


THURSDAY (23rd).— St. Bartholomew's (1.30 p.m.), St. Thomaa’a- 
(3.30 p.m.). University College (2 p.m.), Charing Cross (3 p.m.), St. 
George's (1 p.m.), London (2 P.m.), King's College (2p.m.), Middlesex 
(1.30p.m.), St. Mary’s (2.30 p.m.). Soho-square (2 p.m.), North-West 
London (2 p.m.), Gt. Northern Central (Gynaecological, 2.30 p.m.). 
Metropolitan (2 30 p.m.), London Throat (9.30 a.m.), Samaritan 
(9.30 a.m. and 2.30 p.m.). Throat, Golden square (9.30 a.m.), Guy’s 
(1.30 p.m.), Royal Orthopaedic <9 a.m.). Royal Ear (2 p.m.). Children, 
Gt. Ormond-street (2.30 p.m.). Tottenham (Gynaecological. 2.30 p.m.) 
FRIDAY (24th).—London (2 p.m.), St. Bartholomew’s (1.30 p.m.), St. 
Thomas’s (3.30 p.m.), Guy’s (1.30 p.m.), Middlesex (1.30 p.m.). Charing 
Cross (3 p.m.), St. George’B(l p.m.), King's College (2 p.m.), St. Mary's 
(2 p.m.), Ophthalmic (10 a.m.), Cancer <2 p.m.), Chelsea (2 p.m.), Gt. 
Northern Central (2.30 p.m.), West London (2.30 p.m.), London- 
Throat (9 30 a.m.), Samaritan (9 30 a.m. and 2.30 p.m.). Throat, 
Golden-square (9.30 a.m.), City Orthopaedic (2.30 p.m.), Soho-square- 
(2 p.m. ), Central London Throat and Ear (2 P.M.), Children. Gt. 
Ormond-street (9 a.m., Aural, 2 p.m.), Tottenham (2 30 p.m ), St. 
Peter's (2 p.m.). 

SATURDAY (25th). —Royal Free (9 a.m.), London (2 p.m.), Middlesex 
(1.30 p.m.), St. Thomas's (2 p.m.). University College (9.15 a.m.), 
Charing Cross (2 P.M.). St. George’s (1 p.m ). St. Mary's (10 a.m.). 
Throat, Golden-square (9.30 a.m.), Guy’s (1.30 p.m.), Children, Gt. 
Ormond-street (9.3) a.m.). 

At the Royal Bye Hospital (2 p.m.), the Royal London Ophthalmic 
(10 a.m.), the Royal Westminster Ophthalmic (1.30 p.m.), and the 
Central London Ophthalmic Hospitals operalions are performed dally. 


SOCIETIES. 

ROYAL SOCIETY OF MEDICINE. 20, Hanover-rquare, W. 

Tuesday.- (Pathological Section), 8.30 p.m.. Dr. W. O. Meek; 
Tuberculous Endocarditis. Mr. S. G. Shattock and Mr. W. H. 
Battle : Diffuse Osteoma of Femur following Fracture. Mr. C. 
W. Rowntree : Malignant Disease of the Rectum in a Boy aged 
Ten Years. Dr. H. Colwell. The Effects of Calculi (chiefly 
Vesical) upon a Photographic Plate in the Dark. Mr. W. G. 
Spencer: Card Specimens. 

Friday.— (Epidemiological Section). 8.30 p.m., Dr. B. W. Goodall 
and Dr. H. E. Corbin : Rubella. 

CHELSEA CLINICAL SOCIETY, Chelsea Dispensary, Manor-street, 
Chelsea, S.W. 

Tuesday.— 8.30 p.m.. Dr. F. J. McCann : Symptoms and Diagnosis 
of Cancer of the Body of the Womb (illustrated by lantern 
slides). The President and Dr. J. Mansell Moullin : Patho¬ 
logical Specimens. 


LECTURES, ADDRESSES, DEMONSTRATIONS, &c. 

MEDICAL GRADUATES’ COLLEGE AND POLYCLINIC, 22, 
Chenies-strect, W.C. 

Monday.— 4 p.m., Mr. G. Pernet: Clinique (Skin). 5.15 p.m.. 
Lecture : Mr. L. Mummery The Symptoms aud Diagnosis of 
Cancer of the Largo Iutestine. 

Tuesday. —4 p.m.. Dr. J. Taylor: Clinique (Medical). 5.15 p.m.. 
Lecture :—Dr. W. Langdon Brown : What Constitutes 
Diabetes * j 

Wednesday.— 4 p.m., Mr. A. H. Tubby: Clinique (Surgical). 
5.15 p.m.. Lecture :— Dr. A. B. Giles -. Displacement or the 
Pelvic Organs. 

Thursday.— 4 p.m., Mr. Hutchinson : Clinique (Surgical). 
Frii-ay.—4 p.m., Mr. W. Stuart-Low : Clinique (Throat). 
5.15 p.-m.. Lecture Dr. G. H. Savage: Mental Disorders of 
Childhood. 

POST-GRADUATE COLLEGE, West London Hospital, Hammersmith, 
road, W. 

Monday.— 12 noon: LectureDr. Low: Pathological. 2 p.m., 
Medical and Surgical Clinics. X Rays. Mr. Dunn : Diseases 
of the Eye. 2.30 p.m.. Operations. 5 p.m., LectureDr. 
Saunders : Clinical, with cases. 

Tuesday.—10 a.m.. Dr. Moullin: Gyn:rcological Operations. 
12 noon: Lecture:—Dr. Pritchard: Practical Medieine. 2 p.m., 
Medical and Surgical Clinics. X Rays. Dr. Ball: Diseases of 
the Throat, Nose, and Ear. 2.30 p.m.. operations. Dr. Abraham : 
Diseases of the Skin. 5 p.m., Lecture :—Dr. Ball: Remarks on 
Middle Bar Suppuration (with lantern slides). 

Wednesday.— 10 a.m.. Dr. Ball: Diseases of the Nose, Throat, and 
Ear. Dr. Saunders : Disoases of Children. 2 p.m.. Medical and 
Surgical Clinics. Dr. K. Scott: Diseases of the Eye. X Rays. 
2.30 p.m., Operations. 5 p.m., Lecture:—Mr. Pardoe: Sterility 
in the Male. 

Thursday.—12 noon, Lecture:—Dr. Pritchard: Practical Medicine. 
2 p.m., Medical and Surgical Clinics. X Rays. Mr. Dunn: 
Diseases of the Eye. 2.30^ p.m.. Operations. 5 P.M., Lecture:— 
Mr. Baldwin: Practical Surgery. 

Friday.— 10 a.m.. Dr. M. Moullin : Gynaecological Operations. 
2 P.M., Medical and Surgical Clinics. X Rays. Dr. Ball; 
Diseases of the Throat, Nose, and Ear. 2.30 p.m., Operations. 
Dr. Abraham : Diseases of the Skin. 5 p.m.. Lecture:—Mr. LI. 
Williams : A Discussion on the Dental Conditions which Affect 
the General Health. 

Saturday.— 10 a.m. , Dr. Ball: Diseases of the Throat, Nose, and 
Ear. 2 p.m., Medical and Surgical Clinics. X Rays. Dr. K. 
Scott: Diseases of the Eye. 2.30 p.m.. Operations. 
NORTH-BAST LONDON POST-GRADUATE COLLEGE, Prince of 
Wales’s General Hospital,Tottenham, N. 

Monday.— Cliniques:—10 a.m.. Surgical Out-patient (Mr. H. 
Evans). 2.c0 p.m., Medical Out-patient (Dr. T. R. Whipham); 
Throat, Nose, and Ear (Mr. H. W. Carson); X Ray (Dr. A. H. 
Pirie). 4.30 p.m.. Medical In-patient (Dr. A. J. Whiting). 
Tuesday.— Clinique:—10.30 a.m.. Medical Out-patient (Dr. A. G. 
Auld). 2.30 p.m.. Surgical Operations (Mr. Carson). Cliniques:— 
Surgical Out-patient (Mr. Edmunds); Gynaecological (Dr. A. E. 
Giles). 4.30 p.m., Lecture:—Mr. H. W. Carson : Diagnosis of 
Diteases of the Large Intestine. 




The Lancet,] 


DIARY.—EDITORIAL NOTICE6.—MANAGER’S NOTICES, 


[Jan. 18, 1908. 207 


Wednesday.—C liniques2.30 p.m., Medical Out patient (Dr. 
Whiphatn); Dermatological (Dr. G. N. Meacheu); Ophthalmo- 
logical (Mr. 11. P. Brooks). 

Thursday.— 2 30 p.m , Gynaecological Operations. (Dr. Giles). 
CliniquesMedical Out-patient (Dr. Whiting); Surgical Out- 
patient (Mr. Carson); X Hay (Dr. Pirie). 3 p.m.. Medical 
In-patient (Dr. G. P. Cbappel). 4 30 p.m.. Lecture Dr. T. K. 
W hipbam : Pneumonia in Childhood. 

Friday.— 10 a.m., Clinique : —Surgical Out-patient (Mr. H. lCvana). 
2.30 p.m.. Surgical Operations (Mr. Edmunds). Cliniques: — 
Medical Out-patient (Dr. Auld); Eye (Mr. Brooks). 3 p.m., 
Medical In-patient (Dr. M. Leslie). 

LONDON SCHOOL OF CLINICAL MEDICINE, Dreadnought 
Hospital, Greenwich. 

Monday.— 2.15 p.m., Sir Dyce Duckworth : Medicine. 2.30 p.m., 
Operations. 3.15 pm., Air. W. Turner: Surgery. 4 p.m., Dr. 
SiClair Thomson: Ear and Throat. Out-patient Demonstra¬ 
tions .— 10a.m., Surgical and Medical. 12 noon, Ear and Throat. 

2.15 p.m. . Special Lecture ;— Sir Dyce Duckworth i Sciatica. 
Tuesday.—2.15 p.m.. Dr. K. T. Hewlett: Medicine. 2.30 p.m., 

Operations. 3.15 p.m., Mr. Car less : Surgery. 4 p.m., Mr. M. 
Morris: Diseases of the Skin. Out-patient Demonstrations :— 

10 a.m., Surgical and Medical. 12 noon, Skin. 
1Vedxksday.-~2.15 p..m., Dr. F. Taylor: Medicine. 2.30 p.m., 

Operations. 3.30 p.m., Mr. Cargill: Ophthalmology. Out¬ 
patient Demonstrations :—10 a.m., Surgical and Medical, 

11 a.m., Eye. 

Thursday.— 2.15 p.m., Dr. G. Rankin : Medicine. 2.30 p.m., Opera 
Lions. 3.15 p.m., Sir W. Bennett : Surgery. 4 p.m., Mr. M. 
Davidson : Radiography. Out-patient Demonstrations :— 
10 a.m.. Surgical and 'Medical. 12 noon, Ear and Throat. 

3.15 p.m.. Special Lecture :-Sir Wm. Bennett: The X hays in 
Relation to the Diaguosia of Appendicitis, Ac. 

Friday*. - 2.15 p.m.. Dr. R. Bradford: Medicine. 2.30 p.m., 
Operations. 3.15 p.m., Mr. McGavin: Surgery. Out-patient 
Demonstrations:—10 a.m., Surgical and Medical. 12 noon. 
Skin. 

Saturday.— 2.30 p.m.. Operations. Out-patient Demonstrations :— 
10 a.m.. Surgical and Medical. 11 a.m., Eye. 

CrREAT NORTHERN CENTRAL HOSPITAL, Holloway road, N. 

Monday.— 9 a.m., Operations (Mr. White). 2.30 p.m., In-patients — 
Medical (Dr. Beevor); Out-pailemtB—Medical (Dr. Willcox), 
Surgical (Mr. Low), Eye (Mr. Morton and Mr. Coate). 

Tuesday. - 2.3J p m., In-patients Medical (Dr. Beale), Throat and 
Ear (Mr. Waggett); Out-patients—Surgical (Mr. Edmunds), 
Throat and Ear (Mr. French); Operations (Mr. Beale). 
Wednesday.—2.3 ) p.m.. In-patients-Surgical (Mr. Stabb); Out¬ 
patients—Medical (Dr. Border), Gynecological (Dr. Lockycr), 
Skin (Dr. W'hitheld), Teeth (Mr. Baly); Operations (Mr. Stabb). 
Thuhsday. -2.30 p m.. In patients—Medical (Dr. Morlson). 
Friday.— 3.30 p.m., Lecture:—Dr. J. H. Horder: Residual Sym¬ 
ptoms after Ceiebro-spiual Fever. 

NATIONAL HOSPITAL FOR THE PARALYSED AND EPILEPTIC, 
Queen-square, Bloomsbury, W.C. 

Tuesday.—3.30 p.m., Lecture :— Dr. Tooth : Disseminated Sclerosis. 
Friday. — 3.30 p.m., Lecture:—Mr. Sargent: surgery of the 
Nervous System. 

ST. JOHN’S HOSPITAL FOR DISEASES OF THE SKIN, 
Leicester-square, W.C. 

Thursday.— 6 p.m. , Lecture :—Dr. M. Dockrell: Paratuberculldes 
(due to Tuberculous Toxins): I., Macular; II., Papular; 111, 
Pustular; IV , Pigmentary. 

CHARING CROSS HOSPITAL. 

Thursday.— 3 p.m.. Demonstration:—Dr. Galloway and Dr. 
MacLeod: Diseases of the Skin. 4 p.m.. Demonstration: — 
Mr. Wateihouse: Surgical. (Post-Graduate Course). 


EDITORIAL NOTICES. 

It is most important that communications relating to the 
Editorial business of The Lancet should be addressed 
exclusively “To the Editor,” and not in any case to any 
gentleman who may be supposed to be connected with the 
Editorial staff. It is urgently necessary that attention should 
be given to this notice. 


MANAGER’S NOTICES. 

THE INDEX TO THE LANCET. 

The Index and Title-page to Vol. II. of 1907, which was 
completed with the issue of Deo. 28tb, were given in 
The Lancet of Jan. 4th, 1908. 

VOLUMES AND CASES. 

Volumes for the second half of the year 1907 are now 
ready. Bound in cloth, gilt lettered, price 18s., carriage 
extra. 

Cases for binding the half year's numbers are also ready. 
Cloth, gilt lettered, price 2 s., by post 2s. 3d. 

To be obtained on application to the Manager, accompanied 
by remittance. _ 


TO SUBSCRIBERS. 

Will Subscribers please note that only those subscriptions 
which are sent direct to the Proprietors of The Lancet at 
their Offices, 423, Strand, London, W.C., are dealt with by 
them Subscriptions paid to London or to local newsagents 
(with none of whom have the Proprietors any connexion what¬ 
ever) do not reach The Lancet Offices, and consequently 
inquiries concerning missing copies, ki., should be sent to 
the Agent to whom the subscription is paid, and not to 
The Lancet Offices. 

Subscribers, by sending their subscriptions direct to 
The Lancet Offises, will insure regularity in the despatch 
of their Journals and an earlier delivery than the majority 
of Agents are able to effect. 

The Colonial and Foreign Edition (printed on thin 
paper) is published in time to catch the weekly Friday mails 
to all parts of the world. 

The rates of subscriptions, post free, either from 
The Lancet Offices or from Agents, are :— 


For the United Kinodom. 

One Year .£1 12 6 

Six Months. 0 16 3 

Throe Months . 0 8 2 


To the Colonies ani> Auroad. 

One Y’ear ... .£1 14 8 

Six Months. 0 17 4 

Three Months . 0 8 8 


Subscriptions (which may commence at any time) are 
payable in advance. Cheques and Post Office Orders (crossed 
“London and Westminster Bank, Westminster Branch”) 
should be made payable t,o the Manager, Mr. Charles Good, 
The Lancet Offices, 423, Strand, London, W.C. 


TO COLONIAL AND FOREIGN SUBSCRIBERS. 

Subscribers abroad ark particularly requested 
to note the rates op subscriptions given above. It 

has come to the knowledge of the Manager that in some 
cases higher rates are being charged, on the plea that the 
heavy weight of The Lancet necessitates additional 
postage above the ordinary rate allowed for in the terms of 
subscriptions. Any demand for increased rates, on this or on 
any otner ground, should be resisted. The Proprietors of 
Tin: Lancet have for many years paid, and continue to pay, 
the whole of the heavy cost of postage on overweight foreign 
issues; and Agents are authorised to collect, and generally 
do so collect, from the Proprietors the cost of such extra 
postage. 

The Manager will be pleased to forward copies direct from 
the Offices to places abroad at the above rates, whatever be 
the weight of any of the copies so supplied. Address— 
The Manager, The Lancet Offices, 423, Strand 
London, England. 


It it especially requested that early intelligence of local d ents 
haring a medical interest, or which it it desirable to bring 
under the notice of the profession, may be sent direct to 
this office. 

Lectures, original articles, and reports should be written on 
one tide of the paper only, and when accompanied 
BY BLOOKS IT IS REQUESTED THAT THE NAME OF THE 
AUTHOR, AND IF POSSIBLE OK THE ARTICLE, SHOULD 
BE WRITTEN ON THE BLOCKS TO FACILITATE IDENTI¬ 
FICATION. 

Letters, whether intended for insertion or for private infomia- 
tion, must be authenticated by the names and addresses of 
their writers—not necessarily for publication. 

We cannot prescribe or recommend practitioners. 

Local papers containing reports or news paragraphs should be 
marked and addressed " To the Hub Editor.” 

Letters relating to the publication, sale and advertising 
departments of The Lancet should be addressed "To the 
Manager." 

We oannot undertake to return IfSH. not used. 


METEOROLOGICAL READINGS. 

(Taken daily at 8 JO a.m. by Steward's Instruments.) 

The Lancet OfBoe, Jsn. ISth, 1908. 


Date. 

Barometer 
reduced to 
Sea Level 
and 32° P. 

Direc¬ 

tion 

of 

Wind. 

I Solar 
Rain- Radio 
fall. In 
Vacuo. 

Maxi¬ 

mum 

Temo. 

Shade. 

Min. 

Temp. 

YVet 

Bulb. 

Baft. 

Remarks. 

Jan. 10 

30 25 

N.E. 

... | 47 

37 

31 


32 

Cloudy 

., ii 

30 43 

S.W. 

48 

35 

26 


27 

Foggy 

„ 12 

30 45 

K. 

... ! 49 

36 

26 


29 

Hue 

„ 13 

30 21 

K. 

47 

41 

29 


50 

foggy 

14 

30*27 

S.W. 

... | 59 

47 

30 

39 

40 

Overcast 

„ 15 

30 22 

S.W. 

... I 56 

50 

40 

43 

44 

Overcast 

„ 16 

29 99 

S.W. 

53 

53 

44 

49 

50 

Overcast 


During the week marked copies of the following new-paiera 
have been received .— Scientific American. Standard, Daily 
Telegraph, Birmingham Post, Bristol Mercury. Freeman's Journal, 
Halt Mail Morning Pott, Sheffield Independent. ■>heffi Id Telegraph. 
Westminster Gazelle. Daily Sews. The Harden, pharmaceutical 
Journal, Chemical Hews, Dublin Times, Liverpool Courier, Army 
and Havy Gazelle, Broad Arrow, dec. 








208 The Lancet,] 


ACKNOWLEDGMENTS OF LETTERS, ETC., RECEIVED, 


[Jan. 18, 1908, 


A*— Mr. J. E. Adams, 

Dr. E. Anningson, Cambridge; 
Mr. James Adams, Eastbourne; 
Automobile Contract Co., Lond. 

B.—Sir James Barr, Liverpool; 
Rev. J. O. Bevan, Chillenden; 
Miss C. S. Bremner, Lond.; 
Mr. F. A. Brockhaus, Lond.; 
Miss M. Barnard, Chislehurst; 
Mr. S. Bucciarelli, Rome; 
Birmingham Corporation, Medi¬ 
cal Officer of Health of • Mr. J. 
Boot, Nottingham; Mr. R. G. 
Brown, Glasgow; Boston Daily 
Advertiser , Boston, U.S.A., Pub¬ 
lisher of; Mr. J. A. Batley, 
Leeds; Mr. S. H. Benson, Lond.; 
Belgrave Hospital for Children, 
Secretary of; Dr. John Bier- 
nacki, Lond.; Dr. H. D. Bishop, 
Guernsey. 

O. —Mr. E. Croft, Plymouth; 
Coventry Education Committee, 
Secretary of; C. W. P.; C. W. T.; 
Dr. Ralph H. Crowley, Heaton ; 
Messrs. Arthur H. Cox and Co., 
Brighton; Mr. Richard Cowen, 
Lond. 

D.— Dr. Morgan Dockrell, Lond.; 
Dr. J. E. Dick, Edinburgh; 
Department of Agriculture, 
Ottawa, Veterinary Director- 
General of; Mr. E. Darke, Lond.; 
Dundee Royal Infirmary, Medical 
Superintendent of; The Dental 
Manufacturing Co., Lond.; Mr. 
Alexander Duke, Lond. 

B.— Dr. R. Edwards, Lond.; A. R. 
Elliott Advertising Co., New 
York; Messrs Elliott, Son, and 
Boy ton, Lond.; Eastbourne 
Borough Education Committee, 
Secretary to the; Mr. Arthur 
Edmunds, Lond.; Messrs. Evans, 
Gadd and Co., Exeter. 

P, Mr. W. Hallett Fry, Lond.; 
The Fine Art Society, Lond.; 
Messrs. Fairchild Bros, and 
Foster, Lond.; Mr. P. Clennell 
Fenwick, Christchurch, New 
Zealand; Dr. Theodore Fisher, 
Sidcup. 

G. — Mr. J. Grant, Edinburgh; 
Mr. W. A. Griggs, Leicester; 
Dr. W. F. Greaven, Rosario, 
Argentine Republic; Gloucester 
General Infirmary, Secretary of; 
Messrs. R. W. Greeff and Co., 
Lond.; Messrs. C. T. Getting 
and Sons, Lond.; General Medical 
Council, Lond., Registrar of; 
G. V. 

H. —Mr. Russell Howard, Lond.; 
Mr. R. G. Hann, Leeds; Messrs. 

C. J. Hewlett and Son, Lond.; 
Dr. Eustace Hill, Durham; 
Mr. Reginald Harrison, Lond.; 
Messrs, fl. M. Hobson. Lond., 
Managing Director of; Harting- 
ton Nursing. Ac., Home, Bourne¬ 
mouth, Matron of; Dr. C. 
Heaton, Westgate - on - Sea ; 
Mr. G. S. Haycock. Lond.; 
Mr. M. C. O. Hurdy, Ynyshir; 
Mr. J. Hatton, Buxton; Hull 
Royal Infirmary, Secretary of; 
Hospital for Incurables, Man¬ 
chester, Secretary of. 

I. —The Illuminating Engineer , 
Lond., Editor of; Income-Tax 
Reduction League, Lond., Secre¬ 
tary of. 

J. —Dr. E. Lloyd Jones, Cam¬ 
bridge ; J. G. V. 

JL—Mr. W. S. Kerr. Sheffield ; 
Messrs. H. S. King and Co., 
Lond.; Messrs. G. Keener and 
Co., Lond.; Dr. C. P. Kennard, 
Port Morant; King Edward VII. 
Sanatorium, Midnurot, Secre¬ 
tary of; Messrs. R. A. Knight 


and Co. Lond.; Kidderminster 
Infirmary, Secretary of. 

L.—Mr. fl. K. Lewis, Lond.; 
LeedB Association for the Preven¬ 
tion of Tuberculosis, Secretary i 
of; Messrs. Lloyd, FoBkett, and 
Co., Lond.; Mr. J. D. Leigh, 
Bishop Auckland; Dr. J. C. 
Larkin, Hillsboro 1 , U.S.A.; Mr. 
Hugh Lett, Lond.; Messrs. Lee 
and Nightingale. Liverpool. 

M—Dr. Wilfrid O. Meek, Lond.; 
Mr. D. Matbleaon, Edinburgh; 
Messrs. Merck and Co., Lond.; 
Mr. J. M. Mangan, Ennis; 
Mr. J. Murray, Lond.; Maltine 
Manufacturing Co., Lond.; ! 
Messrs. J. F. Macfarlan and Co., 
Lond.; Mr. F. S. Mackenzie, 
Kyeburn, Otago, New Zealand; 
Dr. G. S. Moore, Huddersfield ; 
Montgomery County Council, 
Welshpool, Clerk to the; Dr. 
A. MacGregor, Clayton West; 

M. B.; Mr. J. May, Wenningtou; 
Mr. J. Y. W. MacAlister, Lond. 

N. —Novo Belt Co., Manchester; 
National Hospital for the Para¬ 
lysed and Epileptic. Lond., 
Dean of; National Anti Vaccina¬ 
tion League, Lond., lion. Secre¬ 
tary of; Mr. J. C. Needes, Lond.; 
Mr. H. Needes, Lond. 

O. —Professor W. Osier, Oxford; 
Ozonair, Ltd., Lond.; Major 
Oliver, R.A.M.C. (V.), Maidstone. 

P. — Dr. D. R. Paterson, Cardiff; 
Dr. F. S. Pitt-Taylor, Rock 
Ferry; Mr.GeorgePernot,Lond.; 
Messrs. Poulides and Co., Lond; 
Dr. T. F. Pedley, Rangoon; 
Dr. B. W. Philip, Edinburgh; 
Dr.T. S. Picken, Paisley; Messrs. 
Peacock and Hadley, Lond. 

R.—Dr. G. Rheiner, St. Gall; 
Lady Russell Reynolds, Lond.; 
Dr. T. H. Rockwell, New York ; 
Dr. Samuel Rideal, Lond.; 
Dr. Alfred Robinson, Rother¬ 
ham; Dr. Burton Rogers, Man¬ 
hattan, Kansas; Royal Sanitary 
Institute, Lond., Secretary of; 
Messrs. Reynolds and Branson, 
Leeds; Royal Meteorological 
Society, Lond. 

8 .— Dr. J. C. Simpson, Cambridge; 
Messrs. G. Street and Co., Lond.; 
Star Engineering Co., Wolver¬ 
hampton ; Captain R. Steen, 

I.M.S., Mainpuri, India; Mr. 
Paris Singer, Paignton; Society 
of Arts, Lond., Secretary of ; 
Mr. Charters J. Symonds, Lond.; 
Dr. C. F. Selous, Barton on-Sea; 
Staffordshire Education Com¬ 
mittee, Stafford, Director of; 
South Wales Argus, Newport, 
Manager of; Scholastic, Clerical, 
Ac., Association, Lond.; St Giles, 
Camberwell, Guardians. Clerk to 
the; Society for the Relief of 
Widows and Orphans of Medical 
Men, Lond., Secretary of; Dr. 
James E. H. Sawyer, Birming¬ 
ham. 

T. — Dr. C. Bell Taylor, Mapperley 
Park; T. S. P ; T. J. H.; Tan¬ 
ganyika Concessions, Lond., 
Assistant Secretary of. 

U. —United Services Medical 
Society, Lond., Joint Hon. Secre¬ 
tary of; University College, 
Bristol, Secretary of, 

V. —Mr. A. de Vallancey, Lond. 

W. — Miss Wise, Loddiswell; Mr. 

E. Wahliss, Lond.; Dr. Herbert 
Williamson, Lond.; Messrs. 
Widonmann, Broicher and Co., 
Lond. 

Z ,—Miss Frances Zanetti, Man¬ 
chester. 


Communications, Letters, &c., have been 
received from— 

Lond.; 


Letters, each with enclosure, are also 
acknowledged from— 


A. — Dr. G. H. Adams, Melbourne; 
Dr. J. Atlee, Lond.; Mr. T. 
Armstrong, Lond.; Mr. D. W. 
Anderson, Newcastle; Mr. W. 
Andrews, Oxford; A. W. B., 
Lond. 

B. — Sir T. Lauder Brunton, Lond.; 

Mr. C. Birehall, Liverpool; 
Mr. E. H. Beaman, Normanton ; 
Mrs. M. H. Bentley, Port wood; 
Dr. P. B. Bennie, Melbourne; 
Dr. T. Buchan, Strathmiglo; 
Dr. B.; Dr. J. B. Blaikie, Lond.; 
Sir John Broadbent, Bart., Lond.; 
Dr. F. C. Brodie, Woottou, Isle 
of Wight; Berry Wood Asylum, 
Northampton, Clerk to the; 
Dr. R. W. Brimacombe, Lond.; 
Mr. H. Butterfield, Northamp¬ 
ton: Surgeon-General G. Bain- 
bridge, cievedon; Bir¬ 

mingham and Midland Free 
Hospital for Sick Children, 
Secretary of; Belfast District 
Lunatic Asylum, Medical Super¬ 
intendent of; Messrs. Brown and 
Son, Huddersfield; Barnsley 
Hall, Bromsgrove, Secretary of; 
Mr. G. W. J. Baker, Stourbridge. 

C. —Dr. W. F. Croll, Aberdeen; 
Dr. S. G. Champion, Bourne¬ 
mouth ; Chesterfield, Ac, Hos¬ 
pital, Secretary of; Messrs. 
Castor and Co.,'Boston, U.S.A.; 
Mr. F. W. Clarke, Chorlton-cum- 
Hardy; Children’s Hospital, 
Sheffield, Secretary of; C. F. P.; 
Messrs. Cadbury Bros., Bourne- 
ville; Mr. E. Chambers, Load.; 
Cotswold Sanatorium, Chelten¬ 
ham, Secretary of; Central 
London Throat, Ac., Hospital, 
Secretary of. 

D. —Dr. J. H. Davies, Port Talbot; 
Mr. G. J. Dowse, Lond.; Mr. A. 
Donn&mette, Paris; D., Ports¬ 
mouth ; Messrs. Douglas and 
Foulis, Edinburgh: Mr. B. C. 
Das, Santipur, India; Dr. A. B. 
Dunne, Nottingham. 

B.— Dr. F. H. Ellis, Southampton ; 
Dr. C. C. Easterbrook, Ayr; 

K. G. A. 

F.— Mr. J. Fitzgerald, Queenstown; 
Mr. H. W. Purniv&U, Woodbury; 
Messrs. Ferria and Co., Bristol; 
Mr. W. Falla, St, Hellers; Dr. 
Farls, Ennis; Dr. J. K. Frost, 
Hereford; F. J. L.; Fermanagh 
County Hospital, Enniskillen, 
Secretary of; Dr. H. S. Faber, 
Marseilles; Mr. L. Franklin, 
Southwick. 

Q.—Mr. R. J. Godlee, Lond.; 
Mr. W. V. Griffith, Coedpceth; 
Dr. W. H. Gregory, Beverley; 
Messrs. Grace Bros, and Co., 
Lond.; G. H. R.; Guernsey, 
Medical Officer of Health of; 
Dr. B. K. Goldsmith, Lond.; 
Mr. J. W. Griffin, Rowley Regis; 
Captain C. A. Gill, I.M.S., 
Lahore. 

H.— Mr. W. H. Hall, Woking; 
Mr. W. Hubert, Billingshurst; 
Mr. W. S. Holden, Liverpool; 
H. E. H.; H. W. G. M.; H. M.; 
Mr. T. Hargreaves, Manchester; 
Mr. Hilliard, Winchester; Mr.T. 
Hawkesley, Lond.; Dr. W. B. 
Heyward, Launceston, Tasmania; 
Mr. F. C. Hitchins, St. Austell; 
Dr. W. Hutchison, Widnes; 
Messrs. J. Hatch and Sons, 
Southport. 

L— International News Co., Lond. 

J.-Mr. G. Jones, Alton ; J. W. F.; 


J. E. T.; J. H. J.; J. L. B.; 
J. M. D. ; J. H.; J. M. T. M. C.; 
J. A. C. 

K.— Mr. S. Karger, Berlin; Messrs. 
H. and T. Kirby and Co., Lond.; 
Dr. K.M. Koury, Dueim, Sudan; 
Mr. B. Kaufman, San Francisco, 

U.S.A.; Kent County Asylum, 
Maidstone, Clerk to the. 

L—Dr. J. W. Linnell, Pavenham; 
Mr. W. W. Linnev, West Croy¬ 
don; Locum, Leicester; Lister 
Institute of Preventive Medicine, 
Director of; Mr. H. Le Soudier, 
Paris. 

M-—Dr. J. McGregor, Bridgend; 
Dr. J. H. Meikle, Edinburgh; 
Manchester Medical Agency, 
Secretary of; Miss Micb6d, 
Emsworth; Messrs. McKesson 
and Robbins, New York; Messrs. 
May, Roberts and Co., Lond.; 
Messrs. Mitchell and Co., Lond.; 
Dr. J. McDonald, Belford; 
Dr. J. E. Macllwaine, Belfast; 
Messrs. Mackie and Co., War¬ 
rington ; Dr. M. D. Morison, 
Old Bridgeport, Canada ; Messrs. 
Menzies and Go., Edinburgh ; 
Dr. W. Milligan, Manchester; 
Messrs. Manlove, Alliott. and 
Co.. Nottingham; Middles¬ 
brough Corporation, Accountant 
to the; Dr. B. M. Madden, 
Bromley; Dr. A. W. Mackay, 
Inverness. 

N. — Dr. R. G. Nothwanger, Cardiff ; 
Mr. H. A. E. Noble. Umtata, 
Cape Colony; Dr. O. Naz, Lond. 

O. —Dr. Ingersoll Olmsted, Hamil¬ 
ton, Canada; Dr. Cyril Ogle, 
Lond. 

P. —Porbander State, India. Chief 
Medical Officer of; Preston 
Royal Infirmary, Secretary of; 
Messrs. Parke, Davis, and Co., 
Lond.; Poplar Borough, Lond., 
Accountant to the. 

R.—Mr. H. Powell Rees, Lond.; 

R. A.; Mr. C. Ryall, Lond.; 
The Hon. Gladys Rice, Llaudilo; 
Dr. A. B. dos Remedios, Lou- 
renpo Marques; Mrs. Roberts, 
Plymptcn. 

8.—Mr. C. Scudamore, Rbymney; 
Mr. Eric H. Shaw, Durham; 
Mr. H. B. Saxton, Nottingham; 
Mr. W. S. Stevenson, Lond.; 
Seltzogene Patent Charges Co., 
St. Helen’s, Manager of; Messrs. 
Siemens Bros, and Co., Lond.; 
Messrs. Sykes, Josephine, and 
Co., Lond.; Mr. U. Scholl, Liver¬ 
pool ; Mr. A. Sieger, Greenock ; 
Mr. E. Smith, Birkenhead; 
Scarborough Urban District 
Council, Accountant to the; 

S. A. B.; Stroud General Hos¬ 
pital, Clerk of. 

T.—Dr. H. Campbell Thomson, 

T. J. C ; Dr. P. L. Townley, 
Gayndali, Queensland; Taunton 
and Somerset Hospital, Secre¬ 
tary of; Mr. J. Thin, Edin¬ 
burgh. 

V. —Mr. G. Vogt, Kendal; Victoria, 
Agent General for London ; Mr. 

W. Vincent, Reading. 

W. —Mr. H. Welter, Paris; W. L.; 
Messrs. Wilson and Son, Lond.; 
Women’s General Missionary 
Society, Pittsburg, Treasurer of; 
Mr. T. F. Wyse, Walkley; 
Messrs. H. Wilson and Son, 
Lond. 

Y.—Dr. A. W. Young, Southamp¬ 
ton. 


EVERY FRIDAY. 


THE LANCET. PRICK 8EVBNPEN0K. 


SUBSCRIPTION 

Fob the United Kingdom. 

One Tear ... ... ... £1 12 8 

Six Month!. 0 16 3 

Three Month! . 0 8 2 


POST FREE. 

To the Colonies and Abroad. 

One Tear .£114 8 

Six Month!. 0 17 4 

Three Month! . 0 8 8 


Subscriptions (which may oommence at any time) are payable In 
sdvanoe. 


ADVERTISING. 

Books and Publication! ... Seven Llnei and under £0 6 0 
Official and General Announcement! Ditto 0 6 0 

Trade and Miscellaneous Advertleementa 1 n i tt , 0 4 8 

and Situation! Vacant . ) 

Every additional Line 0 0 6 

Situations wanted-. First 30 word!, 2!. 6d.: per additional 8 word!, 6d. 
Quarter Page, £1 lOi. Hall a Page, £2 15a An Entire Page, £5 be. 





THE LANCET, January 25, 1908, 


%\\ Jtes 

ENTITLED 

WHY IS TUBERCULOSIS SO COMMON 
IN IRELAND? 

WITH SUGGESTIONS FOR IT8 PREVENTION AND 
TREATMENT. 

delivered in Lurgan on Deo. 18 th, 1907, in connexion with 
the TubereulotU Exhibition, 

By Sib JOHN BYERS, M.A., M.D. (R.U.T.), 

PROFESSOR OF MIDWIFERY 1ST) DISEASES OF WOMEN AND CHILDREN. 
QUEEN'S COLLEGE; BELFAST. 


Appalling State op Ireland ■with regard to 
Tuberculosis 

Mr. Chairman, Ladies and Gentlemen,— That tuber¬ 
culosis (that is, consumption in its various forms)— 
and the Tuberculosis Exhibition here demonstrates that 
almost every part of the body may be affected—is far 
too prevalent in Ireland is evident from the following facts, 
most of which are shown in the statistical charts on the 
walls of thia room. 1 In the records of the various 
countries of the world Ireland stands fourth highest in 
Its mortality from pulmonary tubercnlosis, being only 
exceeded by Hungary, Austria, and Servia. 2. Comparing 
England, Scotland, and Ireland, it appears that while 
in 1864 Ireland stood lowest of the three, with a rate of 
.2 - 4 per 1000 living, the rate for England being 3’3 and 
that for Scotland 3'6, in 1905 and in 1906 Ireland waB 
highest with a rate of 2'7, Scotland next with 2-1, and 
England lowest with a rate of 1 • 6. In 1879 the death-rate 
in England and Ireland from tubercnlosis was about the 
same, and in 1885-86 it was the same in Scotland and 
Ireland. In Ireland in 1906 no less than 11,766, or 15 ‘ 8 
jper cent., of the total deaths were due to tnberculosis— 
that is, more people died from this cause alone than from 
cancer and all the principal epidemic diseases (influenza, 
whooping-cough, typhoid fever, measles, diphtheria, and 
diarrhoea) added together. Further, the majority dying 
■were in the prime of life (between 15 and 46 years 
cf age) and for every death from tuberculosis there 
were at least ten persons suffering from various forms of that 
disease, many of whom have their wage-earning power 
diminished or altogether taken away. It is a terrible feature 
of the white plague in Ireland that the mortality is greatest 
in those ages which ought to form the very backbone of our 
people. 3. Further, since 1873 in England and Wales, and 
since 1870 in Scotland, the mortality from what is ordinarily 
called consumption—pulmonary phthisis—has been reduced 
by one-half among females and one-third among males, yet 
there is no Bucb fail in Ireland. In 1906, again, more women 
than men died in Ireland from pulmonary or tuberculous 
phthisis. 

The above facts Bhow that the condition of Ireland as 
regards tuberculosis is simply appalling and demands the 
most carefnl consideration. 

Tuberculosis an Infectious Disease. 

As you are aware, tuberculosis is now regarded as an 
infectious disease, the immediate cause being the bacillus or 
rod-shaped vegetable organism discovered in 1882 by Koch, 
so microscopic in size that it bas been computed that four 
hundred millions could be ranged close together on the surface 
•of a penny postage-stamp. There are two avenues by which 
the cause of the disease enter the body—first, by inhalation 
of the germs directly by close contact with a person suffering 
from pulmonary phthisis (being disseminated in the act of 
oonghlng, shouting, &c„ in the form of minute moist particles 
of spray), or indirectly, through dust containing the dread 
bacillus given off in the expectoration of a careless person ill 
of the disease ; and secondly, by the ingestion of tuberculous 
meat and milk, but there can be no question that of the two 
<meat and milk) the latter (milk) is much the more im¬ 
portant, because while meat is taken cooked (which destroys 
the bacilli) In small quantities by adults whose power of 
resistance, or immunity as it is scientifically termed, is 
Increased, milk is taken in large quantities in a raw con¬ 
dition—often as their sole food—by children, with relatively 
No. 4404. 


diminished powers of resistance. The bacilli may also find 
an entrance by skin wounds, or they may be carried in with 
air in mouth inspiration, or by dirty objects placed in the 
mouth by ohildren. When the bacilli reach a favourable 
place or nidus they multiply rapidly and by their presence 
and irritation they excite the surrounding tissues to increased 
growth which results in the formation of nodules called 
"tubercles.” These in turn usually soften, and if in a lung 
are coughed up as the expectoration, if in a limb they form 
a discharge (abscess). 

There are two factors in the causation of tuberculosis ; 
first the bacilli, and secondly the predisposition or suscepti¬ 
bility of the individual ; and certain conditions, to be men¬ 
tioned later, might increase or diminish the infectivity of the 
bacilli, while on the other hand certain factors heighten 
or lessen the susceptibility of the individual. We are now 
in a position to attempt to answer the question, 1 ' Why is 
tuberculosis so common in Ireland 1" I propose to-night to 
discuss some of the reasons that have been usually assigned. 

Causes Assigned for the Prevalence of Tuberculosis 
in Ireland. 

1. The damp climate —We have been told that the 
prevalence of tuberculosis in Ireland is due to its damp 
atmosphere, the general humidity causing chest affections 
which tend to form a nidus for the tubercle baoillus. At the 
opening of the Tuberculosis Exhibition in Dublin Professor 
William Osier, in alluding to this view, denied it altogether, 
and pointed out Cornwall with a much damper atmo¬ 
sphere than in Ireland as being a place so free from the 
disease that consumptives were sent there. Id comparing 
different towns I was much struck with the fact that while 
in Belfast the death-rate from phthisis was in 1906 2 77 per 
1000, with a rainfall of 34 • 57 inches, in Glasgow with its 
humid atmosphere and higher rainfall (35*80 inches) the 
phthisis death-rate was only 1 * 5 per 1000. In Bolton with a 
moist climate and a rainfall of 42 43 inches the death-rate 
from phthisis has fallen to 1 • 11 per 1000 for 1906. In Cardiff 
(with a damp climate and with the ground water in many 
places near the surface in the gravel and with the lower part 
of the town near the docks, moors, 4cc., on a stiff marine 
clay, very retentive of moisture) the death-rate for 1906, 
with a big rainfall of 42 * 81 inches in this town (very much 
recovered from the sea as Belfast was) instead of being, 
as in Belfast, with a smaller rainfall of 34*57 inches, 
2 * 77 per 1000, was only 1 ■ 20 j and it ha« steadily 
fallen. In Manchester the climate is both damp and foggy, 
and the deprivation of light is greater than in aDy other 
English city (in spite of strenuous efforts to deal with 
smoky chimneys) ; yet, notwithstanding this, the phthisis 
death-rate has fallen to 1 • 82 in 1906. In Liverpool, a damp 
city, It is 1*82, and in London, with its fogs at times, the 
phthisis death-rate in 19C6 was only 1 * 42. Again, if we go 
to Dublin, with a rainfall less than in Belfast (27 *73 as 
compared with 34*57 inches In Belfast), the death-rate from 
consumption was 2 * 91 (that is, higher than in Belfast) for 
1306. I cannot, therefore, admit that there is much in the 
dampness of the atmosphere as a cause of tuberculosis in 
Ireland. 

2. Dampnett of the toil. —The dampness of the soil has also 
been assigned as a cause. Now, it used to be thought that 
after places were thoroughly drained the phthisis rate fell, 
and the experience of Salisbury and Ely were formerly 
quoted in support of this view ; but it was forgotten that in 
another town, Chichester, that was not drained at all, the 
phthisis death-rate fell, probably owing to the larger pro¬ 
portion of phthisical patients who died in the workhouse in 
that town, while in Belfast the main drainage scheme has 
bad no effect in diminishing the phthisis death-rate. Whilst 
subsoil may be of some importance it is now recognised that 
other conditions are of much more potency in the problem 
of the causation of phthisis. It is a curious fact, as shown 
in the annual report of the Registrar General for Ireland in 
1904, that in reference to the seasonal mortality from tuber¬ 
culosis the greatest number of deaths were registered in the 
June quarter. 

3. Emigration at a came of tvberculotit. —It is held by 
some that the long tide of emigration from Ireland has ielt 
behind a physically inferior population—a race of weaklings 
who propagate weaklings—all very susceptible to phthisis. 
I am aware that many hold this view, but there are serious 
scientific objections to it. First, Why is it that in a compara¬ 
tively new town like Belfast, whioh—from its industries 
supplying employment—attracts the robust and strong from 

D 





210 the lancet,] SIR JOHN BYERS : WHY IS TUBERCULOSIS SO COMMON IN IRELAND? [JAN. 25, 1908. 


the surrounding counties, the death-rate from tuberculosis ie 
bo high? Secondly, the census returns for the last three 
decades indicate an extraordinary influx of lives into Belfast 
between the ages of 15 and 35 years (females showing an 
abnormally high proportion). These are good lives, and yet 
we have a high consumption rate. Thirdly, notwithstanding 
the fact that emigration has produced a curious age distribu¬ 
tion of population in Ireland (persons aged 60 years and 
upwards are equal to 14 • 2 per cent, of the total population 
of Ireland, as compared with 10'4 per cent, of the total 
population of England and as compared with 10 9 of the 
total population of Scotland) it is a remarkable fact that 
the birth-rate, corrected for the number of women at child¬ 
bearing ages and for the number of married women, has 
actually increased in Ireland, while it has decreased in 
Eagland and Scotland, a fact which indicates that fertility 
and vitality have not decreased in Ireland. Fourthly, if the 
cause of the high tuberculosis death-rate in Ireland be the 
physical decadence of the people in Ireland, what about the 
condition of those who leave our shores for America ? Well, 
it is stated that in the United States (and figures have been 
given) the phthisis death-rate for the Irish is higher than for 
other nationalities. According to this view, if the occurrence 
of tuberculosis be taken as a test of a physically inferior 
people those who emigrate are no better than those who 
remain behind. Fifthly, Belfast is in that part of Ireland 
which has probably suffered least from emigration and where 
prosperity is, from a commercial point of view, the greatest, 
and yet its death-rate from tuberculosis is very high. 
Sixthly, in a recent examination of recruits the smallest 
number of rejections were among the Irish. Seventhly, as 
pointed out by Dr. A. Newsholme, in the past it was the 
small farmers, the cottiers, and the labourers who emigrated 
in the largest cumbers and these, owing to their extreme 
poverty, must have been among the least fit, while on the 
other hand those remaining are the offspring of people more 
favourably situated and who have been living under pro¬ 
gressively better conditions than their predecessors in the 
past and who accordingly should be more vigorous. 

4. The susceptibility of Irish people to tuberculosis. —It 
has been stated that there was in the Irish (some Baid 
the Celtic, including the Scotch Highlander) race a soil 
upon which the tubercle bacillus grew with extraordinary 
facility, and American statistics have been quoted to support 
this view, and it has also been laid down that Ireland by 
that reason was severely handicapped in the race with other 
countries to stamp out tuberculosis. I deny altogether that 
Irishmen, as a race, are specially prone to consumption. 
Why was it that according to the Registrar General's return 
Ireland in 1864, when there were far more Celts in the 
country, had a lower death-rate from tuberculosis than either 
England or Scotland ? Again, it was curious that of the 
smaller urban towns in Ireland the one with the highest 

hthisis death-rate was Newtownards, situated in the most 

cottish county in Ireland, Down, where, at the time of the 
Ulster plantation, the people came not from the Highlands, 
the home of the Scotch Celts, but from the Lowlands. The 
people of Ireland are unfortunately suffering from tuber¬ 
culosis not because they are Irish or Celts but because, as I 
shall show later, through want of education, they have not 
been taught in the past how to grapple with the white 
plague, and our emigrants in America suffer largely for the 
same reason, and also because they keep so much together 
and are influenced by their environment (that is, the condi¬ 
tions under which they live). Further, I do not accept the 
view that a high consumption death-rate is a sign of physical 
inferiority any more than I do that the existence of typhus 
fever in Ireland in the past was to be regarded in the same 
way. In both cases their prevalence was, and is, due to 
want of care being taken to stamp them out. 

5. Poverty and social position as a cause of tuberculosis .— 
The fact that comparing the mortality in the four classes 
the rate was, from tuberculosis, 0'63 in the professional or 
independent class, 2 79 in the middle class, 3'54 amoDgst 
the artisan and petty shopkeepers, and 4 • 12 in the general 
service class, shows that amongst those better housed, 
clothed, and fed the mortality is much less than among 
those who have not the same advantages as regards these 
factors, and whose occupation is more exposed, severe, and 
laborious. But this explanation, it must be admitted, applies 
t.o almost every disease (infectious or not) as well as to 
tuberculosis. Yet, on the other hand, we must not forget 
that Ireland has during the past quarter of a century shared 
with England in increased cheapness of food and of living ; 


wages have increased, and the savings bank returns show 
that while in 1870 the lodgments were £2,700,000 they had 
increased to £6,970,000 in 1894. 

6. Food and drink. —There is ground for believing that 
the increased use of tea and white household bread instead 
of the old porridge and buttermilk and the excessive 
use of alcohol have lowered the resistance of the people to 
the tubercle bacillus. The food which is of greatest 
importance in reference to tuberculosis is milk, because it 
is now practically agreed that the bacillus of tuberculosis 
is the same in the cow and in man and that the disease is 
intercommunicable, and in the second interim report of the 
lioyal Commission appointed to inquire into the relation of 
human and animal tuberculosis, Part I., Report, 1907, 
pp. 36 and 37, the Commissioners in their conclusion make 
the following weighty deliverance :— 

A very considerable amount of disease and loss of life, especially 
among the young, must be attributed to the consumption of cow's milk 
containing tubercle bacilli. The presence of tubercle bacilli in cow's 
milk can be detected, though with some difficulty, if proper means be 
adopted, and such milk ought never to be used as fond. There is far 
less difficulty in recognising clinically that a cow is distinctly suffering 
from tuberculosis, in which case she may be yielding tuberculous 
milk. The milk coming irom Buch a cow ought not to form part of 
human food and ought not to he uBed as food at all 

Our resulta clearly point to the necessity of measures more stringent 
than those at present enforced being taken to prevent the sale or l he 
consumption of such milk. 

I am in a position to say, from a communication which 
I have received from one of these Royal Commissioners, 
that ‘‘the German commission has ultimately come to much 
the same conclusion as we have, and the Americans have 
fallen into line.” In Ireland it has been estimated that 
probably at least 30 per cent, of the milch cows are afflicted 
with tuberculosis. Now, - in the children’s hospitals in, 
Belfast—and the same is true of similar institutions in 
England and Scotland—about from 20 to 30 per cent, of all 
the children treated suffer from various forms of tuberculo.-is 
(bones, joints, glands, abdominal and cerebral types). As a 
rule these hospitals do not admit children over 12 years of 
age and it is curious that the pulmonary forms of tuberculosis 
are rare, showing that the disease is not in them so often 
acquired by inhalation as in adults—while, on the other 
hand, the ravages of the disease in children who require 
surgical treatment far outnumber what are called the medical 
forms of tuberculosis. One is driven to the conclusion that 
the disease is acquired in children largely by iDgestion 
through swallowing tuberculous milk. 

7. Industries. —According to some it is the influence of 
industries—especially in towns—which causes the high 
tuberculosis death-rate. Now, it is curious that in Dublin 
they have little or no textile industries as in Belfast, and 
yet the Dublin phthisis death-rate is the higher of the two 
cities. Then in Bolton, Manchester, Uldham, and other 
towns where there are cotton and other industries the death- 
rate from phthisis has fallen, while it has not done so in 
Ireland. Further, in Great Britain, much of the reduction of 
phthisis had occurred before systematic action had been 
well begun for the suppression of dust in factories. Y'ear by 
year the conditions in the mills regarded as inimical to 
health—dust, damp, high temperature, and imperfect venti¬ 
lation—have improved, and in 1904 Commander H. P. Smyth, 
in his report upon flax mills, says : “ I cannot speak too 
highly of the efforts that have been made by many [manu¬ 
facturers]. They have spent time, thought, and large sums 
of money, going far beyond any legal requirements that have 
yet been made.” I am flrmly convinced that the influence 
oi industries—especially the textile ones—as a contributory 
cause of tuberculosis in Ireland has been overstated. Legally, 
the owners of mills are obliged to reduce as much as possible 
anything in their works inimical to health and taking 
Belfast, the great industrial centre of Ireland, as an example, 
supposing the death-rate was proved to be higher among the 
workers in mills and in factories in that city than among the 
rest of the population, still that excess would raise the total 
death-rate only by a twelfth part, because at the present 
time the numbers of these workers are about 25,000 females 
and 5000 males ; therefore, if the mill and factory death- 
rate were 23 per 1000, whilst the total death-rate was 20, to 
eliminate the 30,000 mill-workers would make the death-rate 
19'75, instead of 20 per 1000. 

8. Want of sanitary reform in Ireland. —There can be no 
question that in tbe past we have not made the same 
progress as has been done in England and Scotland in the 
sanitary measures taken to improve tbe dwellings of the 
people all over the country, and in both England and 



Thb Lancet,] SIR JOHN BYERS : WHY rS TUBERCULOSIS SO COMMON IN IRELAND ! [Jan. 25, 1908. 211 


Scotland, from about 1860 to 1882, when Koch discovered the 
bacillus of tuberculosis, owing to sanitary reform, coupled 
especially with the segregation of advanced cases, the disease 
had decreased even before the discovery of its immediate 
cause. Tuberculosis has been well called a dwelling or 
house disease, and, as pointed out by Koch, a person 
suffering from the disease became dangerous only when he 
was personally uncleanly, that is, did not disinfect bis sputa, 
or became so helpless in consequence of the far-advanced 
state of the disease that he was no longer able to see to the 
suitable removal of the sputa, and, finally, that for the 
healthy the dangers of infection increased with the impossi¬ 
bility of avoiding the immediate neighbourhood of a 
dangerous pationt—for instance, in densely inhabited rooms 
—and especially if these rooms were overcrowded and if they 
were badly ventilated and inadequately lighted. Let me 
give f ume interesting experiments on this question. If you 
take virulent sputum (expectoration) from a consumptive 
patient and deposit it on the window-ledge of a house that is 
insanitary—that is, badly ventilated—perhaps built directly 
on the clay and not cut off properly from the ground air 
and water—it will retain its power for months ; nay, more, 
the ordinary processes of disinfection will cot destroy the 
infective activity of such tuberculous material, indeed, it 
will survive freezing and thawing. On the other hand, 
when similar virulent expectoration is exposed in houses 
which have light and air with but little radiant sunshine 
for even two days its power for evil is gone. With 
light and ventilation it does not reach its dangerous 
stite of dust before it is deprived of all power of 
doing harm, long-lived though the bacilli may be under 
certain insanitary conditions. Now sanitary .reform of the 
houses does something else in addition to lessening the 
infectivity of the bacilli: it increases the resistance of the 
human body to their inroads. Those who have thoroughly 
investigated the question tell us how often cases of 
pulmonary consumption in our towns recur in certain houses 
and streets, how frequently one or more persons share the 
room or even the bed of a consumptive, how commonly the 
consumptive changes his house thus multiplying infection, 
and how rarely the house of a consumptive is disinfected 
either during his illness or after his death. I am bound to 
admit that the housing of the people in Ireland has improved, 
but in neither town nor country districts is it at all equal to 
what it is in England, and therefore want of sanitary 
progress in Ireland must, I think, be accepted as a cause for 
the prevalence of tuberculosis. 

9. The domeitie or home treatment of the advanced ca-ut of 
pulmonary tuberoiilotU. —We now come to wbat I regard as 
the most potent cause which has prevented a lowering of the 
tuberculosis death-rate in Ireland and that is the domestic or 
home treatment of advanced cases of phthisis, because 
increasing experience demonstrates that with isolation of 
these advanced or “ open ” cases in any country the death- 
rate falls. Here are a few examples : In Stockholm, a city 
with a population of 300,000 (that is Ibbs than Belfast), over 
1100 cases of pulmonary tuberculosis are cared for in the 
hospitals of the city, with the result that in the last decades 
the death-rate from phthisis has gone down 38 per cent. As 
Koch puts it, we are to derive from this the lesson that the 
greatest stress is to be laid on this measure—namely, the 
placing of cases of pulmonary phthisis in suitable establish¬ 
ments—and far more care should be taken than hitherto that 
such patients do not die in their dwellings where they are 
for the most part in a helpless situation and inadequately 
nursed. In Prussia from 1876 to 1886 the pulmonary 
phthisis rate stood very high; since that time it has 
fallen from year to year and the decrease is now 
more than 30 per cent., that is about one-third ; 
indeed, it has been calculated that though the population 
has meanwhile increased the number of people who die 
every year from pulmonary phthisis in Prussia is now about 
20,000 less than it was 20 years ago, and Koch says that he >s 
firmly convinced that the better provision for patients in the 
last stage of pulmonary phthisis—namely, the lodging of 
them in hospitals which is done in England as well as in 
Prussia to a comparatively large extent—has contributed 
most to the improvement. The very opposite line of prac¬ 
tice—that is, the want of institutional treatment—is the 
cause why in Austria and Hungary the pulmonary phthisis 
death-rate still continues as formerly so high. In Berlin 
the death-rate from pulmonary consumption has decreased 
pari pa»m with the circumstance that during recent 
years more than 40 per cent, of the cases of pulmonary 


phthisis die in hospitals. A disease which comes near to 
tuberculosis in many respects is leprosy. In Norway, by 
isolating the most dangerous caBes, the number of lepers has 
fallen from 3000 in 1856 to 500 at the end of 1905, and Koch, 
pointing to this as an example, emphatically declares that 
advanced cases of phthisis, those which are admittedly the 
most dangerous, ought to be lodged in hospitals. No man 
has devoted greater attention to this question than Dr. 
Newsholme, medical officer of health of Brighton, president 
of the Epidemiological Section of the Royal Society of 
Medicine, and one of the greatest living authorities in 
matters of public health. He made a most elaborate inquiry 
into the principal causes of the reduction of the death-rate 
from phthisis in different countries and came to the conclusion 
that the one common factor present in all places where the 
death-rate from this disease fell was the segregation of the 
patients in general institutions—that is, infirmaries or hos¬ 
pitals. In each country in which the institutional has replaced 
the domestic relief of destitution there has been a reduction 
of the death-rate from phthisis which is roughly propor¬ 
tionate to the change. Here are his interesting observations 
as to the increase of consumption in Ireland contem¬ 
poraneously with its diminution in England. In the United 
Kingdom, he says, paupers receive two kinds of medical 
relief, outdoor or domestic and indoor or institutional (that 
is. workhouse or workhouse infirmaries). In England during 
1861-65 the total number of paupers per 100,000 of the 
population was 4824, of whom 694 were in receipt of indoor 
relief and 4130 of outdoor relief. In 1901-03 the number 
of paupers per 100,000 of the population had diminished to 
2218, and of these those receiving indoor relief were 688 (almost 
the same as 1861-65), while those in the receipt of outdoor 
relief were now only 1530. In Scotland there were during 
1868-70, 3896 paupers per 100,000 of the population, of whom 
253 got indoor and 3643 outdoor relief, while in 1901-03 the 
total number of paupers per 100,000 of population had sunk 
to 1922, of whom 242 (almost the same as in 1868-70) got 
indoor and only 1680 outdoor relief. In Ireland, on the 
other hand, during 1861-65 there were 1036 paupers per 
100,000 of population, of whom 928 received indoor and 108 
outdoor relief, while in 1901-03 the total number of paupers 
per 100.000 of the population had actually increased to 2272, 
and while those who got indoor relief were 947 (almost the 
same as in 1861-65), those receiving outdoor relief had 
increased to 1325. These figures, Dr. Newsholme thinks, 
and I am in entire agreement with him, give the key 
to the difference between Ireland and Great Britain. It 
is the enormous increase in the former country of 
pauperism relieved medically at home by the dispensary 
system which favours the treatment of even advanced 
cases of phthisis at home. Hence, Dr. Newsholme said, 
crowded and insanitary homes had their natural effect— 
when infectious patients have not been removed from them— 
of increasing the consumption death-rate. The fact that in 
Ireland the death-rate from consumption is higher among 
women than among men supports this view as it indicates 
domestic rather than industrial infection. The women 
(wives, sisters, and daughters) nursing the sick at home 
become infected. Further, it has been noted that con¬ 
sumptives do not remain nearly so long in the Irish work- 
houses as they do in the English, and even in Belfast where 
the most admirable arrangements were made in the union 
infirmary to treat consumptive patients in wards by them¬ 
selves there is a common custom for the advanced (and most 
dangerous) cases to go home near the end to die. The same 
practice occurs, though I am glad to say to a less degree, 
with patients in the admirable sanatorium of the Belfast 
Union at Wbiteabbey where in the verandahs in the present 
weather patients are sleeping. It has also been noticed that 
Irish Americans, who contract the disease when they 
emigrate, often come home to die, a practice which of course 
tends to spread the disease among the poor in Ireland ; and 
those living in country districts know how often the people 
who have acquired the disease in Irish towns come in the 
end—often in the hope of recovery in their native air—to 
their old homes in the country to die. 

It is interesting to note that there was no Poor-law pro¬ 
vision in Ireland until 1838, and the Act passed then for the 
more effective relief of the destitute poor in Ireland, unlike 
the English Act, entirely prohibited outdoor relief. Before 
the end of 1840 127 unions were formed, each with its own 
workhouses, and the total 130 arranged for in the Act were 
soon afterwards established and relief could not be obtained 
except in these institutions. During the great famine 




212 Thb Lancet,] SIR JOHN BTBRS : WHY IS TUBERCULOSIS SO COMMON IN IRELAND I [Jan. 26, 1908. 


(1846-48) the restrictions as to the giving of outdoor relief 
were for the time relaxed, and after the famine the rigid rales 
as to outdoor relief were reimpoaed, but, notwithstanding, out¬ 
door medical relief gradually became more general, and from 
1880 onwards the general policy of the Poor-law authorities was 
completely inverted, until in the year 1903-04 it is really 
astounding to record that the proportion of new cases of 
sickness attended, either at dispensaries or in their own 
homes, formed nearly one-eighth of the total population of 
Ireland. When I speak of outdoor relief in Ireland I mean, 
of course, medical relief given in the forms of medical 
attendance, advice, and medicine, either at the dispensaries 
or at the homes of the patients, and if we have to lament 
that pauperism in this sense has not declined in Ireland, it is 
clear that it is due to statistical and administrative causes. 
In Great Britain, as pointed out by Dr. Newsholme, the 
regulation has been generally enforced that in order that 
a sick or disabled husband among the poor may receive 
relief to which his destitution entitles him he must enter 
the infirmary. A sick wife, however, is not entitled to 
parochial relief so long as her husband is in receipt of 
wages sufficient to support her. This iB the reason why a 
much larger proportion of male than of female consumptives 
are treated in England in workhouse infirmaries. 

In an extremely interesting recent paper by Dr. 
Newsholme, to which as well as to his other thoughtful 
writings I gladly acknowledge much indebtedness, he points 
out the remarkable fact that while typhus fever has 
diminished in Ireland, phthisis has contemporaneously 
increased, and asks this question, “Now, if improvement 
in general well-being of the population associated with 
better nutrition, diminished overcrowding, and improved 
houses has, as is commonly Btated, been the main deter¬ 
mining cause of the diminished mortality from typhus 
and phthisis in England and in Scotland, how has the 
equally striking diminution of typhus in Ireland been 
brought about and why has it not only been accompanied 
by any diminution in the death-rate from phthisis but 
by an actual increase in the death-rate from thiB disease ^ ” 
It is plain that the reduction of typhus fever and 
the increase of phthisis in Ireland have both of them 
been associated with Poor-law administration. As Dr. 
Newsholme puts it, at first outdoor or domestic relief under 
the Irish Poor-law was very restricted, but in the process of 
time the Poor-law policy of Ireland was changed, medical 
and other forms of relief being freely given to people still 
living at home. Daring the last 26 years outdoor medical 
relief had been more largely given than indoor relief, espe¬ 
cially when allowance is made for the fact that indoor relief 
includes the provision of a large portion of the general hos¬ 
pital accommodation of Ireland. Associated with this 
changing administration was the fact that residential con¬ 
ditions of relief were imposed, which tended to prevent the 
great vagrancy and mendicancy which had prevailed so 
much in Ireland. What would be the effect on typhus fever 
and phthisis of (1) the increasing immobilisation of the popu¬ 
lation in their own districts, and of (2) the increase in the 
proportion of sickness in the aggregate, and especially of 
phthisis, treated in the homes of the people 7 The readiness 
with which medical treatment, both at home and at the dis¬ 
pensary, could be obtained led to the greater portion of the 
lives of consumptive patients being spent at home. For 
typhus fever it was otherwise. Here was a disease which, 
unlike phthisis, was not infectious for several years but only 
for two or three weeks and which disabled immediately 
instead of after protracted ill-health. The objections of the 
people to the union hospital were easily overcome for this 
disease, but only rarely in the case of phthisis. Hence, Dr 
Newsholme shows, the same measures which were successful 
for typhus fever led to an actual increase of phthisis. 
Typhus fever has been brought to the point of extinction by 
its institutional treatment, acting in conjunction with the 
removal of the motives for vagrancy. Phthisis has been 
rendered even more prevalent than formerly by increasing 
for this disease domestic at the expense of institutional 
treatment, and by thus continuing the enormous number of 
domestic foci of this disease which are implied by the home 
medical treatment of phthisis among the poor. 

10. Popular ignorance of the nature of tuberoulotit .— 
Lastly, want of knowledge on the part of the public of the 
nature of the disease, of the measures needed for its preven¬ 
tion. and of the precautions required to limit its spread is a 
factor of importance as explaining the great prevalence of 
tuberculosis in Ireland. Want of knowledge brings careless¬ 
ness, indifference, and in the end even apathy. 


Having tried, therefore, to show why tuberculosis is still so 
prevalent in Ireland, and remembering that it is an infections 
disease due to a bacillus which may enter the body either 
through the pulmonary system by being inhaled, or by the 
alimentary tract by being swallowed, and occasionally 
through a skin wound, what steps Bhould be taken to combat 
the disease in Ireland ? 

Practical Suggestions for the Prevention and 
Treatment of Tuberculosis in Ireland. 

1. The starting point for dealing with all infectious 
diseases or pestilences is notification, and in my opinion this 
must be made compulsory in the case of tuberculosis all over 
the country. In no other way can we know where the 
disease exists or what stage it is in, and unless both these 
facts are ascertained how can any attempt be made to deal 
with it from a public health point of view 7 Nothing seems 
more incongruous than the prompt care that is properly 
taken to cut short an outbreak of small-pox, typhus fever, or 
spotted fever in Ireland, and the utter apathy displayed in 
dealing with an infectious disease like tuberculosis, whose 
victims are so immensely more numerous than those of all 
the other infectious maladies combined. Compulsory notifica¬ 
tion is the first and most essential step in the anti-tuber¬ 
culosis campaign. 

2. When by notification we know where the disease is, our 
next duty is to pursue in Ireland, as is being done in every 
country where the death-rate from tuberculosis has fallen, 
the institutional treatment of pulmonary phthisis, especially 
of those advanced cases which are so ill as to be unable to 
look after themselves, and who in the interest of the healthy 
members of the household, must be removed, just as cases of 
typhus fever are in Ireland and as advanced cases of leprosy 
are isolated in Norway. Separate wards could be arranged 
for these advanced “open ” cases, which are more dangerous 
the nearer they come to the end, in the union hospitals, 
where they would be so much better attended and nursed 
than at home. As we know that pulmonary consumption is 
mainly spread by infection from a tuberculous patient, the 
placing of such a person in a hospital or an infirmary releases 
his household from its principal exposure to infection, but 
further by reducing anxiety and worry it indirectly improves 
the health of the family. In Ireland, if we are to stamp out 
the disease, the institutional (that is by hospital or infirmary) 
treatment of advanced cases of pulmonary consumption 
must be done on a scale not hitherto thought of, and such 
treatment must be made attractive. If it is absolutely 
necessary, then there should be fresh legislation declaring 
tuberculosis an infections disease; but even without waiting 
for this the Irish Local Government Board might follow the 
example of the Local Government Board of Scotland which 
took the bold and independent course on March 10th, 1906, 
of issuing a circular (Public Health, No. 1, 1906) in which 
it was laid down that tuberculosis of the lungs or consump¬ 
tion was an infectious disease within the meaning of the 
Public Health Act, and that the sections of the Public Health 
Act applicable to other infectious diseases are equally applic¬ 
able to pulmonary phthisis, and the obligation resting on the 
local authority to deal with and control infectious disease 
was made to extend to pulmonary phthisis. 

The provisions of the Public Health Act as to removal of 
cases of infectious disease to hospital and as to the pro¬ 
vision of hospitals are available for dealing with cases of 
pulmonary phthisis as with cases of other infections diseases. 
These provisions, the circular points out, can be adapted in 
practice to any type of case—incipient cases, where the 
danger of infection to others, though for the time at a 
minimum, may suddenly become serious; intermediate 
cases, where the patients, still able to work, may, if un¬ 
controlled, become dangerous; and advanced cases, where 
the patients, frequently unable to attend to themselves, may 
be a source of grave danger. With reference to the advanced 
cases, “the isolation of such dangerous cases,” says this 
circular of the Soottish Local Government Board, “ is a 
primary duty of the local authority.” When a case of 
typhus fever, small-pox, or scarlet fever is sent into a union 
fever or other hospital in Ireland such a case must not be 
removed (being dangerous infectious diseases) whilst so 
suffering under a penalty of £5, and any person in charge of 
the case which is thus removed is liable to a similar fine of 
£5, yet at present aD advanced case of pulmonary tubercu¬ 
losis, the most dangerous of all forms of tuberculosis, and 
admittedly most infectious, can, if in a union or other 
hospital, be removed at any time, and can be taken home to 
spread disease by infection among the family. 



The Lancet,] 


CAPTAIN C. A. GILL, I.M.S.: THE EPIDEMIOLOGY OF PLAGUE. [Jan. 25, 1908. 213 


For the very early cases, in the hope of arresting the 
disease, sanatoriums should be erected, and one might suffice 
for two or three counties. These sanatorinms should be made 
of some cheap material, say wood, so as to be burned at 
times, and not of costly brick or stone, and the cheaper 
they are the better, if only efficient in other respects. 
For those intermediate between the early and the advanced 
cases who are able still to be at their work but too advanced 
for sanatorium treatment the greatest efforts should be made 
to instruct them (and indeed the whole people) as to the 
danger of tuberculosis and how much they can do by 
carefully disinfecting their expectoration and by not 
indulging in the filthy and dangerous habit of spitting, 
which should be made an offence punishable by a heavy fine. 
Everything that tends to educate the people of Ireland as 
to the danger of tuberculosis, such as lectures and exhibi¬ 
tions—like the one that is here—is to be encouraged, and I 
believe the visits among the poor in order to instruct them 
as to what is now known in regard to tuberculosis (especially 
as to cleanliness, sleeping in a room by themselves, and the 
treatment of the sputum) by the members of the various 
branches of the Women’s National Health Association of 
Ireland will be of enormous aid. In the larger towns a dis¬ 
pensary for tuberculous patients should be instituted. 

3. We must educate the people more and more as to the 
importance of keeping their houses clean and sanitary, well 
ventilated, not overcrowded, and so situated as to be properly 
lighted by the sun, and they must be taught what measures 
they can adopt to prevent the onset and spread of the 
disease ; in other words, we must teach the people that they 
themselves have it in their own power largely to control the 
disease. 

4. Temperance in all things should be inculcated, as well 
as the use of nourishing properly cooked food, and the laws 
of hygiene and temperance should be taught in the primary 
schools, which should be medically inspected. 

5. As to meat, every person, rich or poor, should have a 
guarantee that all meat used by him has been inspected, 
and the veterinary inspectors in my opinion should be State 
officials. There should be public abattoirs or slaughter¬ 
houses and all private ones should be abolished. The same 
type of inspection of meat should prevail in town and 
country. 

6. Considering the teaching of the recent report of the Royal 
Commission appointed to inquire into the relations of human 
and animal tuberculosis all cows with tuberculous disease of 
the udders should be forthwith slaughtered and those that 
react to the tuberculin test should be branded. The control 
of our milk-supply is so important that I believe it will never 
be managed rightly until the State takes it under its care, 
the regulations for inspection of the dairies (medical and 
veterinary), and for the clean production, conveyance, and 
distribution of milk being enforced by experts responsible to 
the State. It is time the truth was realised that the con¬ 
ditions which maintain health in the cows are very similar to 
those which we advise for the human race—that is, fresh 
air, proper ventilation, sunlight, suitable food, pure water, 
and cleanliness. The Department of Agriculture and 
Technical Instruction for Ireland and the various agri¬ 
cultural shows and societies, I trust, will unite with the 
Government in devising means for getting rid of tuberculosis 
in animals. I admit all these measures I have suggested 
will cost money and it is clear compensation for loss of cattle 
will have to be paid ; but are we really to speak of money 
when, on the other hand, we contemplate almost 12,000 lives 
lost annually (with 120,000 ill) through a disease which 
science and experience show us is preventable ? What money 
has been expended freely to stamp out cattle plague, 
foot and mouth disease, pleuropneumonia, glanders, 
swine fever, 4cc. ? Are human beings of less value 1 
To those who think that to rid Ireland of the 
white plagne is an impossible task I reply in the 
words of the Spanish proverb in Don Quixote, “The 
beginning of health is to know the disease.’’ We 
are now thoroughly acquainted with tuberculosis as we 
never were before and the experience of other countries 
shows what could be done in Ireland by combined effort. We 
are no longer in the doubtful position of the sailor of whom 
Ovid writes: “ Hope it is which makes the shipwrecked 
sailor strike out with his arms in the midst of the sea, even 
though on all sides he can see no land.” 

“ Haec [spes] fsclt, nt videat cum terras undique nullas, 
NauiraguB in mediia brachia jactet aquls.” 

We now see other lands where years ago tuberculosis was 


far more prevalent than with us, they have since largely 
got rid of it, why can we not profit by their experience 
and follow their methods ? 

I rejoice to know that the public of Lurgan are joining the 
rest of their fellow countrymen in this glorious campaign to 
free our land from a plague that too long—largely owing to 
our want of education—has prevailed among us; but now 
that our mothers and our wives and our sisters have been 
awakened—thanks to the splendid efforts of one of the 
ablest, most benevolent, and large-hearted women that ever 
lived, Her Excellency the Countess of Aberdeen—we are all 
full of hope that a better time is in store for our beloved 
country and that the cloud and the stigma that hang over 
Ireland at present for her high mortality from a preventable 
disease will in time be completely removed. 


THE EPIDEMIOLOGY OF PLAGUE. 

WITH SPECIAL REFERENCE TO ITS MODE OF SPREAD AND 
THE MEANS BY WHICH IT MAY BE COMBATED . 1 

By CLIFFORD ALLCIIIN GILL, M.R.C.S. Eng., 
L.R.C.P. Lond., 

CAPTAIN, INDIAN MEDICAL SERVICE; I'LAOUE MEDICAL OFFICER, 
JHKLL'M DISTRICT, PUNJAB, INDIA. 


The prevention of plague, even if judged merely from the 
hygienic and epidemiological standpoint, involves difficult 
problems which render the subject one of peculiar interest 
to those who in various lands have the care of the public 
health. My knowledge of the complicated bearings of the 
question is derived from the fact that for the past two years 
I have been studying these problems as they present them¬ 
selves in the epidemic which is creating such havoc in India. 
One of the objects of this paper will be to show that there 
are reasonable grounds for believing that the pandemic of 
plague now chiefly affecting India may, in the near future, 
extend itself widely over the world, and by again visiting 
Europe cause another of those devastating epidemics with 
which history has made us acquainted. 

On the present occasion I will keep as much as possible to 
the purely practical side of the question, without entering 
into the clinical, bacteriological, or other aspects of plague. 

The subject may be conveniently arranged under the 
following three heads. 1. The course of the present pan¬ 
demic of plague from its origin to the present time. 2. The 
mode of spread of the disease ; ( a ) within an infected area, 
and ( b ) from an infected to an uninfected area. 3. The 
methods by which the disease may be combated : (a) pro¬ 
phylactic measures in uninfected areas, and (b) preventive 
measures in the epidemic zone. 

The Coune of the Preernt Pandemic. 

For a proper appreciation of the dangers of the situation 
in which we are placed it is necessary to consider the course 
and history of the present pandemic from its origin to the 
present time. Two well-marked centres of endemic plague 
are now recognised to exist and the forms of the disease to 
which they respectively give rise aie not in all respects 
alike. The differences, however, are not sufficiently distinct 
to warrant them being termed ■ ‘ varieties ” ; they are more 
correctly spoken of as different “strains” of the same 
disease and they have been named in accordance with their 
geographical distribution (1) the Western Asian strain and 
(2) the Indo-Chinese strain. Of the differences in their 
characters the two most striking are the greater virulence and 
power of extension of the Indo-Chinese “ strain ” and its 
marked association with rat mortality. 

Plague has long been known to exist in Western Asia, but 
on account of its mildness and lack of power of extension it 
has come to be regarded with indifference, and public 
opinion in Europe has come to regard the disease as a 
purely Eastern one and as possessing no significance for 
modern Europe. It must be remembered, however, as a 
very important point, that the disease with which we have to 
deal nowadays is the virulent and diffusible Indo-Chinese 
strain of plague and not the milder and less important 
Western Asian strain. So far as is known the Indo- 
Chinese strain of plague originated in Yunnan, a pro¬ 
vince of Western China, about the year 1860, though in all 
probability it had existed in this little known province some 

1 Abstract of a paper contributed to the International Cougrees of 
Hygiene and Demography, held at Berlin in September, 1907. 

D 2 




214 The Lancet,] CAPTAIN C. A. GILL, I.M.S.: THE EPIDEMIOLOGY OF PLAGUE. 


[Jan. 25, 1908. 


years previously. From here it appears to have spread 
slowly and in an uncertain manner in an almost due easterly 
direction until it reached the coast. The line of its ex¬ 
tension corresponds accurately with the chief trade route in 
this region and it is by reason of its following this course 
that the Chinese province to the north and India to the south 
with their teeming millions escaped infection at this time. 
It reached Pakhoi on the Tonquin Gulf in the year 1867, 
from which place, and also directly from Yunnan, it travelled 
to Canton which it reached in 1894; Hong-Kong which is in 
close proximity to and in intimate commercial relationship 
with, Canton became infected in the same year. Bombay 
was infected in 1896, a date which marks an important epoch 
in the history of the pandemic, for previously no extension 
inland on a large scale had taken place from any of the 
Infected ports. How the disease was imported into Bombay 
is not exactly known. Plague cases and dead rats were drat 
discovered in the vicinity of the docks accommodating cargo 
steamers from Hong-Kong. It commenced in a slow and 
insidious manner and it was some time before its real nature 
was recognised. The plague history of Bombay since 1896 
has been marked by two features; first, the annual recru¬ 
descence of the disease in an epidemic form ; and secondly, 
its extension inland, so that this city has acquired the 
character of being the great distributing centre from which 
the disease has spread nearly all over India. The rapidity 
and extent with which this has taken place have been 
further increased by the fact that perhaps now, for the 
first time in the history of the present pandemic, modern 
facilities of locomotion became available for its dissemination 
by land. 

It was not until 1901 that the epidemic appeared to reach 
the Punjab, the most northerly province of India; in the 
spring of 1907 Peshawar, a city in the extreme north-west 
comer of India, was infected for the first time, and cases of 
the disease have recently been reported from Jellalabad and 
Kabul in Afghanistan. In addition the disease is Blowly 
spreading westwards along other trade routes leading from 
India into Afghanistan ; thus Dera Ismail Khan at the head of 
the Gomul trade route and Edwardesabad at the head of the 
Tochi valley have this year become infected. Further south, 
by another route, Seistan is already infected, so that the 
disease is showing a marked tendency to spread westwards 
by various channels of communication leading from India. 
It therefore appears highly probable that sooner or later the 
disease will make its appearance on the confines of Europe, 
and whenever this may happen, in consequence of its 
intimate commercial relations with the East, Constantinople 
is not likely to escape long. The historical facts of previous 
known pandemics show that in the first of them which 
occurred in the sixth century Constantinople (Byzantium) 
was infected from Pelusium in Egypt and from this city the 
disease spread widely over Europe. In the second pandemic 
which commenced in the eleventh century and was after¬ 
wards known in England as “ The Black I)rath” the disease, 
similarly starting from the East, entered Europe by way of 
Constantinople. 

The Mode of Spread of Plague. 

The mode of extension of plague epidemics is well illus¬ 
trated by the occurrences in the Punjab. First of all it is 
necessary to state that plague exhibits a seasonal periodicity 
which, though not the same in all places, tends to recur about 
the same time each year in any particular place. Thus in the 
Punjab it is only during the period from February to June 
that plague assumes epidemic proportions. 

During the “free season,” or that portion of the year in 
which the epidemic is not present, the disease may be intro¬ 
duced with impunity. For instance, during the period from 
August, 1906, to February, 1907, plague was imported on 15 
occasions into the Jbelum district without it spreading to 
tbe inhabitants of the village or, as far as could be ascer¬ 
tained, causing rat mortality. As to the reason for this I am 
unable to offer any certain explanation, but the disease did 
not appear to remain latent until the arrival of the epidemic 
season, for no influence, either immediate or remote, could be 
traced to its importation at this time. In the month of 
February when the “plague season” commences a very 
different story is elicited. The occurrence of imported cases 
still continues and perhaps becomes more frequent, but now 
they give rise to rat mortality and to the occurrence of 
indigenous cases of the plague in man. The various modes 
by which this may take place will now be considered 
seriatim. 


Spread by pneumonic plague .—It is a enrions fact that 
pneumonic plague appears to be strictly confined to the 
first two months of the epidemic, a point recognised 
by Guy de Chaullac as long ago as 1348 but which 
recently does not appear to have attracted much atten¬ 
tion, thongh its existence as a disease since its discovery, 
by Lieutenant-Colonel L. F. Ohilde, I.M.8., in 1897 is 
a matter of common knowledge. As to the frequency 
with which it occurs, this appears to vary from year 
to year. During the present year, from personal investiga¬ 
tions made at the time of the outbreak in 56 villages, pneu¬ 
monic plague was responsible for the epidemic in nine, or 16 
per cent., of the total. All of these occurred in the months of 
February or March—i.e., during the first two months of the 
epidemic. During thiB period it is responsible to a consider¬ 
able extent for the spread of plague. Thus the effect of the 
introduction of one case was followed up and traced to five 
villages where, in spite of efforts made to stamp it out, it 
caused the death of 27 persons. But this was not all, for in 
addition it was also responsible for subsequent outbreaks of 
bubonic plague in two of these villages, with the result that 
64 individuals also died from this form of the disease. 

The history in all these cases is very similar and shows 
that the outbreak of the disease closely follows the arrival 
in the village of an Individual Buffering from, or incubating, 
pneumonic plague. It quickly spreads to the other inmates 
of the same house, often with such virulence that every 
individual is wiped out in the space of a few days. In my 
experience recovery rarely, if ever, takes place. The disease 
also spreads with alarming certainty to those who come in 
contact with the sick or tend the dying. By these it is 
spread to other households, who in turn infect their friends 
and relatives. From the evidence which has been collected 
it is impossible to resist the conclusion that the infection in 
pneumonic plague is direct from man to man but that it can 
also pass with ease from man to rat, and when this takes 
place an outbreak of bubonic plague on the usual lines 
follows. 

Spread by the agency of man .—So much for the spread of 
the disease by pneumonic plague. This is, however, not the 
most usual course of events, for the history obtainable in the 
majority of cases is that at the onset of the plague season 
rat mortality was the first sign of the approaching epidemic. 
In the case of endemic areas no cause for this can be 
assigned, but in previously uninfected villages it will 
frequently appear that this has been preceded by the arrival 
of a person suffering from plague or who developed the 
disease shortly after arrival. A typical history of such cases 
is that about one week or ten days after the disease was thus 
imported by an infected individual dead rats began to be 
noticed in tbe vicinity of the house occupied by this 
individual. 

The future course of the disease is characteristic. Starting 
from the house forming the original focuB of infection the 
area in which dead rats are discovered gradually increases, 
then in the vicinity of the house in which dead rats were 
first found a plague case occurs. From this time the 
epidemic may be said to begin, at first slowly, with perhaps 
only one or two cases a day ; subsequently, as the infected 
area becomes larger, the plague figures rapidly rise, so that 
50, 100, or more fresh cases occur daily. After lasting usually 
from one month to six weeks it declines and finally ceases in 
the same order as it commenced. 

It is usual to find in bubonic plague epidemics that the 
rat mortality precedes the occurrence of plague in man, 
thus giving a warning of approaching danger. Heralded in 
this manner by the rat epizootic, the epidemic can often be 
seen to travel from the house forming the original source of 
infection slowly up and down the street, frequently keeping 
for some time to one side of the road before crossing over. 

In the epidemic in the Punjab this is, in my experience, 
by far the commonest history obtainable. Thus, of the 56 
villages in which during the present year the cause of the 
outbreak was investigated at tbe time of its occurrence, in 
36, or 64 2 per cent, of the total, the course of events con¬ 
formed in all essential details to the above. 

Spread by infected clothing or merchandise.—At the end of 
March, 1907, a small merchant visited the village of Lehri, 
a plague-free area, having come from an infected village 
some 40 miles distant. He stayed in the house of a relative 
for four days and then left for Rawal Pindi in his usual health. 
About two weeks after his departure dead rats were found in 
the house he had occupied. A few days later, on April 19th, 
a case of plague occurred in this house; subsequently a rat 



The Lancet.] 


CAPTAIN C. A. GILL, I.M.S.: THE EPIDEMIOLOGY OF PLAGUE. [Jan. 25, 1908. 215 


epizootic followed by a small epidemic, radiating from this 
house, spread through the village. No other person was 
stated to have recently visited the-village, which occupies a 
very isolated position, and was at that time at least 20 miles 
distant from the nearest infected village. This illustration 
strongly suggests that the disease was conveyed to the village 
on the clothing or person of the man or in his baggage, while 
he himself escaped the disease. In the 56 epidemics analysed, 
this mode of infection occurred in two, or 3 6 percent, of 
the total, and in six others, or 10’ 8 per cent, of the total, it 
was thought to have taken place, but accurate information 
was lacking. 

Spread by the migration of rats .—A fourth mode of spread 
of the disease has been described—namely, that under the 
influence of the panic occasioned by the epizootic migration 
of rats from village to village takes place with the result 
that the infection is conveyed in this manner. My observa¬ 
tions on the common rat of India, the black rat (mus rattus), 
go to show that, as regards this rodent, the spread of the 
disease between villages can rarely if ever take place by this 
means. The accidental transportation of infected rats in 
ships and merchandise is. however, a fruitful source of the 
disease being conveyed long distances. 

A few words are necessary as to the manner in which man 
becomes infected. This we have seen in the case of pneu¬ 
monic plague is “direct” from sick to healthy, in the case 
of the bubonic variety a link between man and the rat 
appears necessary ; that this is supplied, in the majority of 
cases, by the rat flea, pulex cheopis (Rothschild), the work 
of the Indian Plague Commission leaves but little room for 
doubt. But this is not the only mode of infection, as 
accidental inoculation in the case of man, feeding experi¬ 
ments and infection through the shaved skin in the case of 
animals abundantly prove. Any method by which the 
bacillus is introduced into the body is capable of producing 
the disease. More knowledge is required concerning the 
habits of the rat flea before its influence can be fully deter¬ 
mined, but at first sight the fact that infection may take 
place in a variety of ways and that in the most virulent type 
of the disease—pneumonic plague—this insect is not con¬ 
cerned, would suggest that the role of the rat flea in the 
transmission of the disease is a passive one. It has recently 
been suggested that the occurrence of the annnal epidemics 
are dependent on and associated with the prevalence of the 
rat flea, but though some relationship does exist between 
flea prevalence and plague prevalence, this does cot appear 
to warrant the assumption that the flea is anything more 
than one of the factors in the case. 

Preventive Measures. 

Up to the present the measures which have been chiefly 
relied on, and which obtained official recognition at the 
International Sanitary Convention of Paris (1903), have been 
confined to the prevention of the importation of the disease 
and to methods of stamping it out when it has occurred on 
board ship or elsewhere. These no doubt are very necessary, 
but they are not sufficient, for it is not always possible to 
detect every case of plague even in the most favourable 
circumstances, and, furthermore, a case of human plague is 
not an essential preliminary to an outbreak of the disease. 
It is for this reason that the large sums of money spent in 
the past on disinfection and similar measures have not been 
attended with success, with the result that not only has the 
progress of the disease not been arrested, but all anti-plague 
measures have fallen into discredit. 

It therefore becomes necessary to consider what other 
means are available to remedy this defect. One of the 
essential requisites is that every sanitary authority should 
possess a special plague department, the sole duty of which 
it should be to frame and to carry out the measures suited to 
the requirements of the area under its control. 

The chief means of the spread of bubonic plague from 
place to place is, we have seen, by the agency of man, and 
methods designed for the protection of uninfected areas may 
therefore be directed to the control and supervision of 
individuals coming from infected areas. It is chiefly on 
such control that most anti-plague measures in the past 
have been based but they have not met with invariable 
success. As regards bubonic plague they are open to obvious 
objections—namely, that adequate supervision is extremely 
difficult and that they take no account of the possibility of 
infection by infected merchandise, clothing, or rats, which, 
as we have seen, are occasionally responsible for the transfer 
of the disease from place to place. While therefore not 


underrating these measures, which should form part of all 
methods of plague prevention, it is necessary to remember 
that although man is the agency by which the disease is con¬ 
veyed from place to place, the rat is the means by 
which the disease, once imported into a given area, 
is afterwards disseminated throughout it. On this account 
I believe that the destruction of rats, combined with the 
other methods already indicated, will be completely 
successful in preventing outbreaks of plague in uninfected 
areas. In my opinion it is to the neglect of this factor 
of the rat that the failure of anti-plague measures in the 
past is to be largely attributed. 

Any seaport in communication by shipping with an 
infected port is liable to infection. Here the principal 
danger lies in the disease being conveyed by infected 
rats rather than by hnman agency. Regulations on the 
following lines are, therefore, necessary and should be made 
obligatory: (1) all ships communicating directly or in¬ 

directly with infected ports should be periodically cleared of 
rats by the Clayton process or some similar method ; (2) in 
addition other methods of destroying rats should be 
carried out. such as periodical poisoning or the permanent 
use of rat-traps, a certain number of which it should 
be obligatory on all ships to carry ; and (3) inspec¬ 
tions by the sanitary authorities of ports should be 
made from time to time to see that these measures are being 
carried out. To prevent the transfer of rats from the dock 
to the Bhip all gangways or other communications between 
the ship and the shore should be removed at night and a 
circular iron sheet having a diameter of three feet and a 
thickness of about a quarter of an inch should be affixed to 
each hawser or cable both near its attachment to the ship 
and also at its shoreward extremity. These “rat-shields” 
would effectually prevent any rats passing from the shore to 
the ship or vice vend. They should be immediately put in 
place on coming into port on all occasions. 

By the adoption of these measures all danger of infection 
from the side of the ship would be abolished except in so far 
as infected merchandise is concerned. Since it is by the 
inclusion of infected rats, or by infection derived from them, 
that merchandise usually becomes contaminated the destruc¬ 
tion of these animals will materially reduce the danger of 
this taking place. 

Similarly, to insure a condition of safety on shore it is 
essential that the destruction of rats in all ports liable 
to infection should be also carried out ; and this is 
particularly necessary in the vicinity of all docks, wharves, 
and warehouses. Herein lies the necessity for a special 
plague department, for the work requires to be carried 
out systematically under careful supervision, such, for 
instance, as is now the case at Bombay and other 
places in India. Some central depot in each town or 
city is necessary to which all rats captured may be taken 
for identification and if necessary bacteriological examina¬ 
tion for plague bacilli. The question of species is Important 
in view of the fact determined by Liston that the black rat 
(mus rattus) is by reason of its habits more concerned with 
the spread of plague than the brown rat (mus decumanus). 
The relative distribution of theBe two therefore becomes a 
matter of importance, but since they are both equally 
susceptible to the disease their extermination is necessary. 

As regards the methods of combating the disease in an 
infected area reliance must not be placed on any one 
particular measure, for the greatest hope of success lies 
in the suitable combination of all methods. Thus the 
access of infected persons to uninfected areas should, 
where possible, be prevented. The destruction of rats should 
be carried out by the best means available, since there is 
good reason to believe that it is by means of chronic plague 
in the rat that the disease is carried over from one epidemic 
to another. It Bhould be carried out in the “ free season,” 
and if poisoning is the means adopted it should be carried 
out just before the breeding season of the rat. On plague 
breaking out evacuation of infected houses should be im¬ 
mediately resorted to, but much harm will result if 
the inhabitants flee to uninfected areas ; hence, where 
possible, arrangements should be made to accommodate 
them temporarily in the vicinity of their homes. Dis¬ 
infection, except at the very commencement of an epi¬ 
demic, is entirely useless, but for carrying it ont at this 
time and also for dealing with imported cases a staff for 
disinfection purpose must be provided and, since the rat-flea 
is an important means of infection, they should be supplied 
with a solution such as phenol, which is both a pulicide 





216 The Lancet,] DR. M. S. PATERSON : GRADUATED LABOUR IN PULMONARY TUBERCULOSIS. [Jan. 25,1908. 


and a bactericide. Haffkioe’a prophylactic should also be 
available in quantity so that it may be immediately dis¬ 
tributed in case of necessity to all those willing to resort to 
it, As regards medicinal treatment no drugs in my hands 
have yielded results worthy of mention. Cases of plague 
appear to bs best treated on general principles with the 
free exhibition of cardiac tonics. In India, at any rate, 
there is no doubt that a large number of unnecessary deaths 
take place from heart failure, due either to leaving the 
recumbent attitude too soon or sometimes directly to fear. 

Jbelum, Punjab, India. 


GRADUATED' LABOUR IN PULMONARY 
TUBERCULOSIS . 1 

BY MAR0U8 S. PATERSON, M.B., B.S. Durh., 
M.R.C.S. Eng , L R O.P. Lond., 

MEDICAL SUPEB1NTERDEKT, BROMPTON HOSPITAL NAN A TO HUM, 
TRIM LEY. 

r The Brompton Hospital Sanatorium is situated on the 
Ohobham Ridges, about two and a half miles from Frimley 
station, at an altitude of 380 feet. It contains 108 beds, 
78 for men and 30 for women. Patients are not admitted 
directly to the sanatorium but are selected from the in¬ 
patients of the Brompton Hospital by the physicians of the 
hospital. 

Early in 1905, while resident medical officer of the 
Brompton Hospital, I was asked by the committee to 
organise the new sanatorium which was on the point of 
completion. I had observed that many tuberculous patients 
who had followed their ordinary occupations up to the 
time of admission were in a very fair condition of 
health. The case of a navvy may be cited as an example. 
He had worked for 40 hours almost without a rest, altering 
a water main, a few days previously, and although he had a 
considerable amount of disease, was apparently none the 
worse for such arduous work. It occurred to me that, if 
some consumptive persons under adverse circumstances, and 
without any medical guidance, could act thus without 
apparent injury they ought, UDdor ideal conditions and 
with the work carefully graduated in accordance with their 
physical state, to be able to undertake useful labour. On 
this assumption manual work should be of great advantage 
to patients undergoing treatment in a sanatorium, as, 
first, it would do much to meet the objection that 
members of the working classes are liable to have their 
energy sapped, and to acquire lazy habits by such treat¬ 
ment ; secondly, it would make them more resistant to 
the disease, by improving their physical condition ; and 
thirdly, would enable them by its effect upon their muscles 
to return to their work immediately after their discharge. 
The idea was a new one and in opposition to the generally 
accepted medical opinion on the subject. It had, however, 
been shown by Dr. Otto Walther of Nordrach that excellent 
results could be obtained by graduated walking exercise, 
especially when, in suitable caseR, this exercise was pushed 
to the extent of walking 20 miles a day. In this iorm of 
exertion, however, the muscles used were chiefly those of 
the lower limbs. I had it in mind to employ also the upper 
limbs which are supposed to have a more direct influence on 
the expansion of the luDgs. The objections naturally 
raised to this method of treatment were : (1) that the disease 
would become active again under the strain ; and (2) that 
the exertion would tend to produce hmmoptysis. 

At the outset great care had to be exercised, not only from 
the fear that as the views which had led to the adoption of 
the method were possibly unsound, harm might be done, but 
also because the patients did not take kindly to the work, it 
being absolutely contrary to their preconceived views of treat¬ 
ment. suitable to their condition. Some of them imagined for 
a time that it was not designed for their benefit but purely 
for the advantage of the institution, and they regarded me 
rather as a labour master trying to get so much work out 
of them than as a medical man who was endeavouring to 
cure their disease. Hire was especially necessary in the 
selection of patients for the work, as had there been a 
case of severe htemoptysis, or of high fever or pleurisy, it 
would prohably have been imprss ble to convince the patients 
that the method was sound aLd they would have refused to 
work. 

‘ A paper read balore the Medical Society ol Loudon on Jan. 13th, 
1908. 


Walking exercise was first ordered, the distance beiDg 
gradually increased up to 10 miles a day. When a patient 
had reached this stage he was given a basket in which to 
carry mould for spreading on the lawns, fee. No case of 
haemoptysis or of pyrexia occurred among these patients. 
When they had bsen on this grade with nothing but 
beneficial results for from three weeks to a month, they were 
given boys’ spades with which to dig for five minutes, 
followed by an interval of five minutes for a rest. 
After a few weeks several of the patients on this work, 
who were doing well, were allowed to work as hard as 
possible with their small spades without any intervals for 
rest. As they had all improved on this labonr larger shovels 
were obtained, and it was found that the patienbB were able 
to use them without the occurrence of hHemoptysis or of a 
rise of temperature. About this time many of the patients 
were feeling so well that it became necessary to restrain 
them from doing too mneh. The tradition of absolute 
obedience to the orders as to the amount of work to be done 
had not yet been firmly established, and one of the patients 
who had improved most of all was found wheeling a heavy 
barrow full of sand without permission. When admonished 
for infringing bis instructions he replied that he felt quite fit 
for such work, and as he would have to leave shortly and do 
hard work he wanted to get into condition for it. This 
argument appeared to be sound, and as he was willing to 
take the risk he was allowed to continue to wheel the barrow 
for the full labour period, which at that time was three hours 
a day. He suffered no ill-effects, but, on the contrary, did 
exceedingly well, and has since been at work for over two 
years. It was thus shown that a tuberculous man could, in 
certain instances, do heavy manual labour and continue to 
improve in health. I accordingly decided to work out a 
carefully graduated scale of labour. 

At the end of the first six months a great advance had 
been made, for the tradition of work as a method of treat¬ 
ment was firmly established and the patients saw clearly 
that it was for their own benefit. The extension of the 
system required great care and minute supervision, for 
the patients, far from objecting to, or attempting to 
shirk, their appointed labour, now had a tendency to do 
more than they were ordered. Harder work was first pre¬ 
scribed for those patients who could be trusted. It was 
found that they could gradually be trained to use the 
heaviest spades, shovels, and 5-pound pickaxes with advan¬ 
tage to their physical condition, and without any attack of 
haemoptysis or rise of temperature. The patients all expressed 
the opinion that the work did them good and that the 
harder they worked the better they felt. Many patients 
have since written to say that they date their improve¬ 
ment trom the commencement of the labour and that 
they think that the hardest work did them the most 
good. Within the first year there were several patients 
who would, despite all instructions, over-exert themselves 
and use heavier tools than they Bhould have done. In 
most instances no serious harm resulted but several of them 
developed fever and subsequently pleurisy. PleurUy, indeed, 
appears to be a frequent result of any excessive work. One 
of these patients was laid up for nearly two months and was 
much worse at the end of that time, although eventually he 
did well and is now at work, bnt the extent of his disease 
was increased by the over-exertion. The necessity of 
absolute obedience to the medical officer's orders was 
firmly established by such cases. Each patient on admission 
is told that be will be treated by prescribed rest and exercise 
and that as he does cot himself know the amount of rest or 
exercise which he requires be must do exactly as he is told, 
aud that whilst harm will result if he does too much he will 
not receive proportionate benefit if he does too little. It is 
also pointed out that he must consider himself under treat¬ 
ment for the whole day, the amount of rest and exercise 
being definitely fixed for the 24 hours. 

Details of the Systtm of Graduated Labour. 

1. Results of physical examination —Each patient on 
arrival at the sanatorium is examined and the extent of the 
disease as indicated by physical signs is noted. The patients 
are then divided into two classes : (a) Those with early 
disease—i.e., slight signs in one or two lobes : and (3) those 
with more extensive disease—i.e., with either extensive infil¬ 
tration of one lobe, or infiltration of two, three, or four lobes 
of some duration, the lesions often showing signs of fibrosis. 

2. General condition .—The next points noted are the facial 
expression and the general physical development of the 




The Lancet,] DR. M. S. PATERSON: GRADUATED LABOUR IN PULMONARY TUBERCULOSIS. [Jan. 25. 1908. 2 1 7 



Grade 1.—Basket work. 


Fig. 2. 



Grades 4 and 5.—Pickaxe and barrow work. 






























218 The LANCET,] DR. M. S. PATERSON: GRADUATED LABOUR IN PULMONARY TUBERCULOSIS. [JAN. 25,1903 


patient. These points should always be considered bogetnei 
with the physical signs, as a patient with tubercle bacilli in 
his sputum may look very ill and have marked wasting and 
poor development, even though no physical signs of disease 
are found on examination of the chest. Such a patient is 
quite unfitted for much, if any, exercise, whereas a patient 
looking fairly well, of good development, but with physical 
signs indicating that even as many as four lobes are affected, 
may be quite capable of considerable muscular exertion. It 
must be remembered that the resisting power of a patient 
with a very limited lesion is practically an unknown 
quantity and has to be determined, whereas a patient with a 
lesion involving four lobes who has continued at work for 
some time and has remained, in spite of the disease, in fair 
condition probably had a good initial resisting power. 

3. Presence or absence of fever .—The next point for 
consideration is the temperature, which is taken in the 
mouth. Should this be, or have been, 99° F. or over 
during the week preceding admission to the sanatorium 
the patient is put to bed after the journey. So long as 
the temperature remains at 99° in the case of men or 
99'6° in the case of women the patient is not allowed up 
for any purpose. Work is prohibited and reading is the 
only recreation permitted. Naturally the object of this 
stringent rule is to try to check the activity of the disease. 
I consider that if a patient with few signs of disease, when 
absolutely at rest in bed, still has a temperature of 99° 
active disease is present. Such patients are usually 
kept together in one ward for the sake of cheerfulness, male 
and female patients being of course in separate wards. 
After the temperature has been normal for a week or ten 
days the patient is allowed up for dinner but returns to bed 
as soon as the meal is finished. So long as the temperature 
is unaffected by this exertion the patient is gradually 
allowed up for longer and longer periods. In practice it is 
found that the longer the time the patient has had to stay 
in bed before his temperature subsides to, and remains at, 
the normal level the more protracted must be the period 
before he can be allowed to remain up for a whole day in 
safety. When this stage is reached the patient commences 
to work with the fingers, sewing, making mats, mops, Ac. 

4. Exercise .—If the general condition and appetite are 
good and the patient is feeling well after from 10 to 14 days 
of this treatment he is allowed to walk half a mile a day for a 
week. He then gradually goes through the grades of exercise 
subsequently to be described as suitable for those patients 
whose temperature is normal. Fatients with apparently 
limited disease, but who are in poor general condition 
and without fever, are allowed to be up all day but are Dot 
permitted to take further exercise than is entailed by walking 
to and from the dining hall for their meals. The remain¬ 
der of the day is spent resting, and work entailing no 
physical exertion is allowed with the sole obj act of occupy¬ 
ing their minds. As their condition improves they are allowed 
to walk half a mile a day, then a mile a day, and bo on, 
until a distance of six miles a day is achieved. The rate of 
increase in the amount of exercise depends upon such factors 
as the patient’s disposition, weight, and appetite. It is not 
possible to make a definite statement as to the number of 
days during which the patient should be set to walk half a 
mile, two miles, four miles, and so on, as each case requires 
to be judged on its merits and on the response to treatment. 
A patient allowed to walk a mile a day for 14 days may be 
doing well yet the increase of half a mile may cause the 
temperature to rise to 99°. If this occurs he is then 
ordered to rest for a day or so before recommencing with a 
mile a day. It will thus be seen that the exertion required 
for each grade of work acts as a test not only of the fitness 
of the patient for such labour but also of his fitness for an 
increased amount of exercise. 

The grades of work may be summarised as follows; 
(Al) Walking from i mile to 10 miles daily; (1) carrying 
baskets of mould or other material; (2) using a small 
shovel; (3) using a large shovel; (4) using a pickaxe; 
and (5) using a pickaxe for six hours a day. Fatients in 
Grades 1, 2, 3. and 4 work for four henrs a day. 

Grade 1 .—Basket work is subdivided into three sections. 
In the first the patient carries a load of about 12 pounds in 
weight a distance of 50 yards up a gradient of 1 in 10 • 7— 
i.e., rising 14 feet in that distance. Such patients carry in a 
day 80 loads, or, in other words, they will carry 8£ hundred¬ 
weights a distance of 50 yards and return for a distance of 
4000 yards with the empty basket. In the second section the 
weight carried is about 18 pounds, the conditions being the 


same, anu these patients Carry about t3 uendreuWeights per 
day. In the third section the weight c cried is 24 pounds. 
A patient on this work carries during the day about 17? 
hundredweights for the same distance. 

Grade 2. —The small shovel is the ordinary coal scoop 
provided with a long handle. Patients commencing on this 
grade of labour will dig two tons of earth a day and raise it 
seven feet into a cart, and as they increase in strength will 
in a day lift about four tons the same height. 

Grade 3 .—The large shovel is the ordinary shovel used by 
a navvy. Patients on this grade will dig and lift about six 
tons a day a distance of seven feet. 

Grade 4 —Pickaxe work is the hardest work possible, and 
consists of breaking unbroken ground, excavating, Ac. 

Concrete mixing comes under the heading of pickaxe work, 
as although the large shovel is used the work is heavier than 
moving sand or mould. Each man moves about ten tons a 
day and has to heep going or he stops the whole of the men, 
whereas on the other work he can take his own time. 

When a patient has been on a grade of labour for about 
three weeks his fitness for harder work is considered. If the 
temperature has been normal, the weight satisfactory, the 
appetite good, and if he is feeling well (this is to be deter¬ 
mined by watching the way in which he performs his work) 
then he is put on harder work. Here may be noted an 
interesting psychological effect of physical improvement. 
Many patients on their arrival are somewhat remarkable for 
a certain sullen and apathetic attitude, but as soon as their 
physical condition undergoes amelioration all traces of gloom 
and depression leave them and they become transformed into 
lively, cheerful individuals. After three weeks it is usually 
found that the patient who is working within his strength is of 
his own accord working harder than he did when first placed 
in that particular grade. This is specially noticed with 
“basket men,” who carry about 8 pounds weight of earth. 
The quantity is gradually increased and finally the patient is 
allowed to fill his own basket, which he usually does to its 
fullest capacity. 

I consider the basket grade the most important of all, and 
patients as a rule spend far more time in this grade than in 
any other. I regard it as the connecting link between walk¬ 
ing and work. It does not entail much exertion and yet 
brings into use nearly all the muscles of the body and so fits 
the patient for light work. I am always careful to have a 
definite and apparent object in this and all work, so that 
the patients can see the result of their labour. Fatients 
hate nothing more heartily than work which is of no 
practical utility. 

Patients who have successfully gone through the above 
grades and worked for six hours a day are three weeks before 
their discharge put to work at their trades, if they have a 
trade, in order that the muscles used in their particular work 
may become accustomed to it before they leave the sana¬ 
torium. These examples are given to show approximately 
what amount of energy is exerted in each grade of labour. 
Patients are not confined to the work enumerated above but 
are given other work corresponding in severity to the use of 
the tools mentioned. For instance, painting, hoeing, and 
chopping wood are equal to the work of Grade 2. Sawing 
trees into firewood is equal to the work of Grade 3. Planing 
wood is equal to the work of Grade 4. Any form of labour 
can be utilised, but an estimate must be made of the amount 
of energy which it involves. Patients who have reached the 
stage of walking four miles a day or any higher grade of 
work make their own beds, change their bed linen, clean 
their wards and windows, polish the floors of adjacent 
corridors, and keep the dining halls clean and the brasswork 
bright. 

The grades of exercise and work for the women are similar 
to those for the men, but the various implements, such as 
baskets, shovels, Ac., are of smaller size. These patients 
are cot allowed to work as hard as the men and consequently 
do not accomplish as much in the same time. They also 
keep in order their own part of the grounds, cultivate a small 
kitchen garden, and, in addition, they have charge of the 
poultry. The final grade corresponding to the hard navvy 
work of the men consists of scrubbing work indoors. 

One of the first indications that a patient is taking too 
much exercise is that he loses his appetite and suffers from 
slight headache. If he continues to do the same amount of 
work the temperature will rise to 99°. ThiB temperature is 
the danger Bignal and any patient who has a temperature 
of 99° and is suffering from the slightest headache is imme¬ 
diately ordered to bed. In cases of extensive disease—e.g., of 





The Lancet,] DR. M. S. PATERSON: GRADUATED .LABOUR IN PULMONARY TUBERCULOSIS. [JAN. 25, 19C8. 219 


three or four lobes with fibrosis—a temperature of 99° has not 
the same significance, but it is still regarded as a danger 
signal and the patient is specially watched. A temperature 
of 99'6° in women appears to correspond with the tempera¬ 
ture of 99° in men. It is necessary to emphasise the 
importance of the significance of a temperature of 99°. If 
this degree of fever is observed and the patient is ordered to 
rest for a few days no harm will result, but if it is disregarded 
and the patient continues to work he will, later, in addition 
to the headache, complain of pains in his joints and limbs, a 
condition very closely resembling influenza. Indeed, this 
result of over-exertion is often called influenza. Should 
the patient still continue to work or should he have 
against orders very much over-exerted himself the tempera¬ 
ture will rise to 100° or over and pleurisy may develop. This 
complication seems to be the invariable result of excessive 
work or overlooking the danger signal—I.e., the tempera¬ 
ture of 99°. 

The following facts are significant. During the first year 
that the sanatorium was opened the patients were allowed to 
play games, such as croquet, quoits, &c., in the evenings and 
on Saturday afternoons, but it was soon found that many 
patients in this way took too much exercise. Their improve¬ 
ment was not satisfactory, as they were apt to get too keen 
over the games and to forget that they were under treatment. 
A rule was therefore made that patients were not to play any 
games, such as croquet, until they had reached the stage of 
basket work. Much better results followed its adoption. 
The reason is obvious : a patient walking his prescribed four 
miles a day is having sufficient exercise, but if he plays a game 
of croquet in addition he has too much. It was therefore 
established, and it is a fact of the utmost importance, that the 
hours of recreation must be regulated with just as much care 
as the hours of work. The accompanying chart shows the 


harder work or more rest. They were considerably under 
the normal weight and their general state did not suggest 
a capacity to undergo an increase of labour. After careful 
consideration it was determined to try the effect of harder 
work with a view to improving the appetite. I am glad to 
state that all such patients have shown progressive improve¬ 
ment on being given work of a higher grade. 

The diet iB liberal and consists of the ordinary food which 
the working-classes provide for themselves when they are in 
a position to afford it. The patients have three meals in the 
day. Breakfast consists of bacon, &c. ; dinner consists of 
meat and suet or milk puddings; and supper consists of 
soup, oat cakes, Cornish pasties, or cheese, Ac. For the first 
16 months the patients used to have three pints of milk 
and an egg every day ; now they only have milk in their 
tea, coffee, and puddings, and they are not given an egg 
every day, but they do just as well on this as on the 
more stereotyped and conventional form of diet and 
do not become excessively corpulent. Of course, patients 
who are very emaciated have milk if it is thought necessary, 
but as a routine milk is not used except as it would be in 
their own homes. The standard aimed at as regards nutri¬ 
tion is to raise the patient’s weight to a few pounds above his 
highest known weight or to a few pounds above the normal 
weight for his height. Patients who tend to become exces¬ 
sively fat have their diet reduced in quantity. 

Medicines such as cod-liver oil, malt, fee., are not used. 
Practically the only drugB prescribed are aperients. 

The following work which has already been accomplished 
will show the scope and variety of the tasks which the 
patients have performed. About 900 tons of mould, sand, 
and gravel have been carried in baskets an average distance 
of 200 yards. The whole establishment has been kept in 
firewood ; it has not been necessary to obtain any from out- 



effect produced by an act of indiscretion upon the tem¬ 
perature of a patient who should have been resting all day. 
It occurred upon a certain summer evening when, as he con¬ 
sidered himself to be free from control, not having realised 
that be was always under treatment, he went for a short 
walk of about half a mile. Playing the piano or singing 
must be regarded as exercise, as I have known a musical 
patient after an hour at the piano experience a rise of tem¬ 
perature to 99°, with headache and general malaise. 

After the sanatorium had been opened about 18 months 
and further experience had been gained I came to the con¬ 
clusion that the patients who had a slight rise of temperature 
(99°) as a result of over-work, and for whom in consequence 
rest for a few days had been prescribed, were not infre¬ 
quently not only none the worse for this sequence of 
events but rather the better. Some patients even appeared 
to date the commencement of their improvement from the 
period of rest following over-work. It was accordingly de¬ 
cided to be unnecessary to put these patients back to the 
earliest grade of work and they were permitted, after a few 
days' walking exercise, to recommence work in the grade 
reached when they suffered from over-exertion. This practice 
has been continued ever since with satisfactory results but 
it is impossible to lay too much emphasis on the fact that 
such patients require to be watched with especial care as 
regards loss of appetite, the presence of headache, or of a 
rise of temperature. In the course of my earlier experience 
I observed cases of another type—i.e., patients who from the 
indications given by the temperature, appetite, and de¬ 
meanour, ought to have been doing well but who remained 
in a stationary condition, and were in fact only ‘' marking 
time.” It was doubtful whether such patients should be given 


side sources. The boots of the patients and staff have been 
kept in repair. The patients’ block of buildings has been 
painted. The whole of the grounds has been kept in order. 
In addition to these occupations the patients have been 
engaged in mixing and laying 1000 tons of concrete and in 
excavating and moving to a distance of 300 feet 5000 tons 
of sand in the construction of a reservoir. The reservoir is 
108 feet long, 54 feet wide, and 12 feet deep ; and the walls 
are 4 feet thick at the base and 1 j feet at the top. In 
addition 3i acres of land have been trenched, cleared, and 
brought into cultivation. 

In order to ascertain the results of the system of graduated 
labour, all patients on their discharge have been requested 
to keep the administration informed as to their progress. 

In considering the following results of the treatment of 
pulmonary tuberculosis by graduated labour it is to be dis¬ 
tinctly understood that 1 have only quoted the cases of 
patients who went through all the grades and eventually per¬ 
formed the highest work. Furthermore, all these individuals 
were patients who were discharged during the years 1905 and 
1906, so that the statistics refer to patients who have been 
at work for from one to two and a half years. Of the above- 
mentioned patients the number discharged during 1905 and 
1906 was 164. Of these 119 had tubercle bacilli in their 
sputum ; four had physical signs and gave a tuberculin 
reaction ; one had definite signs, but the sputum was not 
examined ; 31 had definite physical signs, definite histories 
and definite symptoms of pulmonary tuberculosis but no 
tubercle bacilli were found in their sputum when it was 
examined at the sanatorium; and nine had histories and 
symptoms of pulmonary tuberculosis but no physical signs 
and no bacilli were found in the sputum, nor were they 































220 The Lancet,] DR, INMAN: EXERCISE & OPSONIC INDEX OF TUBERCULOUS PATIENTS. [Jan.25,1908. 


tested by tuberculin. These nine cases are left ont as to their 
after-results, so that the number to be accounted for is 155. 
Of those, 135 are at work, nine have not reported themselves, 
nine are not at work, and two are dead. 

A point which I wish to emphasise is that all of the above 
patients returned to their previous occupations whatever 
they happened to be, and not to light out-door work. To 
advise the latter has always seemed to me like recommend¬ 
ing plenty of good food and milk to those who are 
practically penniless : excellent advice but impossible to 
carry out. 

Some ten months ago Dr. A. C. Inman suggested to me that 
the explanation of the satisfactory results obtained from 
the system of graduated labour was that the work caused 
an inoculation of the patient by his tuberculin. This 
theory, the origin of which is given in Dr. Inman's paper, 
was supported by the fact that after a rise of temperature, 
and therefore an auto-inoculation, patients were often better 
than before, and that patients who were not improving on a 
certain grade of work did improve on harder work. The 
theory is that the harder work gives rise to an auto-inoculation 
whereas the lighter work fails to do so. For the past ten 
months I have used this as a working hypothesis in 
determining the suitability of a patient for any particular 
grade of labour and have found it to be of very great assist¬ 
ance. The method entails a more careful graduation of the 
labour, as two important questions have to be answered : 

1. Is the patient doing work which is too hard ? 2. Is he 
doing sufficient work to keep himself properly inoculated ? 
In other words, suitable work has to be found for what is re¬ 
garded as the exact medical condition of each patient. When 
Dr. Inman commenced to examine the bloods of the patients 
and required cases of a certain kind I was able to find with¬ 
out any difficulty examples of cases required: as, for instance, 
a patient who was auto-inoculating himself slightly, or again 
one with a high opsonic index. The same is true of patients 
with a normal index, also of patients who from excessive 
auto-inoculation had low indices, and of patients whose 
index was constantly low. The results of the exa¬ 
minations of the blood were most convincing, because they 
bore ont so exactly the condition of the patient as deter¬ 
mined by clinical observation. One case was especially 
nseful. It was that of a man who was regarded as possibly 
fit for harder work but whose condition was such that it was 
iudged to be unwise to take the risk of increasing his task. 
The blood was examined and his index found to be 
practically normal. He was then put on harder work for a 
week and the index again taken. Again it was practically 
normal. He was then put on the heaviest work and per¬ 
formed it without harm. In a case of this kind the opsonic 
index proves an invaluable guide, saving perhaps months of 
time, by determining within a week that the patient is fit for 
the hardest work, when clinically we should hesitate to come 
to such a conclusion. Dr. Inman’s work, so far as it has 
gone, confirms the value of graduated manual labour in the 
treatment of pulmonary tuberculosis and has done so in a 
manner that could only be determined by a further trial 
lasting over several years. 

The points bo far determined appeared to me to be as 
follows. 1. Suitably selected patients can be gradually 
trained to do the hardest navvy work for six hours a day, the 
result being that their general condition is much improved 
whilst some lose both their sputum and their tubercle bacilli. 

2. Certain patients who do not improve on light work show 
marked improvement on harder work. 3. Patients who have 
slightly over-exerted themselves and are kept at rest for the 
few following days are subsequently not only not worse 
but may be in their own opinion better. 

My observations so far lead me to the conclusion that 
graduated labour is a definite medical treatment for cases 
of pulmonary tuberculosis and raises the general health and 
resisting power of the patients. 

Finally, I should wish to express very strongly the opinion 
that the combination of rest, pure air, and over-feeding is 
not the only treatment for chronic pulmonary tuberculosis 
and equally strongly to advise those physicians who may 
adopt these suggestions contained in this paper to pay 
particular heed to the word graduated and to remember the 
importance of the temperature of 99° F. 

Frimley. 


A New Medical Pasjia.—P rofessor WietiDg, 

director of the Osman Clinical Hospital, Gulhane, Constanti¬ 
nople, has been raised to the dignity of a Turkish Pasha. 


THE EFFECT OF EXERCISE ON THE 
OPSONIC INDEX OF PATIENTS 
SUFFERING FROM PULMONARY 
TUBERCULOSIS . 1 

By A. C. INMAN, M.A., M.B.Oxon., 

SUPERINTENDENT OP THE LABORATORIES OF BROMPTON HOSPITAL FOR 
CONSUMPTION AND DISEASES OF THF. CHEST, LONDON. 

(IroTn the Bacteriological Laboratory of the Brompton 
Hotpital.) 


The study of the part played by the blood as a protective 
agent in bacterial infections has recently entered npon a new 
phase. Hitherto the subject had been mainly one of 
scientific interest only ; the results obtained and the 
principles and theories evolved bad been for the most part 
confined within the walls of the laboratories. The phago¬ 
cytic action of the white corpuscles and its r61e in immunity 
had ceased to interest the clinician. The discoveries of 
Ehrlich, brilliant as they were, were appreciated by few who 
were not pathologists, the “side-chain theory” with its 
difficult nomenclature having but little effect on bedside 
medicine. But the publication of Sir Almroth Wright’s 
investigations and the principles of immunity expressed by 
him have not only thrown a new light npon clinical problems 
hitherto in obscurity but have produced results and sug¬ 
gested inquiries of great importance in the domain of 
practical medicine. Wright, by a modification of Leishman’s 
technique, completely separated all three elements necessary 
for the phenomenon of phagocytosis—viz., white corpuscles, 
serum, and bacteria—and was thus able to investigate the 
i ole played by the blood in bacterial infections more fully 
than had previously been possible. In his lecture before 
the Harvey Society of New York he shows that as regards 
active immunisation there are three great agencies by 
which immunising responses can be evoked in the organism : 
(1) the inoculation of bacterial vaccines ; (2) artificially in¬ 
duced auto-inoculations; and (3) spontaneous auto-inocula¬ 
tions. In previous publications he had expounded the princi¬ 
ples of vaccine therapy and had been able to show by means of 
curves constructed from the opsonic indices of patients 
vaccinated against their infection the definite train of 
events which follow upon a single inoculation. He has 
defined these successive phases as the negative phase, the 
positive phase, and the phase of maintained high level, 
Freeman, working in Wright's laboratory, next opened up a 
new field for investigation by his observations on the effect 
of massage on gonococcal joints. OwiDg to this work it has 
been possible “ to thorn that auto-inoculation* follow upon all 
active and patsive movement* which affect a focu* of infection 
and upon all valvular changet which activate the lymph- 
ttream in inch a focnt.” Further, it is obvions that, as 
Wright puts it, “where in association with a bacterial 
invasion of the organism bacteria or bacterial products pass 
into the general lymph- and bloodstream intoxication 
effects and immunising responses, similar to those which 
follow upon the inoculation of bacterial vaccines, must 
inevitably supervene.” And it is by the agency of such auto¬ 
inoculations that nature achieves curative effects in bacterial 
infections. The far-reaching importance of these observa¬ 
tions on spontaneous and artificially induced auto inocula- 
tions decided me to investigate the part played by auto- 
inoculatlon in pulmonary tnbercle. Moreover, it is obviously 
desirable before attempting to treat a disease, however 
rationally, to try to find out what the body is doing of itself 
and to what extent extramous circumstances, such as move¬ 
ments, influence these attempts on the part of the body. 

The technique —In these experiments the technique as 
carried out by Wright and Douglas has been followed. 

1. The corpuscles were very carefully washed in sterile salt 
solution (0 • 85 per cent.) after the first centrifugation so as 
to get rid of all traces of serum and citrate solution, 

2. The emulsion. A culture, obtained from a solid medinm, 
and suspended in 1 ■ 5 salt solution was used. 3. The serum 
was always collected in Wright’s tubes and the blood allowed 
to clot at room temperature. The blood was always examined 
the same day as it was drawn, usually within five or six 
hours. Before each experiment a “trial trip” was made 
with the normal seium with a view of seeing that all the 


1 A paper read before the Medical Society of London on Jan. 13th, 
ISOS. 






The Lancet,] DR. INMAN: EXERCISE & OPSONIC INDEX OF TUBERCULOUS PATIENTS. [Jan. 25,1908. 221 


constituents of the experiment were satisfactory. In the 
case of the normal serum, an attempt was always made to 
obtain an average count of one bacillus per cell—i.e., an 
average of about 100 bacilli in 100 cells. In all experiments 
100 polymorphonuclear cells were counted. The films were 
stained as follows: 1. Fixed in a saturated solution of 
hydrargyrum perchloridum, one quarter of a minute. 2. 
Stained with Ziehl’s carbol-fuchsin, warm, one minute. 3. De¬ 
colourised with sulphuric acid 2J- per cent. 4. The red cells 
were decolourised with acetic acid, 4 per cent. 5. Counter- 
stained with aqueous methylene blue, 1 per cent. With a 
view to eliminating as far aB possible the personal element 
and to prevent the possibility of a biased mind influencing 
the results all experiments were made with unknown bloods. 
That is to say, after the bloods to be examined had been 
drawn each blood-tube, bearing the name of the patient, was 
handed over to the assistant who rubbed out the names and 
replaced them with numbers, in any order he liked, and kept 
this key to the bloods himself. The indices were then 
worked out by experiment before seeing the key, and after¬ 
wards the ourves exhibited in this paper were constructed. 
Thus in no cases during the experiment mas it known which 
blood mas being examined. It was found in practice that 
when examining day after day a number of such unknown 
bloods, several samples of the blood of a single healthy 
individual mixed with other bloods showed indices which 
varied rather over one decimal place on either side of unity. 
Further, it has been determined by Bulloch and others that 
the bloods of presumably healthy individuals present opsonic 
indices varying between 0 ■ 8 and 1 ■ 2 on either side of unity. 
It was therefore decided to regard all indices within these 
limits as normal. 

Before considering the effect of exercise upon the opsonic 
index in pulmonary tuberculosis it must be mentioned that 
in active disease spontaneous auto inoculations are con¬ 
tinually taking place even though the patient be at rest. 
Such patients, as Wright has expressed it, are living in “a 
succession of negative and positive phases.” Chart 1 is an 


Chart 1. 



example of this. Further, it must be remembered that the 
degree of auto-inoculation is in proportion to the activity 
of the disease. There are cases, indeed, in which auto¬ 
inoculations cease when the patient is at rest but reappear 
after any movements sufficient to affect the focus of in¬ 
fection. In all charts which follow the first index was taken 
before the patient had got out of bed in the morning, the 
second was taken immediately after exercise, and the third 
and fourth during a subsequent rest of from one and a half 
to two hours’ duration. Chart 2a graphically represents the 
effect of exercise on the opsonic index in cases of early 
pulmonary tuberculosis, Chart 2b the absence of variation in 
healthy persons. 

Wright points out when comparing the respective advan¬ 
tages of artificially induced auto-inoculations and inocula¬ 
tions of bacterial vaccines as means of treatment in bacterial 
infections that if the former method is adopted unmeasured 
doses of a living culture are being used, and therefore the 
method can never be entirely dissociated from risk. Now 
at the Brompton Hospital Sanatorium at Frimley during the 
past two and a half yearn the patients during their stay 
have been treated by gradually increasing amounts of work, 


the last grade being full navvy work, almost as severe as 
it is possible for even a healthy individual to accomplish. 
In spite of the greatest difficulties Dr. M. S. Paterson, 
the medical superintendent, has evolved a scheme of very 



carefully graduated work-exercise, beginning with gentle 
walking and ending with concrete-making, excavation work, 
&c. This has been accomplished with tuberculous patients, 
many of them showing extensive signs of disease in the chest. 



with expectoration containing tubercle bacilli, but without 
fever. The treatment has been remarkably successful. 
It has only been possible to accomplish this (1) by insti¬ 
tuting the most careful graduation of the exercise; and 



(2) by close observation of the temperature chart, work 
being at once stopped when fever appears. It follows from 
what has gone before that the work-exercise scheme at 
Frimley must be associated with auto-inoculation and at 











222 The Lancet,] DR. INMAN: EXERCISE ic OPSONIC INDEX OF TUBERCULOUS PATIENTS. [Jan. 25, 1908. 


probably the treatment consisted unintentionally of carefully 
graduated, artificially induced auto-inoculations. It was 
therefore decided to investigate the Frimley cases from this 
point of view and the following observations were made 
during a stay of one month at the sanatorium. In all, over 
300 bloods were examined, from which a few cases only are 
selected under each heading for the sake of brevity. 

The cases examined may be grouped as follows : (a) Cases 
which when examined at Brompton had a low index and 
which at Frimley with graduated work show a rise of the 
opsonic index. 

Case 1 [Chart 3). —The patient was a female, aged 
18 years. Diagnosis, chronic pulmonary tuberculosis. Left 
upper lobe, rather quiescent second stage ; left lower lobe, 
infiltration. Duration, nine months. Onset, insidious with 
cough. Sputum, tubercle bacilli present. 

Case 2 (Chart 4). —The patient was a male, aged 26 years. 


Chart 4. 



Diagnosis, infiltration of the right upper and lower lobes. 
Duration, 16 months. Onset, cough and haemoptysis. 
Sputum, tubercle bacilli present. 

Case 3 (Chart 5) —The patient was a male, aged 26 years. 
Diagnosis, infiltration of the right upper lobe. Duration, 
one year. Onset, cough followed by large haemoptysis. 
Sputum, tubercle bacilli present. 



Case 4 (Chart 6).—The patient was a man, aged 
23 years, a bookbinder. Diagnosis, chronic pulmonary 
tuberculosis. Extent, extensive infiltration of the left 
upper and left lower lobes; infiltration of the right upper 
lobe. Duration, 11 months. Onset, haemoptysis. Sputum, 
tubercle bacilli present. 

It might be argued that these high readings were not the 
result of auto-inoculation but merely of increased general 
physical fitness due to fresh air, &c., as obtained by sana¬ 
torium life. If a high index were merely evidence of a 
better resistance to the disease this might be so, but the 
high index expresses the fact that in the serum of the 
patient under observation there are substances which 
increase the phagocytic power of the white cells in excess of 


those contained in the blood of any healthy non-tuberculoua 
subject. These substances are elaborated only in response 
to a defined stimulus, the introduction of bacteria or their 
products into the blood and lymph streams, and in these 
cases the only “ tuberculin ” used was that elaborated by the 



patient from himself and for himself. Thus we are dealing 
with examples of artificially induced auto inoculation. 

(K) Investigations on cases working on the different grades 
of the labour scheme. 

Case 1 (Chart 7, a). —The patient was a male, aged 21 
years, a clerk. Diagnosis, chronic pulmonary tuberculosis. 
Infiltration of the left upper lobe and apex of the lower lobe. 
Duration, seven months. Mode of onset, cough. Sputum, 
tubercle bacilli present. The patient is doing very well on 
full work. He has lost sputum and tubercle bacilli. The 
temperature is normal. He is now two stones over-weight. 



Case 2 (Chart 7, b).— The patient was a male, aged 39 
years, a carrier. Diagnosis, chronic pulmonary tuberculosis. 
Right lung, upper lobe, second stage early ; lower lobe, first 
stage. Left lung, upper lobe, second stage early. Duration, 
two years. Onset, insidious (haemoptysis +). Sputum, 
tubercle bacilli present. The patient is doing well on light 
work. The temperature is normal. Still expectoration with 
tubercle bacilli. 

Case 3 (Chart 8, A). —The patient was a male, aged 24 
years, a general labourer. Diagnosis, chronic pulmonary 
tuberculosis. Extent, right upper lobe, excavation ; left 
upper lobe, infiltration. Duration, three years. Onset, 
hremoptysis. Sputum, tubercle bacilli present. 

Case 4 (Chart 8, b). —The patient was a male, aged 
22 years, a blacksmith. Diagnosis, chronic pulmonary 
tuberculosis. Pleurisy left side. Infiltration of the left 
upper lobe. Duration, seven months. Onset, insidious 
(hremoptysis ). Sputum, tubercle bacilli present. 

It was found that in 41 out of 43 cases the index was 
at some time pf the day well above the normal, and, what is 
of even more importance, in no case did the exercise, even 
though severe, lower the index below the normal line—that 
is, the auto-inoculation was never so great as to produce a 







The Lancet,] DR. INMAN: EXERCISE k OPSONIC INDEX OF TUBERCULOUS PATIENTS. [J an. 25,1908. 223 


negative phase and therefore never in excess. It was 
observed daring these investigations that in some bloods 
examined tuberculo agglutinins appeared in association with 
the immune tuberculo-opsonins. This must be taken as 
another evidence of an immunising response on the part of 
the organism. When the difficulties of such a method of 
treatment and the danger of the weapon employed are 
taken into consideration it will be readily understood that 
every now and then, in spite of the most careful super¬ 
vision, an excessive auto-inoculation must take place. Such 



an over dose is readily recognised clinically. A patient 
previously doing well on the grade of work prescribed 
for him and with no abnormality of temperature suddenly 
complains of feeling tired, of loss of appetite and of head¬ 
ache, and the temperature chart registers an elevation to 
99° or 100° F. These are precisely the symptoms which 
are found during the negative phase after an excessive dose 
of bacterial vaccine. Owing to the extreme care and judg¬ 
ment exercised by Dr. Paterson in the selection of suitable 
work for the patients and to the rigid supervision carried 
out, not only during work hours but throughout the day, 
these over-doses are very infrequent at Frimley. During my 
stay of one month at the sanatorium only two transient 
instances of such over-dosage occurred, and in both cases the 
opportunities were taken to examine the bloods (Charts 9 
and 10). In both cases then the febrile rise and other 



symptoms coincided with a negative phase ; and while in 
both cases a positive phase appeared afterwards, in the first 
the recovery was simultaneous with the decline of the fever. 
It should be noted that this patient was kept in bed, while 
the other was allowed to do modified work during his 
pyrexia. 

(a) If a focus of infection becomes arrested auto-inocula¬ 
tions from this focus cease. In Wright's words: "Where 
an artificial inoculation can no longer be induced in a focus 
which previously could be influenced we are entitled to con¬ 
clude that the focus of infection is extinct.” Therefore, some 


of the early cases of pulmonary tuberculosis, many of whom 
had lost expectoration and tubercle bacilli, who were doing 
the hardest possible work without rise of temperature or dis¬ 
comfort, might be expected to alford evidence in their blood 



that their focus of infection was no longer aglow but 
arrested. The following results were obtained from patients 
constructing a water reservoir (full navvy work). 

Case 1 (Chart 11, A). —The patient was a male, aged 24 
years, a brass finisher. Diagnosis, chronic pulmonary tuber¬ 
culosis. Infiltration and fibrosis of the right upper lobe. 
Duration, 18 months. Mode of onset, haemoptysis. Sputum, 



tubercle bacilli present. Highest known weight, 12 stones 
2 pounds. The patient was able to do full work ; lost 
sputum and tubercle bacilli. The temperature was normal. 
The weight on discharge was 12 stones 10 pounds. 

Case 2 (Chart 11, b). —The patient was a male, aged 23 
years, a warehouse salesman. Diagnosis, early pulmonary 
tuberculosis. Extent, infiltration of the left upper lobe. 
Duration, three months. Highest known weight, 9 stones 
10 pounds. Onset, insidious (haemoptysis +). Sputum, 
tubercle bacilli present. The patient was able to do hardest 
work. Temperature normal. Weight on discharge 9 stones 
12 pounds. He lost expectoration and tubercle bacilli, 
though Blight cough persisted. 

Case 3 (Chart 12, a).— The patient was a male, aged 26 yi are, 
clerk. Diagnosis, chronic pulmonary tuberculosis. Extent, 
right upper lobe, infiltration ; left upper lobe, infiltration. 
Duration, nine months. Onset, hemoptysis. Sputum, tubercle 
bacilli present. The patient was able to do hardest work. 
Temperature occasionally 99° F. Weight on discharge, 
10 stones 12 pounds. Lost cough, expectoration, and tubercle 
bacilli. 

Cask 4 (Chart 12, n).—The patient was a male/aged 25 
years, an iron-moulder. Diagnosis, chronic pulmonary 
tuberculosis. Extent, infiltration and fibrosis of the right 
upper lobe. Duration, 12 months. Onset, pleurisy (nine 
years ago). Sputum, tubercle bacilli present. Highest 
known weight, 9 stones 12 pounce. The patient was able to 





224 The Lancet,] DE. INMAN : EXERCISE & OPSONIC INDEX OF TUBERCULOUS PATIENTS. [Jan. 25,1908. 


do hardest possible work. Temperature normal. Weight on 
discharge 10 stones 5 pounds. Lost expectoration and 
tubercle bacilli. 

All these cases showed a return of the opsonic index to the 
normal, although the patient was doing the hardest of work. 
Therefore, the clinical opinion that the disease was arrested 
is confirmed by a precise scientific observation. These 



curves again negative the supposition 'that the high index 
noted in earlier stages might be due simply to increased 
general fitness of the body due to sanatorium life, since 
cases doing best of all and about to be discharged as showing 
“total arrest” gave an index no longer above the normal 
but within normal limits. The stimulus had been removed 
and the body was no longer called upon to elaborate pro¬ 
tective substances ; while if the high index in these cases 
had been caused solely by generally improved health it 
ought to have persisted so long as the robust health 
continued. 

Two cases maybe added in which the progress from a high 
tuberculo-opsonic index produced by graduated artificially 
induced auto-inoculations to a normal index during the 
performance of the hardest work was actually observed. 

Case 1 (Chart 13).—The patient was a male, aged 26 years, 
a shop assistant. Diagnosis, chronic pulmonary tuberculosis. 
Extent, infiltration of the right upper lobe. Duration, three 
months. Onset, “ influenza ” and cough. Sputum, tubercle 


Chart 13. 


2-4 

2-4 

M 

«•! 

2-0 

1 « 

13 

1 • 

1-5 

14 

1-3 

7 

//v>C 

A 

n jo 

/ 


7 

P 

•?< 

/J Jo 


1*1 

_[L 

/ 



_____ 

- 


W> 







E 


0-7 

08 

Oft 

04 

OJ 

02 

o-i 










bacilli present. Highest known weight 10 stones 15 ounces. 
Able to do hardest work. The patient lost expectoration and 
tubercle bacilli. Temperature normal. Weight on discharge 
10 stones 3 pounds. 

Case 2 (Chart 14).—The patient was a male, aged 32 
years, a tin-worker. Diagnosis, chronic pulmonary tuber¬ 
culosis. Extent: right upper lobe, infiltration ; left upper 
lobe, infiltration. Duration, 11 months. Onset, pleurisy. 
Sputum, tubercle bacilli present. 

(d) There are cases which give a normal index before and 
after the hardest exercise, and yet have not lost all expectora¬ 
tion or tubercle bacilli in the sputum. The patients were 
without fever, were apparently in robust health, were doing 


full navvy work, and showed physical signs of arrest, but in 
the early morning occasionally expectorated a little sputum 
which contained a few tubercle bacilli (two or three on a 
slide). (Cf. Dr. J. K. Fowler's case quoted in his book on 
“Diseases of the Lung,” Fowler and Godlee, 1898, Ch. 34 v 
p. 369). 

Chart 14. 



Case 1 (Chart 15, a).— The patient was a male, aged 39- 
years, a butler. Diagnosis, chronic pulmonary tuberculosis. 
Right lung : upper lobe, infiltration ; lower lobe, infiltration. 
Left lung: upper lobe, infiltration. Duration, pleurisy four 
years before. Onset, cough six months. Sputum, tubercle 
bacilli present. 

Case 2 (Chart 15, B).—The patient was a'man, aged 2® 
years, a compositor. Diagnosis, chronic pulmonary tuber¬ 
culosis. Extent, infiltration of the left upper and lower 



lobes. Duration, 16 months. Onset, haemoptysis. Sputum,, 
tubercle bacilli present. Highest known weight, 7 stones 
7 pounds. The patient was able to do hard work. Moist 
sounds in the lung disappeared. Temperature normal. 
Weight on discharge, 8 stones 2 pounds 12 ounces. Scanty 
expectoration in the early morning which still contained 
tubercle bacilli. 

The practical outcome of these investigations is this. The 
labour scheme so ably devised and carried out by Dr. 
Paterson has been submitted to a new scientific test by 
means of which its effect on the blood of the patients has 
been traced. The opsonic index has shown that the exercise 
lias supplied the stimulus needed to induce artificial auto¬ 
inoculation, and that its systematic graduation has regulated 
this in point of time and amount. This cooperation with the 
natural efforts of the blood has enabled Dr. Paterson to send 
his patients back to their accustomed work, however hard 
it may be. But the investigation has done more than 
explain a successful mode of treatment. Dr. Paterson 
agrees with me that with the aid of the opsonic index 
he can regulate the stimulus with scientific accuracy 
and obtain his results more certainly and more rapidly. 
This, of course, involves work in the laboratory. But it alBO 
means a more rapid and a more certain discharge of th& 




The Lancet,] DR. W. FORD ROBERTSON : BODIES IN CARCINOMATOUS TUMOURS. [Jan. 25, 1908. 225 


patient, which is the main object of the sanatorium, and as a 
consequence of this the power to treat a larger number of 
patients. I may be permitted to conclude by expressing my 
thanks to the staff of the Brompton Hospital for their 
permission to publish the cases under their care and for their 
continuous encouragement and useful advice during the 
whole of my work. 

Brompton Consumption Hospital, Fulham-road, S.W. 


NOTE ON THE PRESENCE AND SIGNIFI¬ 
CANCE OF CERTAIN ROD-SHAPED 
BODIES IN THE CELLS OF 
CARCINOMATOUS 
TUMOURS. 

By W. FORD ROBERTSON, M.D.Edin., 

PATHOLOGIST TO THE SCOTTISH ASYLUMS. 


In the course of investigations, of which some of the 
results have already been described, 1 I had occasion to stain 
sections of a carcinoma of the breast by the palladium 
methyl violet method, a staining process that has long been 
employed for nervous tissues in the laboratory of the Scottish 
asylums. The preparations obtained, besides serving for the 
purpose intended, revealed in the protoplasm of very many of 
the epithelial cells one or more rod-shaped bodies somewhat 
resembling tubercle bacilli. I have since applied the 
method to 36 tumonrs of various kinds and have found that 
similar rod-shaped bodies are constantly present in certain 
forms of carcinoma. I have observed them in all of ten 
carcinomata of the breast, in all of ten squamous 
epitheliomata, in both of two malignant adenomata 
of the sigmoid flexure, in a secondary cancer of the 
liver, in a cancer of the prostate, in a secondary 
cancerous growth in the dura mater, and in a tumour 
of the choroid composed of large epithelial cells. 

I have been unable to detect them in five adeno¬ 
mata of the breast, an adenoma of the cervix nteri, a 
papilloma, a uterine fibroid, a glioma of the brain, and a 
spindle-celled sarcoma, as well as in normal squamous 
epithelium, a mammary gland from a case of puerperal 
insanity, in a case of chronic mastitis, and in brain tissue. 


Fig. 1. 



Section of a carcinoma of the breast showing three rods in 
protoplasm of epithelial cells. Palladium motliyl violet 
method, x 800. The white line indicates the gioup of 


Whilst the most typical form of these bodies is that of a 
straight or slightly curved rod, closely resembling the 
tubercle bacillns (about 3,u in length and 0 3^ in thickness), 
much smaller and also much larger forms may frequently be 
observed in sections in which the bodies in question happen 
to be numerous. The smaller and medium-sized varieties 
usually stain evenly of a reddisb-violet tint bat the larger 

1 The Lancet, August 10th, 1907, p. 358. 


forms are generally distinctly granular in appearance and 
may sometimes present one or more pale or colourless trans¬ 
verse bars. The edges are always smooth. The ends are 
generally blunt and there is no evidence of the presence of 
flagella. These rods are tot stained by Gram’s method. 
In sections stained by the Ziehl-Xeelsen method for 
tubercle bacilli they are invisible. In sections stained 
with carbol thionin or methylene blue only seme of 
the larger forms can be detected as faintly stained bodies, 
generally lying in a ground work of the same tint. 
The rods are most commonly to be seen in the protoplasm of 
the epithelial cells and they aie to be found in largest 
numbers in the most rapidly growing parts of the tnmonr 
(Fig. 1). In the most successful preparations they appear as 
reddish-violet bodies lying in a pale yellow protoplasm. They 
are also very commonly, though less frequently, to he 
observed in the nuclei of the epithelial cells. Regarding 
their occurrence outside these cells little can be said, 
because the special staining method also colours the elastic 
fibres which are generally abundant in these tumours and 
which, especially if fragmented, cannot be distinguished 
absolutely from rods similar to those that occur in the 
protoplasm of the cells. In some special preparations in 
which elastic fibres have not complicated the picture the 
rods have appeared to be almost exclusively intracellular. 

In five carcinomata of the breast I have found these 
intracellular rods to be present in very large numbers. In 
some preparations a hundred or more may readily be 
counted in a single field nnder an oil immersion lens. 
Single epithelial cells may occasionally be cbseived with 
from 20 to 30, or even a larger number, lying in their proto¬ 
plasm (Fig. 2). In five other carcinomata of the breast in 


Fig. 2. 



Section of a carcinoma of tbe breast siiowing numerous rods 
in the protoplasm of an epithelial cell. Palladium methyl 
violet method, x 800. The white line indicates the croup 
of rods. r 

which thi se rods have been detected they appear to be 
present in comparatively small numbers. 1 nave found 
them to be numerous in only three squamous epitheliomata ; 
in seven other tumours of this kind in which they have been 
clearly recognised they occur only occasionally. They have 
likewise been observed only in small numbers in the other 
carcinomatous tumours in which they have been detected. 

So far as I have been able to ascertain attention has not 
previously been directed to these peculiar bodies, either by 
those who have described parasites in carcinomatous tumours 
or by others. The evidence which can be adduced in support 
of the view that they are parasitic in nature is, I think, 
conclusive. They present features which prove them to be 
growing organisms and they have been cultivated in an 
artificial medium. The possibility of their being bacilli can 
be excluded at once. It can be shown that they arise from 
comparatively large rounded bodies which are certainly not 
bacterial organisms. It is further to be noted that they 
have not the characters of the spircchmta microgyrata which 
has been described as occurring in carcinomata of the mouse. 

My observations lead me to conclude that these rod shaped 


226 TH* Lanoet,] PROFESSOR J. E. SAL VIN-MOORE & MR. C. E. WALKER : CANCER CELLS, ETC. [Jan. 25,1908. 


bodies represent a stage in the life cycle of the protozoan 
organisms described by Dr. Henry Wade and myself as 
occurring in certain carcinomatons tnmonrs. We had pre¬ 
viously observed such rode in the old silver-gold preparations 
but never in large numbers, and we were unable to attach any 
significance to them. In sections prepared by the improved 
ammonia-silver process and decolourised by cyanide these 
rod-shaped bodies tend to retain the black deposit for a short 
period subsequent to their development ; at a later stage 
they are much more readily bleached by the cyanide. These 
preparations reveal in the protoplasm of many of the 
epithelial cells, especially in carcinatoma of the breast, 
more or less numerous spherical or oval bodies which were 
described in previous papers, and from these bodies the 
rods can be seen to originate. In palladium methyl violet 
preparations these globular bodies can also be recognised, 
often appearing distinctly nucleated, and various stages in 
their transformation into rods can easily be observed. The 
evidence of the histological preparations upon this point is 
confirmed by that derived from an agar culture from a 
secondarily infected gland in a case of malignant adenoma of 
the intestine, described by Dr. Wade and myself. This 
culture contains in the substance of the agar numerous 
spherical bodies with the staining reactions of those demon¬ 
strable in the protoplasm of some carcinoma cells, and the 
study of preparations of this culture stained by the methyl 
violet method has revealed the fact that these spheres 
become transformed into rod-like bodies identical with those 
that] can be seen in the tissues. In a future paper I hope 
to deal fully with the subject of the life cycle of these proto¬ 
zoan organisms. If these rods represent merely a single 
phase in a complicated life cycle, it should be easy to under¬ 
stand how in many carcinomatous tumours they can be found 
only in small numbers whilst in other tumours of the same 
kind they are abundant. It Beems to me probable from 
evidence collected that not one species of protozoan 
organism but several closely allied species are the pathogenic 
agents in the production of carcinomatous tumours. It at 
least appears that the forms found in carcinoma of the breast 
present certain characters which distinguish them from those 
that may be observed in squamous epitheliomata and in 
intestinal tumours, although the life cycles are essentially 
the same. 

1 have endeavoured to ascertain what becomes of the 
rods, but as yet only a few facts have come to light. At 
first it seemed probable that these bodies are motile 
forms which escape from the cell in which they have 
originated and which, after travelling some distance, infect 
other cells, but this hypothesis on being tested has failed to 
obtain any confirmation. The evidence, indeed, very strongly 
supports the view that the rods, instead of tending to escape 
from the cell, seek to penetrate the nuclear membrane and 
that they undergo a further evolution within the substance 
of the nucleus. Not only may the rods frequently be seen to 
abut upon the nuclear membrane, but they may sometimes 
be observed to have partially penetrated it, either by move¬ 
ment or by means of end-growth. The occurrence of 
characteristic rods wholly within a nucleus is quite common 
and occasionally several may be seen in one nucleus. 

In conclusion, I would say that if pathologists will apply 
the palladium methyl violet method to a few properly fixed 
and somewhat recently obtained carcinomata of the breast 
and squamous epitheliomata, I am confident that they will 
quickly be able to confirm and to extend these observations 
which I have here briefly recorded. I have to express 
my indebtedness to Mr. F. M. Caird, Mr. David Wallace, 
and Dr. M. B. Hannay for most of the tissues used in these 
investigations. 

Appendix, 

The palladium methyl riolet method. — The reagents 
required are saturated solution of palladium chloride in 1 per 
cent, citric acid in water, 1 per cent, solution of methyl violet 
6 B or 5 B, saturated solution of iodine in 2 • 5 per cent, potas¬ 
sium iodide, equal parts of turpentine and benzole, equal parts 
of pure anhydrous aniline oil and benzole, benzole and benzole 
balsam. The tissues should be fixed in S per cent, formalin 
in | per cent, salt solution (and preserved in the same fluid 
or in alcohol), or for 24 hours in Heidenhain's sublimate 
solution, with subsequent removal of the mercury by 
means of iodine in the usual way. Cat thin sections 
by the dextrine freezing method. Place the sections over¬ 
night in the palladium solution. W T ash them in three 
changes of water and then place them for from 10 to 20 
minutes in the methyl violet stain. Wash the sections 


shortly in water and transfer them to the iodine solution, in 
which they should remain for from 10 to 20 minutes. Next 
transfer the sections to a bowl of water. In this they may 
be left for an hour or longer without suffering harm. 
Steel needles must not be used in these operations. 
Take a section up from the water upon a perfectly clean 
slide. Carefully remove water from around it by means of a 
towel. Next lay the slide upon the table and with a piece of 
smooth blotting or filter paper (folded double) blot the 
section in the same manner as one dries a sheet of wet 
manuscript. Immediately afterwards, without allowing it 
to dry completely in air, pour over the section some drops of 
a mixture of equal parts of turpentine and benzole. Renew 
this turpentine-benzole after a few seconds and then place 
the slide upon the heater (described below), where it must 
remain at a temperature of about 60° C. until completely 
dehydrated. If the turpentine-benzole tends to evaporate 
off the section add more by means of a pipette. When 
dehydration is complete the previously black and 
opaque tissue assumes a dark blue and faintly trans¬ 
lucent appearance. Generally from 15 to 20 minutes 
are required. When the section seems dehydrated 
remove the slide from the heater, allow it to cool, 
and then pour off the turpentine-benzole. Decolourise 
with aniline-benzole. Renew this two or three times. Avoid 
breathing on the slide as the smallest trace of moisture in 
the aniline-benzole will cause complete decolourisation of the 
section. When the dye ceases to come away wash the 
section in several changes of pure benzole and mount in 
balsam in benzole. It is essential that the section should be 
completely dehydrated on the heater. Any spot in which 
moisture has been allowed to remain will be decolourised 
by the aniline-benzole. A heating apparatus of a very 
simple form is sufficient for the purposes of this method. 
I use a small spirit lamp placed below a tripod stand, on 
the top of which there is a thin metal plate, and upon 
this again two small iron bars laid parallel to each other 
and at such a distance as just to allow the two ends of a 
microscopic slide to rest upon them. By such an arrange¬ 
ment heat is transmitted only by the two ends of the 
slide and the turpentine benzole is driven to the centre. 
Tissues that have been in alcohol or in formalin for over two 
years do not, as a rule, stain deeply enough, and must then 
be regarded as unsuitable for the application of this 
method. _ 


ON THE RELATIONSHIP OF CANCER 
CELLS TO THE DEVELOPMENT 
OF CANCER. 

By J. E. SALVIN-MOORE, A.R.C.S., F.L.S., F.Z.S., 

PROFESSOR OF EXPERIMENTAL AND PATHOLOGICAL CYTOLOGX AND 
DIRECTOR OF THE CANCER RESEARCH LABORATORIES, 
UNIVERSITY OF LIVERPOOL; 

AND 

O. B. WALKER, 

ASSISTANT DIRECTOR OF THE CANCER RESEARCH LABORATORIES, 
UNIVERSITY OF LIVERPOOL; AND HONORARY LECTURER 
IN CYTOLOGY IN THE LIVERPOOL SCHOOL OF 
TROPICAL MEDICINE. 


IN the present communication we wish to record some 
observations made in the Cancer Research Laboratories, 
University of Liverpool. The observations in question relate 
to the propagation of cancer in mice. The tumours utilised 
are derived from a growth originating sporadically in a 
mouse, and most generously placed at the disposal of the 
Liverpool Cancer Research Committee by Professor Ehrlich of 
Berlin. The tumours upon which these observations have 
been made are of exceptional virulence. They are graftable 
from one mouse to another—that is to say, if small frag¬ 
ments of the growth be removed from an animal these 
fragments will grow when placed under the skin of a 
healthy individual. So far as can be ascertained from 
purely cytological examination of the process, the new 
tumour in inoculated mice appears to proceed directly from 
the cells belonging to the original tumour which have been 
mechanically transferred. The grafted tumour, in fact, 
apparently arises from the implanted cells, and not through 
any alteration of the tissues of the new host which surround 
the graft. 

For purposes of investigation portions of these tumours 
were removed from mice and subjected for periods of from 




Thb Lancet,] MR. WALTER EDMUNDS : TREATMENT OF GRAVES’S DI8EASE, ETC. [Jan. 25, 1908 227 


20 minutes to half an hour to the action of liquid air. They 
were then at once introduced into healthy mice beneath the 
skin, the presumption being that in these circumstances the 
tumour cells would be destroyed by the action of the liquid 
air, and consequently that they would multiply no further. 
However, among the inoculations made with the frozen 
material it was found that in some cases new tumours 
were produced. Further, in a number of mice wherein 
tumours of the same strain were already growing similar 
inoculations were made in a remote part of the body; 
in some of these also the same positive result was obtained. 
From these observations it is rendered clear that exposure to 
liquid air at a temperature of about - 195° does not neces¬ 
sarily destroy the potentiality of the substance of a mouse 
tumour to produce fresh tumours of the same kind in mice 
into which such frozen tumour substance has been grafted. 

These facts in themselves are somewhat surprising, and 
they immediately raise a number of questions which it will 
be desirable to have elucidated in the interests of research 
concerning the nature of cancer. In the first place, it is 
rendered clear that exposure to liquid air for a certain period 
of time does not destroy the principle upon which the 
vitality of mouse cancer depends. If, as may be the case, 
the cells composing the mass of the tumour, and constituting 
the grafts, are killed by exposure to liquid air, then the 
development of mouBe cancer after such exposure indicates 
not merely that the growth of similar tumours is independent 
of the integrity of the “cancer cells,” but also that the new 
tissues are not necessarily formed from the implanted cells 
at all, and may arise from the cells of the new host in 
response to some stimulus introduced along with the frozen 
material, and quite independent of the integrity of the so- 
called “ cancer cells.” 

This matter is at present engaging onr attention, 
but the fact that the capacity for originating new 
growths is not necessarily destroyed in the substance of 
tumours after exposure to liquid air, certainly suggests that 
the production of new tumours in the hosts into which the 
frozen cancer tissue has been introduced may possibly not be 
dependent upon the introduction of the “ cancer cells ” at 
all, but upon the action of a virus which is independent of 
these cells, and retains its activity after being subjected to 
the temperature of liquid air. It is well known that a 
number of bacteria are not killed by this temperature. 
The fact that cancer can be originated in mice by implanta¬ 
tion of portions of frozen tumours may indicate that 
there exists Borne such cause as an organised irritant or 
parasite acting as an agent in the production of cancer. 
On the other hand, however, it is not yet certain that 
the cells from the tumour introduced into a new individual 
are killed by half an hour’s exposure to the temperature of 
liquid air, particularly as the seeds of some plants and 
trypanosomes are said to survive this temperature. 


NOTE UPON THE EFFECT OF LIQUID AIR 
UPON THE GRAFTABLE CANCER OF 
MICE. 

By J. E SALVIN-MOORE, A.R.C.S., F.L 8., F Z S., 

PROFESSOR OF EXPERIMENTAL AND PATHOLOGICAL CYTOLOGY AND 
DIRECTOR OF THE CANCER RESEARCH LA HOKATORIES, 
UNIVERSITY OF LIVERPOOL ; 

AND 

J. O. WAKELIN BARRATT, D.Sc., M D. Lond 
F.R.C.S. Enq. 


In the present communication we wish to record some 
observations made upon the graftable tumours of mice. The 
tumours under observation were obtained for the Liverpool 
Cancer Research Laboratories, through the kindness of 
Professor Bang of Copenhagen, and were received originally 
from Professor Jensen. For purposes of certain experiments 
not yet completed fragments of the tumonr in question were 
placed in liquid air for from 20 minutes to half an hour and 
after thawing were placed under the skin of fresh mice in 
the ordinary way. It was presumed that by exposure fo the 
temperature of liquid air the tumour cells would be 
immediately killed. However, in a number of such grafts 
after a period of from ten to 20 days fresh tumours appeared 
at the site of the inoculations. 


These observations appear to be of interest in themselves ; 
but more especially so becanse they lead up to a cumber of 
important qnestions. It seems to be probable from what 
has been observed in relation to healthy skin that exposure 
to the temperature in liquid air rapidly kills the cells com¬ 
posing it. It may, of course, be that cancer cells differ in their 
capacity to resist such a temperature, but at the same time 
since some bacteria and other organisms are known not to be 
killed by the temperature in question it is clearly suggested 
that there may be an organism in or among the cancer cells 
able to withstand the treatment to which they have been 
subjected and afterwards consequently capable of setting up 
the formation of a tumour derived from the tissues of a 
new host. These are, however, matters which are engaging 
our attention and at present it is undesirable to say more 
concerning them. 


TREATMENT OF GRAVES’S DISEASE WITH 
THE MILK OF THYROIDLESS 
GOATS. 

By WALTER EDMUNDS, M.A., M.C. Cantab., 
F.R.C.S. Eng., 

SURGEON TO THE PBINCE OF WALES'S HOSPITAL, TOTTENHAM. 


Since the discovery of the nature of myxcedema it has 
been thought that the symptoms of Graves’s disease are doe 
to an excessive secretion from the enlarged thyroid gland 
Fnrther, it has been thought that a remedy might be found 
in the serum or milk of thyroidless animals, the idea being 
that to counteract the thyroid secretion the normal body 
secretes an antithyroidin, and that in thyroidlees animals 
this antithyroidin would be in excess and available to act as 
an antidote to the excess of thyroid secretion in Graves’s 
disease. 

There are, however, some difficulties in the way of this 
theory. The severity of the symptoms of Graves's disease 
is by no means always in proportion to the size of the goitre, 
nor is this always one of the first symptoms; indeed, from 
the history of the cases it would seem that they often start 
from some mental strain. Another difficulty arises from the 
fact that myxcedema and Graves’s disease sometimes coexist. 
Babinski mentions two such cases and Dr. Samuel WeBt has 
recently recorded a very clear case occurring under his care 
at St. Bartholomew’s Hospital. 

A third difficulty arises from the symptoms produced by 
the excision of the thyroid varying in different animals. In 
dogs and cats the operation produces severe nervous 
symptoms, tremors, paralysis, and convulsions, quickly 
followed by death. In goats, on the other hand, as a rale 
no ill effects follow. I have recently performed the 
operation on ten goats. One of them was young and not 
fully grown ; the effect of the operation was that it ceased 
to grow and became in fact a cretin. The other nine goatB 
were fully grown and in seven of them the operation 
produced no effect ; in the other two there came on 
after some months a swelling of the face, due no 
doubt to myxoedema; this was treated with thyroid 
tabloids and disappeared but both animals died. A 
small percentage of the dogs submitted to complete 
thyroidectomy escape the acute symptoms; they then 
remain well ; they do not later develop myxcedema nor 
does this occur in those dogs in which nearly the whole of 
the thyroid gland is removed and one or more parathyroids 
are left. Thus dogs do not have myxcedema and goats do not 
have the acute nervous symptoms which occur in dogs and 
which are attributed by Gley and others to the removal of 
the parathyroid glands. Monkeys, however, which are nearer 
to man than either dogs or goats, may have aparathyroidea 
or myxcedema or both. As a rule, it seems that monkeys 
when submitted to thyroidectomy die from the nerve sym¬ 
ptoms ; those, however, which survive or escape this may 
have, and some do have, myxcedema. 

Thus, even if it is admitted that the symptoms of Graves’s 
disease are due to the thyroid secretion, the question may 
not be merely one of too much or too little, but we may have 
to distinguish between the secretion from the thyroid proper 
and that from the parathyroids. 

A fourth, and last, objection to the theory is that it leaves 
out of account the possibility of any action of the central 
nervous system on the secretion of the gland. Exter, and 
later myself, have shown reason for thinkir g that there is 




228 TheLancet,] DR. MELANDRI&MR. LEGG : ACUTE SUPPURATION IN THYROID ADENOMA, ETC. [Jan.25. 1908. 


such an action ; nor ia this disproved by the recent and im¬ 
portant experiments of Payr. lie transplants one lobe from 
the neck of a dog into its spleen ; by a later operation he 
excises the lobe remaining in the neck—this produces no ill- 
effect ; and by a third operation he removes the Bpleen with 
the transplanted thyroid lobe in it—this is followed by the 
death of the dog. By the aid of the experience gained in 
these experiments Payr performed an important operation on 
the human subject. He had under his care a cretinons child, 
aged six and a half years. The child had been treated by 
thyroid feeding almost without result. Payr excised part of 
the thyroid of the child’s mother and planted it in the spleen of 
the child, with the result that the child was greatly improved. 

Notwithstanding the foregoing objections it may well be 
that the enlarged thyroid of Graves’s disease does yield an 
excessive secretion, that this is injurious to the economy, 
and that these ill-effects may be relieved by the administra¬ 
tion of the milk of thyroidless goats, a treatment suggested 
and practised by Lanz.. To this treatment it may be 
objected that even if the blood serum of the goat contains 
an antidote this would not pass into the milk, which is a 
secretion and not a transudate. In this connexion it may be 
pointed out that if after total thyroidectomy in the dog the 
removed lobes are simply dropped back into the wound before 
it is closed the symptoms resulting will be altered; the dog 
■will die, but it will live a few days longer than it otherwise 
would and it will not have the tremors, paralysis, and con¬ 
vulsions which usually follow the operation, but will die from 
asthenia. This difference is presumably caused by the 
absorption of the replaced lobes. 

Following these lines I removed from three cats the 
thyroid gland and fed the cats on ordinary cow's milk. Two 
of these cats died with the usual symptoms, tremors and 
paralysis, in four and five days ; the third died from asthenia 
in 15 days. In three other cats the same operation was 
performed and they were fed subsequently on the milk of a 
thyroidectomised goat. None of the three had tremors or 
paralysis ; they died from asthenia in 9, 12, and 14 days. 
The fact that not one of these three cats had the usual sym¬ 
ptoms certainly suggests that the goat’s milk contained some 
special constituent. 

In a disease like Graves's, in which many of the cases 
greatly improve under any reasonable treatment, it is not 
easy jto say with confidence that any particular remedy has 
done good. However, there are several cases on record in 
which the milk treatment of Lanz seems almost certainly 
to have been of benefit. Thus Lanz himself gives one case 
so severe that from his previous experience he expected 
the patient to die who yet made a good recovery. Other 
satisfactory cases have been recorded on the continent and 
one in America. 

The first case at the Prince of Wales's Hospital treated in 
this way was that of a young woman, aged 23 years, under 
the care of Dr. R. Murray Leslie, to whom I am indebted 
for permission to refer to the case. The patient was first 
admitted in August, 1906 She came with a history of 
having had a month or two previously an attack of 
rheumatic fever. On admission she was suffering from palpi¬ 
tation, with a pulse of 120, slight prominence of the eyes, and 
a Boft pulsating goitre which gave a blowing sound on 
auscultation. She improved under rest and medical treat¬ 
ment and went ont on Oct. 22nd. Her weight at this time 
was 7 stones 5 pounds. After her return home she became 
worse and was readmitted to the hospital on Jan. 3rd, 1907. 
Her weight was now 6 stones 10 pounds. She had marked 
exophthalmos so severe that she could not completely close 
her eyes. The thyroid gland was greatly enlarged with a 
loud systolic murmur over it ; there was also a systolic 
murmur at the heart's apex. The pulse was 120 There 
were marked tremors of the hands. The patient was at first 
placed on the same treatment as she had done well on before. 
After a few days she was ordered rodagen, which she took 
for one month without any bsnefit. Her weight was now 

6 stones 9 pounds. She was then put back on her former 
medicine and also had some applications of the x rays 
to the goitre. She did not improve, but lost flesh consider¬ 
ably, her weight on March 26th being 5 stones 12 pounds. 
She was now given the milk of a thyroidectomised goat, 
taking for some time the whole of the milk which the goat 
gave. The patient now gradually and markedly improved. 
Her weight steadily went up; on May 7th it was 6 stones 
11 pounds and on June 18th (shortly before she left) it was 

7 stones lj pounds. Besides this she felt, and obviously 
was, much better and stronger ; the goitre and exophthalmos 
were somewhat less and the pulse-rate was about 105. 


The second case was not in the hospital but occurred 
in the practice of a medical friend. The patient, a 
married woman, aged 48 years, was first seen in April, 1907* 
She complained of palpitation, of feeling weal4 and of 
loss of flesh. Her weight, formerly 11 stones, was now 
9 stones. The eyeballs were prominent and there was 
slight thyroid enlargement. The pulse was 120. She was 
treated with bromide, belladonna, digitalis, and arsenic 
without any good result. On June 18th she was kept in bed 
and Leiter’s tubes were applied to the goitre. The pulse 
was 120. On July 9th she began to take milk from thyroid¬ 
ectomised goats. She gradually improved. On the 26th 
she began to get up. On August 17th the pulse was 84. On 
Oct. 17th she had continued to improve, her weight was 
8 stones 4j pounds, and the pulse was 80. She was still 
taking a small quantity of the milk (the yield of the goats 
was at this time diminishing). On Dec. 14th her weight 
was 8 stones 12 pounds and the pulse was 84. She ate and 
slept well. There was very little palpitation. She could do 
a little light household work. While taking the milk the 
only medicine given was bicarbonate of sodium and gentian. 

A third case was also under the private care of a friend. 
The patient was a woman, aged 28 years. About nine 
years ago she developed unilateral proptosis without any 
other symptom. She had had two severe attacks of 
influenza, the last two years ago. After the second attack 
she had a cerebral seizure, falling and becoming momentarily 
unconscious. This was followed for a time by convulsive 
movements of the left arm, which were worse during sleep ; 
this slowly passed off. About a year ago the patient one 
night felt a pain in her throat and on putting her hand up 
to her neck found a swelling which proved to be a goitre. 
After this the second eye became also prominent. Besides 
this she had slight choking attacks at night and was 
very restless in her sleep. She was treated for several 
weeks with drachm doses of rodagen twice a day ; 
this did not produce the slightest improvement. On 
July 25th she commenced taking about one and a half pints 
of the milk of a thyroidectomised goat a day. There has 
been no material change in the pulse-rate, which has usually 
been under 100, or in the weight, which has been fairly 
steady at about 8 stones 12 pounds. But there has been 
considerable improvement in her general condition, as shown 
by her subjective sensations and the observations of her 
friends; also the attacks of palpitation to which she was 
subject have become less frequent. The exophthalmos, 
which was throughout slight, has not altered. 

There is no great difficulty in carrying out this treatment, 
especially in the country. Goats take ether well ; the thyroid 
gland in them consists of two separate lobes lying one on 
each side of the trachea ; there is no isthmus. As iar as my 
experience goes it is best to choose an animal two or three 
years old and to operate about three or four weeks after 
kidding. Goats as a rule have their young in the spring. 

That others may be induced to try this treatment this year 
is my reason for what I fear may seem to be a premature 
publication of results. 

Iliblioffrnphy. —Bablnskl: Sememe Medicals, 1895, p. 330. Edmunds 
Journal of Pathology aud Bacteriology, vul. xii., 1907. Ericlisen 
Therapeutic Gazette, U S.A., 1906, p.666. Exner: Vou Elaelberg In 
Vlrchow'B Archiv, vol. clili., 1898. Gley: Archive* de Physiologic, 
Paris, 1893. Halsted : American Journal of the Medical Sciences, 
vol. cxxxiv.. 1907. Lanz: Miinchener Mediclnische Wocbenschrift, 
Jan. 27th. 1903. l’ayr Langenbeck'a Archiv. vol. lxxx., 1506. West; 
St. Bartholomew's Hospital Keporls, vol. xlii., 1907. 

Devonshire-ptace, W. 


A CASE OF ACUTE SUPPURATION IN A 
THYROID ADENOMA DUE TO THE 
BACILLUS TYPHOSUS. 

By F. G. MELANDRI, M.D. Bologna, 

PHYSICIAN TO THE ITALIAN HOSPITAL, '.QUEEN-SQUARE, LONDON; 
AND 

T. P. LEGG, M.S. Lond., F.R.C.S, Eng., 

ASSISTANT SURGEON TO THE ROYAL FREE HOSPITAL, GRAY’S INN ROAD, 
LONDON, AND TO THE ITALIAN HOSPITAL. 


The patient, an Italian, aged 26 years, was admitted to 
the Italian Hospital on April 13th, 1907. His illness dated 
from four days previously. His pulse rate was 116, the 
respirations were 36 per minute, and there were signs in the 
chest of acute pneumonia. Ou the 21st, the twelfth day of 
illness, the temperature came down to normal bat the 




The Lancet,] 


CLINICAL NOTES. 


[Jan. 25,1908. 229 


general condition of the patient did not improve. There 
was great prostration and frequent vomiting, the vomit con¬ 
sisting first of thin yellow and later of dark green material. 
The tongue and mouth were in a very foul condition. This 
state lasted for six days. On the 27th the temperature again 
rose to 101 • 6° F. and the pulse to 136 per minute. A 
generalised erythematous rash, accompanied by severe sore- 
throat, appeared and persisted for three and a half days. A 
diagnosis of scarlet fever was made and the patient was 
isolated. He had some diarrhoea but there was nothing note¬ 
worthy in the stools. From the 27th to May 3rd the tempera¬ 
ture was intermittent. Nothing abnormal was detected in 
the chest and a gradual improvement in the general condition 
followed, the vomiting ceasing and the tongue becoming clear. 
The urine had constantly contained albumin. On the 8th 
desquamation began and during the next fortnight the 
temperature remained considerably elevated (see chart). 


About May 20th or 21st the patient first complained of pain 
in the neck and a tender swelling was discovered in the 
region of the right lobe of the thyroid. The patient then 
told us that he had known of the existence of a swelling in 
this situation for some years but that it had not caused any 
symptoms. By the 24th the tumour had rapidly increased 
in size and was exceedingly tender. It moved up and 
down on swallowing but did not cause any dyspnoea or 
dysphagia. The swelling occupied the greater part of 
the right lobe of the thyroid; it was globular in 
shape, very elastic, bnt not definitely fluctuating. 
The left lobe was normal and the trachea was dis¬ 
placed to the left side of the mid-line. The temperature, 
which had continued to be intermittent, rose on the evening 
of the 24th to 102'2°. A diagnosis of-suppuration in a 
thyroid adenoma was made. 

On May 25th a transverse incision was made over the lower 
part of the swelling. The infrahyoid muscles were found to 
be cedematous and adherent to the swelling; they were 
divided and then peeled off its surface. An attempt was 
made to enucleate the tumour, but in doing so it was 
ruptured and two ounces of pus were evacuated. A couple of 
drainage-tubes were placed in the cavity, one of them being 
brought out at the posterior border of the sterno-mastoid 
through a separate incision and the other one through the 
middle of the incision, which was only partially closed by 
two or three stitches, the rest being packed with gauze. 
The tubes were left out on the 29th. By June 17th the 
incision bad quite healed, and all pain, swelling, and tender¬ 
ness had disappeared. For a week after the operation, in 
Bpite of the local condition being quite satisfactory and of 
there being no evidence of insufficient drainage, the 
temperature remained constantly above normal. The pulse- 
rate was about 100, and the respirations were 24 per minute. 
On June 4th the temperature came down to normal 
permanently and convalescence was thereafter uninterrupted. 

Films made from the pus at the time of the operation 
showed that the cells were nearly all polynuclears, and very 
few organisms were seen. Cultures, however, gave a copious 
and pure growth of a non-Gram-staining motile bacillus, 
which on further chemical examination gave the fermenta¬ 
tion and other reactions of the typhoid bacillus in a typical 
manner. The bacilli were readily clumped by a human and 
animal typhoid Berum in high dilutions. The patient’s own 
serum with a 1 in 50 dilution gave a positive Widal’s reaction 
on two separate occasions at a week’s interval. There can 
be no doubt that this was a case of suppuration in a thyroid 
adenoma due to the typhoid bacillus. 

The interesting point is, from what source did the organisms 
reach the gland ? As already described, the illness was by 
no means of the ordinary typhoid type, and after the bacilli 


had been found we carefully examined the abdomen for 
enlargement of the spleen but failed to detect it or any other 
abnormal condition suggesting typhoid fever. The stools did 
not at any time have the characters of those of a typhoid 
patient. Moreover, the patient made such a rapid recovery 
that he was able to leave the hospital on June 22nd. We 
questioned him as to his having had typhoid fever in the 
past, but we were unable to satisfy ourselves on this point. 

We have thought this case to be worth publishing because 
an acute abscess in the thyroid, though a well-recognised 
condition, is not of very common occurrence, and when it 
does occur, apart from traumatism, such as puncturing a 
cyst, is most often observed in connexion with an acute 
febrile disease and generally at a late stage of the 
illness. Typhoid fever is one of the commoner of such 
diseases to be followed by an acute thyroiditis and usually 
' the abscess is a late complication. In this patient the signs 


developed at the end of the sixth week from the beginning 
of the illness. As soon as suppuration has occurred the pus 
should be evacuated, or if the abscess has developed in an 
encapsuled tumour enucleation should, if possible, be per¬ 
formed. If left, the pus is very likely to penetrate the gland 
capsule, leading to diffuse cellulitis of the neck and 
mediastinum or to burst into the trachea or pharynx. 
Whichever of these events occurs the result is likely to be 
very disastrous. And free drainage must be provided at the 
time the pus is let out. The incision should not be closely 
sutured ; if a transverse incision is made the scar is very 
little noticeable. In this patient it is a thin curved line. 

We are indebted to Dr. W. d'Este Emery for kindly under¬ 
taking the pathological investigation. 


dDIrairal goto: 

MEDICAL, SURGICAL, OBSTETRICAL, ANU 
THERAPEUTICAL. 


NOTE ON A CASE OF FENESTRATION OF THE 
ANTERIOR PILLARS OF THE FAUCES. 

By P. Watson Williams, M.D. Lond., 

LECTURER ON DISEASES OF THE NOSE AND THROAT, UNIVERSITY 
COLLEGE, BR18TOL; LARYNGOLOGIST AND RHINO LOG 1ST, BRISTOL 
ROYAL INFIRMARY; AND CONSULTING SURGEON FOR 
DISEASES OF THE EAR, NOSE, ANI* THROAT, 

PONTYPOOL HOSPITAL. 


The exact mode of origin of this peculiar condition is a 
disputed point. Some of the cases recorded were considered 
to be congenital, in others it is believed to be cau-ed by 
ulceration dne to scarlet fever. I consider that this case 
looks like a congenital defect on account of (1) the absence 
of any cicatrices or unevenness in the margins of the 
fenestne ; (2) the bilateral symmetry of the malformation ; 

(3) the arrangement of the strands of mucous membrane and 
the muscle fibres, and that they obviously correspond to the 
anterior pillars of the fauces, as shown in the drawing; and 

(4) the fact that although the posterior faucial pillars do 
not Bhow fenestration yet the palato-pharyngeus muscles 
are collected into a separate bundle of fibres on each side, 
with only a thin layer of mucous membrane in continuity 
with the lateral walls of the pharynx. Thus, in front the 
palato-glossus musole forms a separate bundle, passing 
down to the tongue, and forms the inner boundary of a 


APE 














CLINICAL NOTES. 


[Jan. 26, 1008. 


230 The Lancet,] 


fenestra on each side, while the palato-pharyngeuB forms the 
inner boundary of a thin web of mncous membrane. 

The patient, a male, aged 18J years, bad never suffered 
from sore-throat since be was two years old, at which time 
he had scarlet fever with a ‘ bad throat.” When I saw him 
there were no symptoms whatever, and the voice did not 



to the rectum. Anteriorly there was a large firm swelling of 
the size of an orange situated to the left of the middle line 
reaching from the pubes to within one inch of the nmbilicuB. 
It was fixed and did not fluctuate. 

I opened the abdomen in the middle line below the 
nmbilicns and immediately exposed the tumour. The apex 
was a small knob of the size of a walnut. On examining 
further the mass could be traced downward into the pelvis 
and was found closely adherent to the rectum. There was 
no adhesion to the bladder. I passed a needle into the apex 
of the tumour and drew off hydatid fluid. The tumour was 
then opened and a great quantity of large and small cysts 
were evacuated. When filled with fluid from the douche 
the empty sac held 250 grammes. I drained the Bac and 
fixed it to the abdominal wall. 

The patient has had no difficulty in micturition and has 
now left the hospital in good health. 

Christchurch, N.Z._ 

NOTE ON A CASE OF TUBERCULOSIS OF THE 
TESTIS ILLUSTRATING AN UNUSUAL ABNOR¬ 
MALITY OF THE YAS DEFERENS. 

By Russeli. J. Howard, M.S.Lond., F.R.C.S. Eng., 

SURGEON TO OUT-PATIENTS, ROYAL WATERLOO HOSPITAL; ASSISTANT 
DEMONSTRATOR OP ANATOMY, LONDON HOSPITAL MEDICAL COLLEGE. 


appear to be modified in any way. There wsb no other 
defect observable In the throat, nose, eye, or ear. 

A possible explanation of these fenestrations is that the 
condition of the anterior faucial pillar was similar to that 
shown In the posterior pillar nntil scarlatinal angina caused 
the thin web of mucous membrane to ulcerate, leaving 
the strands of palato glossus muscle seen in later life. 

The illustration has been drawn with great care and I 
think that it very accurately represents the existing con¬ 
ditions. A similar case was illustrated by Fullerton, 1 who 
refers to other recorded instances. 

J Description of the ilhietration .—-The anterior pillars of the fauces 
which contracted welt on stimulation and on phonation arc seen to be 
strands of muscle fibre passing down to join the tongue and are covered 
with normal mucous membrane, forming the inner boundary of a 
fenestra on either side. 

The posterior pillars show Indication of a separate bundle of muscle 
united to the lateral pharyngeal walla by thin mucous membrane. The 
tonsils are small but lie between tbe anterior and posterior pillars, and 
amah remains of tho plica tonsillaris are present. A small mass of 
adenoid tissue lies behind tbe left posterior lauclal pillar. 

Bristol. 


Retroversion of the testis, a condition in which the 
epididymis lies anteriorly and the body of the testis with the 
tnnica vaginalis posteriorly, is a not unusual abnormality. 
It occurs probably in 1 in 20 of all testes and is always to be 
considered in tbe diagnosis of testicular disease and in 
operations upon the genital gland. If this condition be 
present, the testicle, in a case of vaginal hydrocele, will 
lie in the front of tbe fluid and directly under the place 
usually selected for tapping. Unless tbe exact position of 
tbe testis has been ascertained by tbe translucent test the 
trocar may be plunged directly into the gland. In tuber¬ 
culous epididymitis the hard nodular swelling of epididym¬ 
itis is found in front of the soft elastic body of the testis 
and the diagnosis of tbe disease is obsenred unless tbe con¬ 
dition of retroversion is recognised. In the majority of caseB 
of retroversion of tbe testis the vas deferens passes down in 
the tissues of the cord to enter the globus minor of the 
epididymiB in the usual way, and will be the most anterior 
structure in the scrotum. In the case to be described 
the teBtis was retroverted with tbe epididymis in front, 
bat the vas passed down behind the body of the testis 


NOTE ON A CASE OF HYDATID CYST IN THE 
PELVIC CAVITY. 

By P. Clemnell Fenwick, M.B.Loxd, F.R.C.S. Edin., 

HONORARY SURGEON TO CHRISTCHURCH HOSPITAL, NEW ZEALAND. 


Hydatid disease is so frequently seen in this colony that 
little notice is taken of its occurrence in the lung, liver, or 
brain. I have recently had a case of a cyst almost filling 
the pelvic cavity and causing partial retention of urine which 
may be of interest to surgeons who specialise in urinary 
disease. 

Tbe patient, a man, aged 27 years, was admitted into 
Christchurch Hospital complaining of pain in the lower part 
of the abdomen and difficulty in passing urine. He stated 
that for the last seven years he bad had attacks of pain in 
the right iliac fossa, but during the last three weeks the pain 
had occurred all over the abdomen. The pain ran down into 
the right testicle and was severe enough to make him 
perspire profusely. Micturition was normal except when 



he had held urine for longer than usual, and then he found 
that he oould not begin the act. The urine was normal. 
Per rectum a large hard swelling was felt extending up the 
rectum on the anterior aspect. The swelling was adherent 

1 Brit. Med. Jour,, May 4th, 1895, 



S.O., Spermatic cord. S.A., Spermatic artery. G.M., Globus 
major. V.D., Vas deferens. A.O., Abscess cavity com¬ 
municating with tuberculous deposits which may be seen 
throughout the body of the teatia. 

and curled round its lower edge. The spermatic cord 
and the Bpermatic artery were lying in their usual position 
in relation to the epididymis and body. About two inches 
above the globus major the vas left the cord and passed over 
the bach of the body of the retroverted testis accompanied 
only by the artery of the vas and a small plexus of veins. 
At the lower pole of the testis the vas passed formardt to 
end the globus minor of the epididymis. 




Tot Lancet,] ROYAL SOCIETY OF MEDICINE : OBSTETRICAL Si GYNAECOLOGICAL SECTION. [JAN. 25,1908 . 231 


The case was of interest on acconnt of the nnnsnal physical 
signs presented. The patient was 51 years cf age, and had 
suffered from caries of the spine when he was 32 years old. 
Twelve weeks before he was admitted into the London Hos¬ 
pital (under the care of Mr. F. S. Eve) the left testis had 
become swollen and painful. Nine weeks after the swelling 
first appeared a soft red spot was discovered in the front of 
the scrotum which enlarged and eventually burst, discharging 
pus. On examination in hospital there was an abscess with 
a sinus in the anterior wall of the scrotum. Behind the 
abscess a hard nodular mass was felt which later was found 
to be the tuberculous epididymis and behind that a soft 
globular structure which was the body of the testis. The 
vas could be felt in the spermatic cord ; it was not beaded. 
On examination by the rectum the left vesicula was found to 
be swollen and hard. 

Orchidectomy was performed 12 weeks after the first 
symptoms and as much of the vas as possible was removed. 
The epididymis was quite destroyed by tuberculous deposits 
and many nodules of tubercle were scattered through the 
body of the testis. The abscess cavity opened into the 
globus major of the epididymis. The wound healed by the 
first intention. 

I am indebted to Mr. Eve for kindly allowing me to 
publish the case. 

Weymouth-street., W._ 


HJtbital jteties. 


ROYAL SOCIETY OP MEDICINE. 


OBSTETRICAL AND GYNAECOLOGICAL SECTION. 
Enucleation of a Uterine Fibro-myoma during the Seventh 
Month of Pregnancy.—Haemorrhage into the Pone Va/rolii 
ae the Immediate Cause of Death in the Eclampsia of 
Pregnancy.—Exhibition of Specimens. 

A meeting of this section was held on Jan. 9th, Dr. 
Herbert R. 8fencer, the President, being in the chair. 

Dr. Herbert Williamson read a short communication on 
a case of Enucleation, daring the seventh month of pregnancy, 
of a Uterine Fibro-myoma weighing 17£ pounds, which was fol¬ 
lowed by premature labour two days later. The patient was 
a primigravida, aged 32 years. When four months pregnant 
she suffered from repeated attacks of acute abdominal pain 
and became emaciated with some fever, and the distension of 
the abdomen was so great that she was unable to lie down in 
bed. At the time of the operation the tumour, which could 
be felt distinct from the gravid uterus, was thought to be 
a malignant growth of the ovary, but it was found to be a 
uterine fibro-myoma undergoing necrotic degeneration. The 
area of attachment of the tumour to the nterus was rather 
narrow but required enucleation. A premature child was 
expelled three days later but the patient made an uninter¬ 
rupted recovery. 

Dr. Norman C. Carver and Dr. John S. Faibbairn 
communicated a case of Haemorrhage into the Pons Varolii 
as the Immediate Cause of Death in the Eclampsia of 
Pregnancy, with illustrative cases. The patient was a 

g rimigravida, aged 24 years, who, after exhibiting signs of 
upending eclampsia, was found unconscious and straight¬ 
way admitted to hospital. In view of the history of the 
illness and the presence of cedema and a high degree of 
albuminuria the case was thought to he one of eclampsia, 
and as the patient was in a state of deep coma, with 
Cheyne-Stokes respiration, rapid dilatation of the cervix 
was done, followed by the extraction of a foetus of 
between five and six months' development. The patient 
died a few hours later and at the necropsy death was 
found to be due to an extensive haemorrhage into the 
pons Varolii. Dr. Carver and Dr. Fairbairn argued that 
although the immediate cause of death was a pontine 
haemorrhage the case was primarily one of eclampsia, 
and in support of this quoted four recorded cases 
of a similar nature, in which an unsuspected cerebral 
haemorrhage was found post mortem. Details of these 
cases were given and, from an analysis of the symptoms 
presented by them and the above case, attention was 
drawn to such features in them as might serve to aronse a 
suspicion of the occurrence of apoplexy in the conrse of an 
eclamptic attack. These were, briefly, deep coma and 
cyanosis, with marked respiratory disturbance, occurring in 


a young patient presenting the urinary and other signs of 
eclampsia, and they were especially suggestive when the 
attack was unaccompanied by the usual eclamptic con¬ 
vulsions.—The President thanked Dr. Carver and Dr. 
Fairbairn for the interesting paper. He had not met 
with a case of hemorrhage into the pons Varolii in 
eclampsia but he could recall two cases of hemorrhage 
into the substance of the brain, one observed at a post¬ 
mortem examination and the other in which hemiplegia 
occurred, from which the patient slowly recovered. He thought 
that apoplexy was a well-known cause of death in eclampsia, 
and was surprised that Dr. Carver and Dr. Fairbairn had not 
found more cases recorded, although they did not claim that 
their paper was exhaustive. In view of the possibility of the 
occurrence of cerebral biemorrhage in eclampsia, the intra¬ 
venous injection of a large quantity of saline fluid 
would appear to be not unattended with risk.—Dr. 
Macnaughton-Jones recalled the fact that the “ apo¬ 
plectiform ” was one of the old writers’ divisions of 
eclampsia in which sanguineous and serous effusion 
occurred into the ventricles. The symptoms were such as 
described in this case. He dwelt on the importance of early 
anticipation of the eclampsia, especially through the ocular 
symptoms and signs which were often present, and in which 
an ophthalmoscopic examination afforded most valuable 
evidence of the approaching danger. One of the most 
valuable therapeutical means they possessed to control the 
increased blood pressute in these cases of threatening 
cerebral hmmorrhage he believed to be the employment of 
weak doses of pilocarpine which was also useful in checking 
the convulsions. If necessary, its full physiological action 
might be neutralised by T Jath of a grain of atropine. He had 
known eclampsia ending fatally to occur as early as the fourth 
month of pregnancy.—Mr. A. Lionel Hall Smith said he 
had seen three cases of cerebral haemorrhage complicating 
eclampsia or toxaemia of pregnancy, in all of which the 
diagnosis was confirmed at the necropsy. In one of them 
the haemorrhage occurred in association with eclamptic con¬ 
vulsions after delivery, but in the other two the patients 
were not in labour and had only reached about the thirtieth 
week of pregnancy.—Dr. Am and J. M. Routh had not 
bad an opportnnity of seeing a post-mortem examina¬ 
tion of any case dying from puerperal eclampsia where 
cerebral haemorrhage had been found, bnt thought that 
Dr. Carver and Dr. Fairbairn had shown how often 
such hiemorrhage might supervene and be the immediate 
cause of death. He thought it unwise to increase arterial 
tension, as must have been done in the first oase reported, 
when 10 ounces of blood were removed and 40 ounces of 
saline infusion injected. This may well have increased the 
tendency to haemorrhage. He presumed that saline infusion 
in these cases was given to dilute the toxins at each given 
point and to increase the leucocytosis to combat the toxins ; 
but it was doubtful if it should be given when it increased 
arterial pressure. He considered that the suggestion to give 
pilocarpine (at all events in the doses usually prescribed— 
viz., Jth grain) was fraught with grave danger. He con-idered 
that it should never be given in cases where apoplectic sym¬ 
ptoms were present or where there was coma, for he had 
seen patients under its influence suffocated by the enormous 
quantity of ropy mucus secreted by their salivary and 
broncho-pharyngeal glands. He was interested in the fact 
that epigastric pain had been mentioned as a precursor of 
eclampsia in some of these cases of albuminuria of 
pregnancy. He considered this sign, following ocular 
evidences of high arterial tension, increasing albuminuria, 
and diminishing excretion of urea, a valuable indication 
that eclampsia was impending and that steps should be 
taken to induce labour without needless delay.—Mr. 
D. C. Rayner referred to a case of eclampsia under 
bis care in which a fatal termination was due to 
cerebral hiemorrhage. The patient was in the eighth month 
of her third pregnancy when convulsions set in. They were 
frequent and seemed more marked on the right side. The 
pupils were also noticed to be unequal. The urine contained 
albumin and the patient was not in labour. Coma deepened 
and the patient died in a few hours. There was extensive 
haemorrhage into the right corpus striatum and optic 
thalamus.—Dr. R. H. Hodgson said that he thought the 
lesson to be learnt from this instructive paper was, in al 
cases of eclampsia in pregnant women empty the uterus 
He had done so in six cases and in all the women 
recovered, five very rapidly, and one in whom some sligh 
convulsions continued for five days was quite well after one 




•232 The Lancet,] 


MEDICAL SOCIETY OF LONDON. 


[Jan. 25, 1908. 


injection of pilocarpine. EmptjiDg the uterus caused the 
blood to flow to the portal system and thus lessened 
the danger of cerebral hasmorrhage. He did not under¬ 
stand the object of the saline injection.—Dr. Fair- 
bairn, in reply, said no attempt had been made to 
make an exhaustive collection of cases of apoplexy as the 
cause of death in eclampsia, and the cases collected 
were those of haemorrhage into the pons or base of the brain 
without unilateral symptoms to suggest apoplexy. Large 
cerebral haemorrhages were not frequent in eclampsia, as was 
shown by the statistics quoted in the paper. The cases re¬ 
corded were undoubtedly rare but the possibility of a deeply 
comatose and cyanosed eclamptic patient having also a 
cerebral hemorrhage ought not to be lost sight of, especially 
in giving a prognosis. 

The following specimens were shown :— 

Dr. J. P. Hedlky : (1) Hydrosalpinx with Torsion of the 
Pedicle ; and (2) Double Haemorrhagic Cysts of the Ovaries. 
Mr. Harold S. Sington : Tumour of the Ffetal Head. 

Dr. A. H. N. Lewers : Cancer of the Cervix (advanced) ; 
hysterectomy by Wertheim's method. 


MEDICAL SOCIETY OF LONDON. 


Graduated Labour in Pulmonary Tuberculosis .— Ike Opsonic 

Index in Tubereulout Patients engaged in Physical 

Exercise. 

A meeting of this society was held on Jan. 13th, Dr. 
J. Kingston Fowler, the President, being in the chair. 

Dr. M. S. Paterson read a paper on Graduated Labour in 
Pulmonary Tuberculosis, which is printed at p. 216 of this 
issue of The Lancet. 

Dr. A. 0. Inman read a paper on the Effect of Exercise 
on the Opsonic Index of Patients suffering from Pulmonary 
Tuberculosis ; this also is printed in this issue of The Lancet 

(p. 220). 

The President said that the two papers which they had 
just heard marked an epoch in the treatment of pulmonary 
tuberculosis. He contrasted the work done at the Hospital for 
Consumption and Diseases of the Chest at Brompton 15 to 
20 years ago with the work demonstrated by the two papers 
read that evening, and pointed out the difference between the 
groping in the dark then and the light which was now shed 
on pulmonary tuberculosis. 

Sir A. E Wright, whiUt admitting the possibility of the 
auto-inoculation method being useful, observed that by 
employing tuberculin they could begin with minimum doses 
and increase the amount as required, thus insuring more 
control than in auto-inoculation. 

Dr. C Theodore Williams mentioned that when Frimley 
Sanatorium was opened there was no idea of starting 
graduated exercises which were begun by Dr. Paterson. 

Dr. K. Maguire said that the auto-inoculation treatment 
must not be applied to every case of pulmonary tuberculosis. 
Success depended on the careful selection of fit cases for 
that treatment at the sanatorium ; if the method were to be 
earried out indiscriminately it would soon be found to fail 
when com Dared with artificial inoculation. 

Dr. F. J. Poynton emphasised the importance of recog¬ 
nising that there was more in the sanatorium treatment at 
Frimley than mere auto inoculation. He did not think that 
the patients whom they had heard about that evening would 
have done so well as they did on the tuberculin treatment. 

Dr. Paterson, in reply, dwelt on the necessity of dis¬ 
charging patients from the sanatorium ready to return to 
their usual work without fear of relapse. 

Dr. Inman, in his reply, said that the advantages of sana¬ 
torium life were of inestimable value in the treatment of 
pulmonary tuberculosis. He did not think that the injection 
of tuberculin would ever replace artificially induced auto¬ 
inoculation. 


EDINBURGH MEDICO-CHIRURGICAL 
SOCIETY. 


Exhibition of Cases. — Appendicitis.—The Optic Nerve in 
Cases of Intracranial Tumour. 

A meeting of this society was held on Jan. 15th, Dr. 
Jambs Ritciiie, the President, being in the chair. 

Dr. Robert A. Fleming showed a case of Spastic Diplegia 
of Infantile Origin in a man aged 45 years. The tendon 


reflexes were greatly exaggerated, as was also Baginsky’s 
sign. Athetoid movements were present, chiefly in the left 
arm which was paralysed. Nearly all the muscles were 
hypertrophied, including those of the neck ; when he Bpoke 
there was a marked spasm of the platysma myoides. The 
patient’s intellectual power was good ; there was no family 
history of nervous disease, but one brother stammered 
greatly; the athetoid movements and spasticity had been 
present as long as the patient conld remember. The lesion 
must have been either a meningo encephalitis or a meningeal 
bieraorrhage. 

Mr. J. \V. Dowden showed a man after operation for 
Perforated Duodenal Ulcer as illustrating the good reBnlts 
of early complete suture of the abdominal wounds. The ulcer 
was situated towards the gastric end of the duodenum ; it 
was excised by a longitudinal incision, the cavity of the 
abdomen was washed out with saline solution, and drainage 
openings were made at the lower part of the abdomen. On 
account of the giving way of the sutures the bowels pro¬ 
lapsed two days later ; they were replaced and all the abdo¬ 
minal openings were theu securely sutured and healed by 
first intention. 

Mr. F. M. Caird showed a man after Removal of Half of 
the Tongue. The operation was done under cocaine, the 
tongue being snipped out by scissors. No gag was neces¬ 
sary and the man walked back to bed. A few hours after 
the operation he could articulate perfectly and the 
wound healed much more satisfactorily than in cases done 
under a general amestbetic. All the glands in the front of 
the neck were subsequently dissected out, and though each 
was microscopically examined no trace of malignant disease 
was found in them. 

Dr. Edwin Bramwell showed a boy suffering from 
Poliencephalomyelitis. He had been healthy until three 
months ago when he felt sick, vomited, and had pain at the 
back of the neck. On the following day he could not move his 
head. The movements of the arms and legs were normal, 
showing that the spinal cord was unaffected, but his head was 
held stiffly and this was not due to rigidity of the muscles 
but to excessive weakness of the deep cervical muscles as 
well as the sternomastoid and trapezius muscles, which were 
much wasted and exhibited the reaction of degeneration. A 
general improvement was taking place and the prognosis was 
favourable. 

Mr. H. Alexis Thomson showed a case after Osteoplastio 
Amputation through the Middle of the Leg, in which a 
portion of the tibia was retained in the anterior flap and 
brought into contact with the sawn section. 

Dr. D. Chalmers Watson showed two cases of Chronio 
Pancreatitis. He said that the disease was much more 
common than was supposed. Oue of the patients had been 
treated for catarrhal jaundice in August, 1906 ; on account of 
the pain a neoplasm at the head of the gall-bladder was 
diagnosed and an operation was performed. He was now 
pale, sallow, and emaciated and subject to severe paroxysmal 
attacks of ague-like severity every six weeks. The second 
patient bad Buffered for ten years with indigestion, jaundice, 
and emaciation. 

Mr. Dowden read a communication entitled “ Deductions 
from 100 Consecutive Operations for Appendicitis.” He con¬ 
fined his statements almost entirely to acute attacks. He 
said that the appendix was dependent on a single artery as a 
rule for its blood-supply and was consequently unable to cope 
satisfactorily with the urgent demands for blood caused by 
severe inflammation. In his series of 100 operations 82 were 
acute cases (52 males and 30 females), while the so-called 
“interval operation” was performed on 14 males and four 
females. Recurrent attacks were noted in 37 cases. Among 
the 82 acute cases there were 16 deaths, while among the 18 
" interval cases ” there were no deaths. A classification of 
the acute cases according to age showed that 16 cases with 
six deaths were under 16 years of age ; 50 oases with 9 
deaths were from 16 to 30 years of age ; and 16 cases, 
with one death, were over 30 years. On the first day of the 
illness there were 11 operations performed with no death; 
on the second day there were 16 operations with 
two deaths ; on the third day there were 18 opera¬ 
tions with seven deaths; and at later periods there 
were 37 operations with seven deaths. The sym¬ 
ptoms were often treated as those of acute in¬ 
digestion. It could not be sufficiently emphasised that 
every attack of so-calltd acute or subacute indigestion called 
for a careful local examination, including, if in doubt, a 
rectal examination. The presence of pain to the left of, and 



The Lancet,] 


ROYAL ACADEMY OF MEDICINE IN IRELAND. 


Jan. 25,1908. 233 


a little below, the umbilicus might delay a correct diagnosis 
and had to be borne in mind. In three cases the symptoms so 
closely simulated perforated gastric nicer that the duodenum 
and stomach were explored first and later the appendix. One 
patient was admitted to hospital as suffering from suppura- 
tive arthritis of the hip-joint, while in reality it was a large 
appendicular abscess extending below Poupart's ligament. 
If in a first attack an early diagnosis were made and an early 
operation performed the appendix could be removed through 
an incision planned to avoid the possibility of a ventral 
hernia ; the acute symptoms rapidly subsided and the patient 
could be allowed up within a fortnight with the assurance of 
no subsequent attack. In such cases the prognosis was 
extremely good ; of 14 cases so treated all recovered. If an 
abscess had developed the prognosis was rendered much 
more grave. The early local dangers were peritonitis, 
multiple abscesses, and obstruction, while the early general 
dangers were pymmia and septicaemia. Even if the appendix 
were removed other abscesses might arise as well as fiecal 
fistula. Many patients were permanently disabled, though their 
lives bad been saved by operation. The proper treatment 
for this disease was the removal of the appendix at the 
earliest possible moment. If a surgeon could not be readily 
obtained morphine should never be administered, but the 
patient should be put on starvation treatment with eDemata 
of saline fluid for the first 24 hours, with the local 

application of heat or cold. If a patient recovered 

from an attack, no matter how mild, he ought to 

be operated upon. The mortality in interval operations 
was very small, while if performed within 24 hours 

in acute cases it might be as low as 0 5 per cent.— 
Mr. J. M. Ootterill said that if the case were seen in the 
country then an operation should be performed at once and 
at any stage, but in town it was different. An operation 
performed within 20 hours of the onset was almost absolutely 
safe ; if, however, two or three days had elapsed then it was 
better to wait and to perform the interval operation. —Dr. J. O. 
Affleck said that he had never been converted to the view 
that appendicitis was a disease only to be considered by the 
surgeon. He bad seen healthy appendices removed because 
the symptoms had indicated appendicitis. Operation involved 
a risk to life and in his opinion it was best not to lay 
down any hard-and-fast rule bat to weigh every case 
on its own merits.—Mr. Cairo said that in the wards 
with which he had been connected there had been 174 
interval operations in seven years with no deaths. Even in 
such cases there was a danger, however, and he had grown 
bacillus coli communis and a diphtheroid organism from the 
gelatinous matter covering over an old perforated appendix. 
—Mr. H. J. Btiles said that if he were called at night and 
found a fulminating case he would operate at once and in 
acute cases always within 48 hours. The difficult cases were 
those seen for the first time two or three days after 
the onset ; in such the surgeon’s own experience must be 
the guide. A point which helped in diagnosis was the 
presence of fine crepitation in the subcutaneous tissue of the 
right iliac foBsa. Among 52 acute cases he had bad six 
deaths, or 11'5 per cent., and among 150 interval cases in 
two years he had one death.—Dr. D. 0. A. McAi.i.UM, Dr, G. 
Lovell Gulland, the President, and others also took part 
in the d'scussirn. 

Dr. Fleming gave a demonstration of the Changes in 
the Optic Nerve in cases of Intracranial Tumour. He 
said that the marked hypertrophy and proliferation of the 
neuroglial cells in the optic nerve in these cases were different 
in some respects from wbat was seen in the neuroglial cells in 
the brains of cases of general paralysis of the insane. There 
was nuclear mitosis, often two or more nuclei being seen iD one 
cell, and the cytoplasm in some of the cells lacked definite out¬ 
line. resembling a condensation of fibrilise in the neighbour¬ 
hood of the original cell body. The processes became much 
thicker and more easily traced for a considerable distance 
from the parent cell. These changes were best marked in 
the orbital portion of the optic nerve, being most obvious at 
the periphery of the nerve near the pial sheath but were also 
seen throughout the whole of the nerve. They were not 
nearly so obvious in the optic tracts, although they were very 
characteristic in the neighbourhood of the tumour or tumours 
in the brain. Dr. Fleming considered that the limitation of 
these pathological changes depended on the great develop¬ 
ment of neuroglia, normally, in the orbital part of the optic 
nerve in contrast to the small number of these cells in the 
optic commissure and tracts. He noted in several cases a 
complete break in the continuity of the neuroglial 


hypertrophy between the optic neives and the brain 
tissue near the tumour. The neuroglial changes were 
most satisfactorily demonstrated in cases of optic neuritis 
which were advancing to consecutive atrophy. He 
showed incidentally how the neuroglial hypertrophy 
brought iDto prominence the existence of other elements in 
the neuroglia which Dr. W. Ford Robertson bad designated 
mesoglial cells. These cells might possibly increase in 
number to some extent in optic neuritis, but they did 
not undergo any hypertrophy. The neuroglial cells 
in primary and secondary atrophy of the optic nerve 
showed no hypertrophy at all comparable to that found 
in optic neuritis due to intracranial tumour. Ia tuber¬ 
culous meningitis do optic neuritis occurred unless there 
were coexistent tumours in the brain substance. In neuro- 
retinitis of renal origin similar neuroglial changes were 
found and closely resembled those seen in intracranial 
tumour. Dr. Fleming argued in favour of a toxic origin for 
the neuroglial changes in optic neuritis due to intracranial 
tumour. He considered that the hypertrophy of neuroglial 
cells was primary, although by that statement be did not 
intend to convey the idea that it constituted the only primary 
lesion. The lymph channels in the orbital portion of the 
optic nerve were more numerous than in the remaining part 
of the visual tract and this, together with the greater 
number of neuroglial cells histologically, might account for 
the position of the most marked neuroglial hypertrophy and 
proliferation. 


ROYAL ACADEMY OF MEDICINE IN 
IRELAND. 


Section of Pathology. 

Exhibition of Specimens. 

A meeting of this section was held on Jan. 10th, Dr. A. R. 
Parsons, the President, being in the chair. 

Dr. Henry T. Bewi.ey exhibited specimens of Septic 
Endocarditis obtained from a man born in 1885. In 1898 he 
had suffered from rheumatic fever, being laid up for six 
months, and during the following three years he had further 
attacks. He went into hospital in February, 1905, suffering 
from breathlessness and palpitation. He was found to have 
a hypertrophied heart, double aortic disease, and mitral 
regurgitation. He was again admitted to hospital on 
Oct. 19th, 1907, and died on Dec. 16th. His last illness had 
begun in the previous June with feverishness, occasional 
sweatings, and loss of strength. While in hospital his 
evening temperature rose to 101° and 102° F., and his morning 
temperature varied from normal to 100°. The condition of 
the heart was much the same as before and sometimes a pre- 
systolic thrill was felt. The diagnosis was septic endocarditis. 
At the necropsy the heart was found very much enlarged 
and the pericardium was found to be universally adherent— 
a condition of which there was no clinical sign whatever. 
The right cavities of the heart were comparately small, the 
left ventricle was enormous, and both the mitral and aortic 
valves were festooned with soft piDk vegetations. The 
kidneys were enlarged, the spleen was very much enlarged, 
and there was an abscess in connexion with an infarct in the 
spleeD. Dr. W G. Harvey made an examination of one of the 
vegetations, which showed enormous numbers of cocci of the 
streptococcus type. The case was therefore one of endo¬ 
carditis, with an organism of extremely mild virulence ; the 
sepsis had lasted fully six months. 

Dr. R. Travers Smith gave the main clinical facts of a 
case of Intra-tboracic Tumour. The patient, a man, aged 56 
years, was admitted to hospital on April 23rd, 1907, and died in 
about six weeks. A few months before admission he received 
a heavy blow on his chest, but it could not be said how much 
that had to do with the growth in his thorax. An effusion in 
the patient’s right pleural sac accumulated rapidly and on 
tapping it they found that it had the character of a passive 
effusion, with poverty of albumin and cellular elements. He 
had to be tapped several times. Cyanosis was then very 
remarkable and he began to breathe with a slight stridor. 
About a week before his death he became very oedematous in his 
lower extremities, and some fluid formed in the peritoneum. 
One day he complained of violent pain in his right axilla 
and died six or seven hours afterwards from respiratory 
embarrassment. The disease was found to be a lympho¬ 
sarcoma involving all the structures in the thorax. The 
whole of the superior vena cava was absolutely filled with it, 




234 The Lancet,] SOUTH-WEST LONDON MEDICAL SOCIETY.—iESCULAPlAN SOCIETY. [Jan. 25. 1908. 


and it grew high np and into the innominate vein. It pro¬ 
jected into the right auricle of the heart and filled it up, and 
projected into the ventricle. 

Dr. Hbnry C. Earl exhibited a specimen of Extensive 
Lympho-sarcoma in the Upper Farts of the Thorax bat 
lying more in front of the structures than surrounding them. 
It grew down on to the pericardium and the heart was 
covered all over with a thick layer of tumour. It extended 
to the left pleura and from it into the lung. There were also 
several globular secondary growths in the liver of the same 
structure. 

Dr. William Boxwell exhibited a specimen of Aortic 
Aneurysm taken from a man, aged 33 years. At the necropsy 
the aorta was found to be the seat of a saccular aneurysm of 
the size of a duck’s egg. The innominate artery was involved 
in the aneurysm, while the left carotid and subclavian 
opened directly into the sac. The aneurysm lay directly 
under the right sterno clavicular articulation and caused a 
partial dislocation of the joint. The sac was crossed in 
front by the left innominate vein, which was incorporated in 
its wall and nearly obliterated, its function having been 
taken on by an enlarged left superior intercostal. Both 
recurrent nerves must have been subjected to considerable 
pressure, as were also the trachea and oesophagus. 

Dr. Boxwell also showed specimens obtained from two 
cases of Poisoning by Crude Phenol. The first patient was a 
girl, aged 15 years, who swallowed four ounces of the 
poison. She was dead when brought to hospital and the 
necropsy was made about 24 hours afterwards, no attempt 
having been made to counteract the effects. The stomach 
was of a leathery consistence ; the serous surface was dull 
and of a bright cherry-red colour. The same appearances 
were noticeable on the contiguous surface of the spleen. The 
mucosa of the stomach and oesophagus was hard and brittle, 
dull greyish white in colour, with whiter points resembling 
incrustations, as if roughly painted with white lead. There 
was no evidence of this necrosis on the tongue or fauces, 
although in the latter an oeiematons condition of the 
mucous membrane was very remarkable. The second patient 
was a child, aged 12 months. The amount of the poison 
swallowed could not be accurately ascertained. The child 
was still alive when removed to the hospital. About four 
ounces of whisky were administered within a few minutes of 
the dose of phenol, followed by a copious irrigation of 
whisky and water. There was no other antidote used. The 
amount of coagulation necrosis was not great, the Btomach 
bearing a marked contrast to that of the previous case. The 
condition of the pharynx and oesophagus in the two cases was 
much the same. Some detaiU of a third case were also given, 
where a woman, aged 27 years, had swallowed eight ounces 
of crude phenol. She also was treated with whisky, whisky 
and water, and glycerine and water given through a stomach- 
tube. A considerable quantity of brown fluid smelling 
strongly of carbolic acid was syphoned off with the initial 
dose of whisky and as a result of the treatment the woman 
was doing well. It was a remarkable fact that within a few 
minutes of the administration of whisky she recovered con¬ 
sciousness and within an hour was vomiting naturally. 

The Secretary exhibited an old museum specimen show¬ 
ing a Round Worm doubled up in the trachea and larynx of 
a child. 


South-West London Medical Society.—A 

meeting of this society was held on Jan. 8th, Dr. 
A. Dumville Roe, the President, being in the chair.— 
Mr. Charles Ryall opened a discussion on the Diagnosis 
and Treatment of Hsemorrtaage from the Mouth, Nose, 
and Stomach. Dealing chiefly with haemorrhage from the 
stomach Mr. Ryall spoke of the importance of accurate 
diagnosis and of keeping in mind the possibility of car¬ 
cinoma sup-rvening on what appears to be a simple chronic 
inflammatory condition. He referred in detail to the condi¬ 
tion known as gastrostaxis and to the haemorrhage in 
cirrhosis of the liver and from the oesophagus. Treatment of 
severe hae norrhage resolved itself into the use of morphine 
and rest. Drugs were of little use except in less severe 
cases ; ice, which should be ground, was useful, and the ice- 
bag when used should not be allowed to produce pressure on 
the abdomen. Gistro-enterostomy was frequently successful 
in removing the more prominent troubles in suitable cases. 
Mr. Ryall having briefly referred to bleeding from the nose 
and month, the discussion was continued by the President.— 
Mr. Mark Ilobinsoi inquired what was the reason that the 
p.csence of blcod in the stomach induced vomiting.—Mr. J. 


Gay spoke of hoematemesis in hysteria, and referring to- 
epistaxis wondered if plugging the posterior nares was 
not less frequently required nowadays. He had found that 
in a large number of cases the haemorrhage came from 
a septal vessel just within the nares where it could 
be easily controlled.—Mr. E. F. White thought that 
drugs were useless in severe cases. He had administered 
adrenal with little local effect and had seen toxic sym¬ 
ptoms arise from over-absorption. He had had experience 
of haemorrhage from the dilated veins of the oesophagus and 
noted that in duodenal ulcer the course was commonly more 
rapidly downhill than in any form of gastric uloer.—Dr. M. G. 
Biggs agreed that a large number of oases of epistaxU were 
due to the rupture of a septal artery. He had had experience 
of gastrostaxis which was more alarming to ttJe medical 
attendant than to the patient who was used to it. He 
inquired whether the view of the Leeds school that all gastric 
ulcers should be excised when discovered as a precaution 
against subsequent carcinoma was widely held and prac¬ 
tised.—Mr. Aitken recorded two cases of gastrostaxis and 
advocated an absolute starvation in all cases of gastric ulcer. 
He had found calcium ohloride of little use unless it was 
given in teaspoonful doses of the dry salt; In that form 
much benefit appeared to be obtained.—Dr. W. G. Dickinson 
mentioned two cases of sudden death from gastric haemor¬ 
rhage, and Dr. R. Carswell, Dr. C. E. McDade, and Mr. E. J. 
Pritchard joined in the discussion which was closed by Mr. 
Ryall. 

/Esculapian Society. — A meeting of this 
society was held on Jan. 17th, when Dr. W. Langdon Brown, 
the President, showed the lollowing cases 1. A mat, aged 29 
years, with Congenital Heart Disease, who had well-marked 
clubbed fingers, haemoptysis, and a systolic apical murmur. The 
condition was probably one of patent septum ventriculornm. 
2- Two ohildren, brother and sister, with Congenital Defects 
The boy, aged three years, had congenital heart diseaso. 
He had marked cyanosis, dabbed fingers, and a systolic 
apical murmur due to an imperfect septum. The girl, aged 
nine months, had her left hand like a flapper, absence 
of nearly the whole of the radius and of the thumb. 
3. A man, aged 59 years, with Melanotic Sarcoma of the 
Lung. Four years ago he had his right eye removed for 
“cancer.” Six months ago he had five and a half pints of 
blood-stained fluid removed from a left-sided pleural effusion. 
There was bulging of the left side of the chest posteriorly in 
the lower half. There were markedly enlarged veins over 
the upper chest and the lower abdomen on the left side, 
the blood flowing away from the bulging area. There were 
several small nodules over the abdomen and the chest, and a 
shotty nodule above the left clavicle was excised and found 
to be melanotic sarcoma.—The President also showed the 
Heart of a man, aged 39 years, who had died from 
well-marked Stokes-Adams Syndrome.—Dr. L. U. Young 
showed a Fibroma of the size of a large orange which 
he had removed from the left labium majus of 
a healthy, muscular woman, aged 21 years, and which had 
existed for from four to five years.—Dr. D. Ross demonstrated 
a well-nourished lad, aged 18 years, who was a typical 
Ruminant. From 15 to 20 minutes after a meal, at interval* 
of about four minutes, the food returned by mouthfuls, to 
be remasticated and again swallowed. It ocourred mostly 
when be ate hurriedly and was unattended by nausea, 
retching, or discomfort. Farinaceous foods and those con¬ 
taining cellulose almost invariably regurgitated. He de¬ 
scribed the second mastication as giving rise to a pleasant 
sensation. The condition was probably a motor gastric reflex 
neurosis.—Dr. Ross also showed a man, aged 47 years, who 
had undergone Gastro-enterostomy for Cancer of the Wall of 
the Stomach and who had very much improved since the 
operation. 

Edinburgh Royal Medical Society.—A t a 
meeting of this society held on Jan. 10th Professor Robert 
Muir (Glasgow) gave a demonstration on Repair. Hypertrophy, 
and Tumour Growth In the Liver. His results were taken 
from human livers which had come into his hands and hence 
were of more value than experimental results. In a case of 
14 days’ old rupture of the liver there was clearly seen 
evidence of proliferation of the epithelium of the bile ducts 
to form new liver cells and also of hypertrophy and prolifera¬ 
tion of the uninjured liver cells to increase their functional 
power. Cells undergoing this proliferative change were 
found larger, less granular, and often mnltinucleated. The 
result of such changes was irregularity in shape and size 





The Lancet,] 


REVIEWS AND NOTICES OF BOOKS. 


[Jan. 25, 1908 . 235 


of the lobules, with displacement eccentrically of the 
central vein. These changes were demonstrated also 
from livers showing subacute yellow atrophy and cirrhosis. 
This proliferative change in cirrhosis often went further and 
gave rise to the malignant epitheliomata of the liver seen in 
cirrhotic livers. In such tumours all stages of cell growth 
were seen, from the proliferative changes found in rupture 
to the moat irregular forms of cells, many having very many 
nuclei. These tumours were often multiple and seemingly 
of the same age, so that the influences determining tumour 
growth in one part of the liver muBt have been effectual in 
determining suoh growth at another part. Professor Muir, in 
summing up, showed how this was comparable to multiple 
epitheliomata after psoriasis. 

Pathological Society of Manchester.— A 
laboratory meeting of this society was held in the Pathological 
Department of the University on Jan. 15tb at which the 
following specimens were shown. Dr. W. B. Anderton : 
Specimens recently added to the museum.—Dr. C. H. 
Melland : Microphotographs of the Blood in Various Con¬ 
ditions and Illustrations of the Methods of Staining Blood 
Films.—Dr. G. E. Loveday : Epithelial Olontomata,—Dr. F. 
Craven Moore : Specimens illustrating Morbid Conditions of 
the Stomach.—Dr. D. Orr and Dr. R. G. Rows : Specimens 
illustrating Morbid Lesions of the Central Nervous System, 
Natural and Experimental.—Miss Elsie M. Royle : Specimens 
from two cases of Leucocytbsemia.—Dr. J. Lorrain Smith : 
Hsemolymph Glands.—Dr. Lorrain Smith and Dr. W. Mair : 
Specimens illustrating the Application of Weigert's Myelin 
Method of Staining.—Other specimens were shown by Dr. 
C. Powell White, Dr. N. J. H. Gavin, Mr. Wolstenholme, 
and Mr. Roberts. 

Society of Tropical Medicine and Hygiene.— 

A meeting of this society was held on Jan. 17th, Sir Patrick 
Manson being in the chair.—Dr. W. Carnegie Brown, in an 
interesting biographical sketch of Professor Fritz Schaudinn, 
eaid that the great professor's life was lost as a direct result 
of his disastrous experiment of self-infection and it was more 
than probable that his health was undermined by his almost 
reckless industry, for Schaudinn would sit continuously for 
many days and nights following the life-cycles of a series of 
different organisms. Schaudinn won for himself in his short 
lifetime a reputation that in his own branch of science was 
altogether without parallel and he achieveil this by his un¬ 
wearying industry, by his marvellous facility of technique, 
by his phenomenal power of interpretation, and by his almost 
supernatural scientific “ flair.”—Dr. G. C. Low read a paper 
on the Unequal Distribution of Filariasia in the Tropics. 


debiting sub ftrfbs of Jflobs. 

Diseases of ’Women: A Clinical Guide to their Diagnosis and 
Treatment. By George Ernest Herman, M.B. Lond., 
F.R.C.P. Load., Consulting Obstetric Physician to the 
London Hospital. Third edition. With 265 Illustrations. 
London and Paris: Cassell and Co. 1907. Pp. 900. 
Price 25*. 

The more often we consult this wofk of Dr. Herman the 
more we are impressed with the excellence of the teaching it 
•contains and the clearness of its style. Perhaps it does not 
appeal to the ordinary student so much as other books 
written more ostensibly for the purpose of enabling him to 
pass examinations, bat as a safe gnide to good treatment we 
know of no work on gynaecology in our language which is its 
equal. The third edition has now appeared and the author 
has revised carefully the whole work. He has made certain 
alterations and additions which tend to increase its value but 
it retains all the original featnres which distinguish it from 
most other text-books. The chief danger which besets the 
neophyte in the practice of gynaecology is the tendency to 
neglect the teachings of general medicine in his treatment 
of his patients. A careful reading of the first part of this 
book would go far to cure him of such a tendency but the 
best method of avoiding any such circumscribed view is to 
acquire a thorough grounding in general medicine before 
taking up a special branch. If anch a coarse were pursued 


more frequently by intending specialists we should hear less 
of their narrow-mindedness as regards their particular 
" allotment of the body,” as we have heard it called 
by a layman with little reverence for the present-day 
tendency to over-excessive specialisation. 

In an endeavour to present a clear view of the exact 
nature of that important disease hysteria Dr. Herman has 
elaborated his account of this affection and has embodied 
in his chapter on the subject the modern conception of 
it as a disease characterised by definite physical signs. 
Written as this book is from the point of view of the 
clinician no mention was made iu former editions of the 
pathological histology of the various diseases described. In 
view of the great importance of the recognition of cases of 
early carcinoma of the uterus by the aid of the microscope 
Dr. Herman has given a brief account of the appearances 
under the microscope of cancer of the uterus with some 
additional illustrations. And here perhaps we may be 
allowed to find some fault. Many of the illustrations are 
of interest from the historical aspect and some are 
exceedingly good in themselves, although they are badly 
reproduced and of old standing. On the other hand, many 
of the illustrations could readily be replaced by better ones, 
not only better examples of the different diseases which they 
are intended to illustrate, but also infinitely better examples 
from an artistic standpoint. We know Dr. Herman’s 
appreciation and veneration for many of the masters of 
English gynaecology but we would venture to suggest 
that he should not allow bis book to have its valne 
diminished by the reproduction of so many poor and old 
drawings. The section dealing with the interesting disease 
of chorion-epithelioma has been considerably amplified 
and there are some most excellent illustrations in this 
case taken from the monograph of Dr. J. H. Teacher. 
The recent work of Dr. H. Williamson and Dr. W. H. Atlee 
on the Nature of Vascular Caruncles has also been incorporated 
in the chapter on Painful Micturition. We regret to see 
that in the chapter on Cancer of the Cervix the author still 
recommends bisection of the uterus in performing vaginal 
hysterectomy, a plan which we cannot but think faulty, in 
that it must increase the risk of implantation of the cancer 
cells. 

The section on Abdominal Hysterectomy has been revised 
and brought np to date. We gather Dr. Herman thinks 
that for simple cases of fibroid tumours not involving the 
oervix subtotal hysterectomy is a sufficient and good opera¬ 
tion, and that he would reserve pan-hysterectomy for growths 
which cannot for various reasons be treated by the former 
operation. We consider this is the common-sense view to 
take of the question ; the mortality of the two operations at 
the present day is practically the same and the reasons 
which are brought forward by the adherents of the one 
or the other seem fairly equally balanced when regarded by 
the impartial observer. 

This, in onr opinion, is the best text-book of gynaecology 
in the English language. Written by a scientific physician 
from the clinical point of view its teaching is based on 
sound principles which have stood the test of practical 
experience. 

Eye Injuries and Their Treatment. By A. Maitland 
Ramsay, M.D. Glasg., Ophthalmic Surgeon, Glasgow 
Royal Infirmary; Professor of Ophthalmology, St. Mungo’s 
College, Sec. Glasgow : James Maclehose and Sons. 1907. 
Pp. 210. Price 18*. net. 

IN bygone generations it was customary for the medical 
Chrysostoms of the day to publish their words of wisdom in 
the form of collected essays and clinical lectures. These 
were always ponderous and dignified, often dogmatic, as 
befitted ex oatkedrd statements ; they were usually models of 
classioal erudition and literary style, and sometimes they 






236 The Lancet,] 


REVIEWS AND NOTIOE8 OF BOOKS. 


[Jan. 25, 1908. 


contained useful knowledge and even new facts. Too often 
the teaching was gilt, not golden. Since medicine has 
become more a science and less an art this sort of literature 
has begun to die out. We watch its death struggles with 
equanimity, though when some peculiarly aggressive 
dicker of vitality manifests itself we are inclined to wish 
that it would “get on with its dying.” We may regret the 
deterioration of literary style and deplore the too frequent 
lapses of grammar and composition which characterise so 
many of the medical writings of to-day, but we may be proud 
of the fact that while these defects are only too patent the 
science of medicine forges ahead by leaps and bounds. 

The volume before us combines some of the virtues of both 
the old and the new types. It is well printed on large pages, 
with wide margins, uncut edges, and a gilt top ; it is 
sumptuously illustrated—quite an idition de luxe. It is true 
that most of the subject matter will be found in any good 
treatise on diseases of the eye but it is brought forward here 
in such a pleasant fashion that it may well prove attractive 
to the busy general practitioner, for whom, we presume, it 
is primarily intended. There are many things in it which 
will be of interest and value to the trained ophthalmologist, 
for he cannot but benefit by the ripe experience of a dis¬ 
tinguished oonfrerc. His attitude must necessarily be a 
critical one. He will regret the incompleteness of the book 
as a treatise on injuries of the eye. We cannot think that he 
will always agree with the author's methods and still less 
with his views on some points of ocular pathology. As 
examples of the first-named he may doubt the advisability of 
attempting to replace a prolapsed iris after an ordinary 
injury and of aiding this procedure by the instillation of 
eserine. Separating the conjunctiva all round the cornea, 
passing a purse string suture throngh its free margin, and 
pulling this tight so as completely to cover the cornea, will 
only exceptionally be indicated, in his estimation, in the 
treatment of perforating wounds. He will probably prefer to 
introduce a glass ball rather than paraffin into Tenon's 
capsule as a modification of enucleation. Th author’s views 
on the theory of sympathetic ophthalmia savour of antiquity. 
“ Numerous experiments have conclusively demonstrated 
that irritation of the ciliary nerves in one eye produces not 
only dilatation of the blood-vessels but also increased secre¬ 
tion of albumin into the aqueous humour of the other.” 
Romer's recent extremely delicate experiments entirely, and 
in our opinion conclusively, negative this statement. 

Dr. Ramsay describes the methods of determining the 
presence, and localising the situation, of intraocular foreign 
bodies. The large magnet which he uses is apparently the 
same as Volkmann’s; he considers it preferable to Haab’s. 
The chapter on ocular therapeutics is the one which will 
most attract the ophthalmologist, for it gives many hints of 
the author's predilections in drugs. He rightly lays stress 
on the general treatment of the patient, which is too often 
forgotten in the absorbing interest of the local condition. 
Various silver preparations, anresthetics, mydriatrics, and so 
on, are passed in review and attention is drawn to the indica¬ 
tions for subconjunctival injections. The formulae in use 
at the Glasgow Ophthalmic Institution form an appendix to 
the work. 

Special note must be taken of the coloured plates which 
adorn the book. The drawings of the eyes are extremely 
good but the artist has been unfortunate in his choice of a 
skin tint. The foreigner glanciDg through the book might 
conclude that Dr. Ramsay has an extensive practice amongst 
negroes The outline drawings contain many inaccuracies. 
Two plates illustrate Dr. Thomas Reid’s unorthodox histo¬ 
logical views; it would have been well to point out that 
these views are not generally accepted by histologists. 

In conclusion, we may express a doubt as to whether books 
of this kind are worth the trouble and expense which they 
entail. Do beautifully reproduce! coloured drawings of 


common pathological external conditions serve any very 
useful purpose 1 We think not. Anyone will learn far more 
from careful examination of the patients and no one will be 
made much more competent to treat such cases by study of 
the drawings. 

Platma nnd Zelle. Er6te Abteilung: Allgemeine Anatomie 
der lebendigen Masse. Bearbeitet von Professor Dr. 
Martin Heidenhain in Tubingen. Erste Lieferung: 
Die Grundlagen der mikroskopischen Anatomie, die 
Kerne, die Centren und die Granulalehre. (Plasma and 
Cell. First Section : General Anatomy of Living Matter. 
Edited by Professor Martin Heidenhain of Tiibingen. 
First Part: The Elements of Microscopical Anatomy, the 
Nuclei, the Centrosomes, and the Granule Theory.) With 
276 (in part coloured) illustrations in the text. Jena : 
Gustav Fischer. 1907. Pp. 506. Price M.20; to sub¬ 
scribers M.16. 

This work of Professor Heidenhain, which constitutes the 
last part of Bardeleben’s “ Handbuch der Anatomie des 
Menschen,” has appeared at a most opportune moment and 
supplies a work the need of which has been very greatly 
felt. The author, as it were, here “puts the finishing 
touches ” to our knowledge as regards many points of vital 
interest in the study of this subject. The anatomical aspect 
of living matter is the chief point under consideration, but 
the author also, in a most comprehensive and interest¬ 
ing manner, touches upon the various branches of biology. 
No such complete treatise on this subject has hitherto 
been published and we strongly recommend the book to 
every medical man who is interested in the biological side of 
his profession. It cannot fail also to be of great benefit to 
biologists as a book of reference and we are confident that 
it will be received by them with sill the enthusiasm which it 
deserves. 

Professor Heidenhain, as usual, proves himself complete 
master of his subject." The general aspect which he puts forth 
in dealing with the different problems is a very pleasing one 
and comprises the biology of the cell in the full sense of the 
word. He gives a fairly comprehensive review of the 
historical development of our anatomical and biological 
knowledge of the cell in general. Here and there we find 
the author's own ideas put forth. In the question of the 
differentiation of living matter he considers that there is no 
constant connexion between the structure of the nucleus and 
the function of the protoplasm. Regarded from a general 
point of view, the nuclei of the tissue cells are markedly 
inactive. The work also contains much interesting and 
instructive information as regards the chemistry both of the 
nucleus and of the protoplasm. The methods of staining, 
and so on, are also considered but the author does not go into 
detail concerning this subject. 

In several minor points we are able to agree with the 
ideas set forth by the author. For instance, we consider 
that the lining of the cell plays quite as important a role 
as the author seems to indicate. It is a noteworthy fact 
that, although he does not actually commit himself to any 
decided opinion, he yet does not appear to support the 
hypothesis of the individuality of the chromosomes. The im¬ 
portant subject of spermatogenesis is a point upon which the 
author has enlarged and with which he has dealt in a com¬ 
prehensive, interesting, and altogether satisfactory manner. In 
the fourth portion of the first part Professor Heidenhain deals 
fully with our knowledge of the granules. Altmann’s theory 
that the granules are active parts of the protoplasm, granu¬ 
lation in gland cells, mitochondria, the vital staining of the 
granules, and so on, are points which are noted. In the last 
chapter the protomere theory—i.e., the composition of the 
plasma out of minute dividing particles—is gone into at some 
length. 

In conclusion, we should like to draw attention to the com¬ 
plete bibliography which is given at the end of each chapter. 
The value and interest of the work are also much enhanced 






238 Th» lancet,] 


REVIEWS AND NOTICES OF BOOKS. 


[Jan. 25,1908. 


salts and their metabolism in the body has been extended 
and is a useful study of the subject. The consideration of 
beverages is also full and inclndes tables of the composition 
of the most important mineral waters and a useful summary 
of the effects of alcohol and of its uses in health and disease, 
in which the opinions of several authorities are quoted at some 
length. The effects of a number of factors upon foods and 
their use in diets are given, including the questions of the 
concentration, the preservation, and the cooking of foods, 
and of food adulteration and the varieties of food poisoning. 
The subject of the feeding of infants is very fully dealt with 
and this section is one of the best in the book. The diets 
adapted to special conditions are given, such as those for the 
agel and those advised during pregnancy. In this con¬ 
nexion the dietary recommended by Prochownick in pregnancy 
with pelvic contraction is given in detail. About half the 
book is devoted to the presentation of diet in disease ; each 
disease is separately considered and various diets are sug¬ 
gested in many cases. This method is a convenient one, 
since, although it involves considerable repetition, it facili¬ 
tates the use of the book as a work of reference. In most 
cases not only is the total quantity of food to be given 
indicated but also the times at which the meals are best 
taken and also the amount of fluid to be permitted. Where 
different diets are advised by several authorities these are 
clearly separated from one another and are discussed by the 
authors. Various forms of dietary used in institutions are 
given in detail with their heat values. A chapter Is devoted 
to recipes for beverages and special articles of diet. 
The concluding section consists of lists of substances which 
may and may cot be given in various diseases, constituting 
what the authors term “ rapid reference diet lists.” 

The book is well printed, is easy of reference, and is a 
valuable presentation of the subject of which it treats. 


LIBRARY TABLE. 

An Introduction to Phytiology. By William Townsend 
Portbh, M.D., Associate Professor of Physiology in the 
Harvard Medical School. London and Philadelphia : J. B. 
Lippincott Company. 1906. Pp. 687.—This work is drawn 
up to meet the requirements of the “ concentration ” system 
as practised in Harvard Medical School at Boston, a system 
which meanB that the student at the time shall study only 
one principal subject such as pathology or physiology. In 
Harvard the first half year in the medical school is devoted 
to anatomy and histology, and the second to physiology and 
biological chemistry. The traditional teaching of physiology 
is preceded by experiments and observations by the student 
himself. In the old method the stress is upon didactic 
teaching ; in the new there is less didactic teaching bnt the 
stress is on observation. This book is very much like some 
of the works on practical physiology published in this 
country but there is much less chemical physiology. 
The scope of the work will be best understood by stating 
that it gives an account of fundamental and accessory 
experiments in some fields of physiology. These are general 
properties of living tissues, methods of electrical stimulation, 
graphic method, electrical, chemical, and mechanical stimu¬ 
lation of nerve and muscle, and irritability and conductivity. 
The second part deals with the “income of energy” under 
the following heads: fermentation, blood, and respiration ; 
while Part III. treats of the “ outgo of energy.” It comprises 
the consideration of animal heat, electrometric phenomena 
of muscle and nerve, the change of form of a contracting 
muscle, the central nervous system, skin, general sensations, 
taste, eye and vision, mechanics of respiration, circulation 
of the blood, and innervation of the heart and blood-veBsels. 
The directions are clear, definite, and precise, while 74 
illustrations help the student in the setting up his apparatus 
and arranging his experiments. Students preparing for the 


higher examinations will find it most helpful. This is the 
second edition and in its “ final form ” it will constitute “ A 
Laboratory Text-book of Physiology.” 


JOURNALS AND MAGAZINES. 

The Edinburgh Medical Journal. —In the January number 
of this journal Dr. W. Allan Jamieson records some interest¬ 
ing observations on rarer varieties of bullous affections of 
the skin—anomalous herpes zoster, dermatitis herpetiformis, 
pemphigus foliaceus and vegetans, and lichen planus with 
bullous lesions. An address by Dr. G. A. Gibson on Arterial 
Pressure emphasises the value of instrumental measurement 
of blood pressure, examples of which are to be seen in acute 
pneumonia and in aortic disease, wherein it is a useful guide 
to prognosis. Dr. J. S. Fowler writes on the “energy- 
quotient ” in infant feeding, and Dr. D. Chalmers Watson on 
chronic arthritis, in which disease he holds that sufficient 
attention has not been paid to other organs besides the 
joints. A presidential address delivered before the Edin¬ 
burgh Royal Medical Society by Dr. David M. Barcroft on 
Some Clinical Accessories deals pleasantly with the dis¬ 
coveries of the method of percussion, of the stethoscope, and 
of the sphygmograph. 

The SeottUh Medical and Surgical Journal. —The first 
number of the new year opens with a presidential address 
by Dr. A. Rudolph Galloway to the Aberdeen Medico- 
Chirurgical Society on the subject of Sight-testing and the 
drawbacks and dangers inherent in the prescribing of 
spectacles by opticians. A paper by Dr. Alexander Goodall 
and Miss Isabel Mitchell on the Physiological Action of the 
Formates may be commended to the study of those who 
have been impressed by some recent writings in praise of 
these drugs as stimulants. These authors find that the 
sodium and potassium salts are toxic, while the calcium 
salt may perhaps be useful as a soluble salt of lime in place 
of the chloride or lactate but not on account of its acid 
radicle. The sixth instalment of Dr. A. Dingwall Fordyce’a 
studies on infant feeding deals with artificial substitutes for 
breast milk and among other things advocates the use of 
Bcalded rather than sterilised cows’ milk. 

The Brittol Medico-Chirurgioal Journal. —In the December 
issue Dr. Henry Waldo writes on Syphilis in the light of re¬ 
cent investigations on the spirocbscta (treponema pallidum) 
He supports the intermittent method of administering mer¬ 
cury which is in favour on the Continent. Mr. Ernest W. 
Hey Groves writes on Spinal Anaesthesia which he believes 
to be useful in certain special emergencies but not as a 
routine method ; and Dr. F. Percy Elliott continues hie paper 
on the Value of Compression of the Aorta in Post-Partuzn 
Haemorrhage. A case of Generalised Sarcoma recorded by 
Dr. F. G. Bushcell was remarkable for the alterations in 
the blood, which showed a high degree of lymphocytosis- 
(large lymphocytes, 37 per cent. ; small, 29 per cent.), the 
polymorphonuclear cells only reaching 13 per cent. Dr. 
William Cotton pleads for uniformity in radiography to 
enable different observers to compare notes with some degree 
of accuracy. 


The HosriTAL Saturday Fund.—S ir Savile B. 

Crossley presided at a special meeting of the board of 
delegates of the Hospital Saturday Fund Association on 
Jan. 18th at the offices, Gray’s Inn-road, W.C. On the 
recommendation of the distribution committee it was decided 
that the sum of £24,708 Os. 2d. should be awarded to the 
209 participating medical charities—namely, 33 general 
hospitals, £8268 5c ; 16 cottage hospitals, £323 15s. ; 75 
special hospitals, £8416 12s. ; 29 dispensaries, £818 16s. ; 
24 convalescent homes, £1483 17s. ; 19 nursing institutions, 
£420 15s. ; and 13 miscellaneous (including ambulance, dis¬ 
tribution, and surgical appliance committees), £4986 0s. 2d. 
The total receipts for 1907 amounted to £27,168, as com¬ 
pared with £26,460 in 1906, an increase of £708. 





The Lancet,] 


NEW INVENTIONS. 


[Jan. 25, 1908. 239 



A TRUSS BELT FOR MOBILE OR FLOATING KIDNEY. 

In a paper on Mobile Kidney published in The Lancet of 
August 3rd, 1907. p. 283, Mr. E. Sbanmore Bishop said that 
his experience of the use of trusses, belts, or corsets in this 
condition was not altogether favourable but he mentioned 
the appliance manufactured for that purpose by Salt and Co. 
of Birmingham as being perhaps among the best. This iirm 
has now sent us one of its truss belts for mobile kidney in 
which there is an alteration from the earlier patterns. The 
belt is made of a stout grey fabric, completely encircles the 
waist, and, as shown in the illustration, is fastened with 



three buckles. Inside there is a pocket containing a 
removeable indiarubber air-pad for the purpose of making 
pressure where required. The recent alteration already 
referred to consists in the addition of a specially constructed 
steel spring device fixed immediately over the air-pad, by 
which it is claimed that a more regular and correct pressure 
is obtainable than with earlier patterns of the appliance. 


A NEW MERCURY INTERRUPTER FOR X RAY WORK. 

For the greater part of the work done with an induction 
coil as a source of energy it is felt by most of those engaged 
in this line of investigation that some form of break employ¬ 
ing mercury is probably the best to use. First came those 
in which a wire or blade was made to dip in and out of a 
vessel containing mercury. These were a great improvement 
on the platinum break and so long as workers were content to 
use voltages not exceeding 24 very good results were obtained 
with the coils then in use. Owing to the almost universal 
desire to use the current from the street mains directly for 
coils and also to their higher and increasing voltage 
interrupters of new design became necessary and these were 
all constructed upon a common principle—viz., a jet of 
mercury impinging upon a metal blade. In some the jet itself 
revolves and in others the jet is stationary while the blade or 
blades revolve around but close to it—all this taking place 
under the surface of a liquid dielectric, such as alcohol or 
petroleum, or in an atmosphere of hydrogen or coal gas. 
Except in the latter case there was, of course, great 
churning up of mercury and liquid dielectric which mili¬ 
tated against good contact between jet and blade, and this 
was still further interfered with as time went on by the 
emulsification of the mercury which always took place sooner 
or later. For these reasons the output of a coil working 
with a mercury jet break is always more or less limited, 
which limit becomes lower and lower as the mercury becomes 
emulsified and dirty. 

The Sanitas Electrical Company of 61, New Cavendish- 
etreet, W., has lately brought out a mercury break which 
possesses many advantages. It is driven by an electric 


motor which is placed at the bottom of the instrument with 
its shaft in an upright position. Upon the end of this shaft 
is mounted a hollow iron container—of about the size and 
shape of a small ginger jar—which revolves with it. This 
container, being of larger diameter at the middle than else¬ 
where and having a certain quantity of mercury and petro¬ 
leum placed therein it follows that if it be rapidly rotated the 
mercury, &c., will rise so as to occupy the largest diameter 
of the jar, the mercury as the heavier liquid lying against 
the wall of the jar as a continuous band. Inside the con¬ 
tainer on a level with its equator is mounted a disc of fibre 
revolving freely on a vertical axis, which can be moved 
nearer or further from the wall of the container, and having 
two or more metal segments. This disc is so adjusted that its 
periphery is slightly imbedded in the mercurial band and 
contact is made and broken as the metal segments of the 
disc enter and leave the mercury, the disc being driven 
around by the mercury itself. The face of the metal contact 
piece is broad and contact is positive owing to the metal being 
plunged into the mercury, and as the speed is necessarily 
high the “break” is sudden and complete. Apparently 
there is little or no tendency for the mercury to become either 
dirty or emulsified. The contents of one interrupter which 
we examined after several hours’ nse were found to be per¬ 
fectly clean. In practical use the output of the coll is under 
the most perfect control and can be varied from a short thin 
spark to a long and almost continuous ribbon resembling 
that obtained with an electrolytic interrupter Rut with a 
smaller consumption of current. Whether it will take 
the place of the electrolytic break is not yet certain 
but there is no doubt that this new form is a great advance 
on the other mercury breaks hitherto available. 


BI-PRONGKD FORCEPS. 

Mr. S. Gerald Gomes, F.R.C.S. Edin., of Tokio, Japan, 
writes : “ I have designed for use with Iteverdin's needle a 
pair of bi pronged forceps which have proved very successful. 
For several years I have used Reverdin's needle and other 
simpler patterns and felt the want of a better means than 
the two hands of an assistant to carry the suture down to 
the slot in these needles, especially in deep and awkwardly 



placed wounds in the abdomen. After some experience with 
the forceps I find that the above-mentioned difficulties are 
obviated by its use. Moreover, it can also be effectively used 
in place of the ordinary dissecting forceps and wherever the 
usual pattern forceps are required. The instrument has 
been made for me by Messrs. C. J. Hewlett and Son, 35-42, 
Charlotte-Btreet, London, E.O.” 


University of Oxford : Radcliffe Travelling 
Fellowship, 1908. —An examination for a Fellowship of the 
annual value of £200, and tenable for three years, will be 
held during the present term, commencing on Tuesday, 
Feb. 25th. Candidates must have passed all the examina¬ 
tions required by the University for the degree of Bachelor 
of Arts and for the degree of Bachelor of Medicine. They 
must not have exceeded four years from the time of passing 
the last examination required for the degree of Bachelor of 
Medicine. The successful candidate must before election 
declare that he intends to devote himself during the period of 
his tenure of the Fellowship to the study of Medical Science 
and to travel abroad with a view to that study. The Regius 
Professor of Medicine and the examiners, two months before 
the expiration of the second year after the election of each 
Fellow, present a report on the work done by him to the 
electors who may, if they think the report unsatisfactory, 
declare the Fellowship forfeited. The examination will 
occupy four days. Papers will be set in physiology, path¬ 
ology, and preventive medicine, and a subject will be pro¬ 
posed for an essay. There will also be a practical examination 
in pathology. Any candidate desiring to offer in addition a 
speoial branch of either medicine or surgery must send 
notice of this to the Regius Professor of Medicine. All 
intending candidates should send their names, addresses, 
qualifications, &o., to the “Regius Professor of Medicine, 
University Museum," on or before Saturday, Feb. 8th. 






240 Th* Lanobt,] TREATMENT OF PULMONARY TUBERCULOSIS BY GRADUATED LABOUR [Jan. 25,1908. 


THE LANCET. 


LONDON: SATURDAY, JANUARY iS. 190S. 


The Treatment of Pulmonary 
Tuberculosis by Graduated 
Labour. 

The open-air or sanatorium treatment of pulmonary tuber¬ 
culosis has now become generally recognised as a valuable 
therapeutic measure. First carried out under a regular 
system by, Dr. Brehmer at Gobersdorf in Silesia, sub¬ 
sequently many institutions were founded upon his model, 
while various modifications in detail have been made by 
diiferent physicians as has been recorded from time to time 
in our columns. All the developments of the treatment have 
not been in the same direction, and diiferent opinions have 
prevailed as to the ideal environment of the tuberculous 
patient in a sanatorium, but we are only considering now 
the question of exercise. While some authorities attached 
great importance to rest in the open air, Dr. Brehmer con¬ 
sidered that exercise, especially hill-climbing, was essential to 
the obtaining of the full value of this treatment, and Dr. 
Walther at Nordrach showed that excellent results could be 
obtained by graduated walking exercise, especially when, in 
suitable cases, this exercise was being pushed to the extent 
of walking 20 miles a day. Following upon the observa¬ 
tions of the German physicians numerous sanatoriums have 
been established in this country, the essential principle being 
that the patient should live as much as possible in the open 
air but a certain amount of exercise was considered advis¬ 
able. The sanatorium treatment has now entered upon a 
new phase and a most important one. At a meeting of the 
Medical Society of London held on Jan. 13th Dr. Marcus S. 
Paterson, the medical superintendent of the Brompton Hos¬ 
pital Sanatorium at Frimley, read a paper on Graduated 
Labour in Pulmonary Tuberculosis, which was supplemented 
by another on the Effect of Exercise on the Opsonic Index of 
Patients suffering from Pulmonary Tuberculosis by Dr, A. 0. 
Inman, the superintendent of the laboratories of the 
Brompton Hospital. These two papers are published in full 
in our present issue and upon being read were described by 
Dr. J. Kingston Fowler, President of the Medical Society, 
as marking an epoch in the treatment of pulmonary tuber¬ 
culosis. 

Dr. Paterson had observed that many tuberculous 
patients who had followed their ordinary occupations up 
to the time of admission to the hospital were in a very fair 
condition of health. It therefore occurred to him that if 
some tuberculous patients, being in adverse circumstances 
and without medical guidance, could act thus without 
apparent injury they ought, under ideal conditions and 
with the work carefully graduated in accordance with their 
physical state, to be able to undertake useful labour. Acting 
on this idea he has elaborated a system of graduated labour 
which not only carried out the intention of rendering the 


patients fit to return to their ordinary occupations on leaving 
the sanatorium but has proved a most valuable therapeutic 
measure in the treatment of pulmonary tuberculosis. In his 
paper he describes in detail the various grades of labour 
through which the patients are made to pass, together with 
the precautions which had to be observed in order to protect 
them from the harm which might ensue if too much effort was 
attempted. He also mentions the symptoms which suggest 
that the patients have overtaxed their physical resources. 
Those physicians who wish successfully to carry out this 
method of treatment will do well to study carefully Dr. 
Paterson’s remarks, for it is on the care that is devoted to 
detail and on the loyal cooperation of the patient that 
the result of the treatment will depend. The patients 
who were sent to the Frimley sanatorium for treat¬ 
ment had all been for some time at the parent institu¬ 
tion at Brompton. They were all carefully selected as 
regards the extent of the disease, the state of the tempera¬ 
ture chart (no markedly febrile cases being despatched to 
the sanatorium!, and the evidences which they exhibited 
of satisfactory resistance to the progress of the disease. 
When they reached the sanatorium the treatment by 
exercise was at once commenced. Every patient was 
informed that he would be treated by prescribed rest 
and exercise and that as he did not himBelf know the 
amount of each required he must do exactly as he 
was told. Absolute obedience to the orders of the 
physician in charge of the case was seen to be essential. 
Dr. Paterson brings out two points in particular in his 
valuable paper: First, that special heed must be paid 
to the word “graduated” in arranging the amount and 
kind of work to be done by each patient; and secondly, 
that the effect of that work on each patient as shown 
by the temperature chart and other signs must be 
carefully watched. He describes in considerable detail how 
the labour is graduated at Frimley, while he concludes that 
if the patient’s temperature remains above 99° F. in the 
case of men or 99 6° in the case of women the patient 
should be confined to bed, work should be prohibited, and 
reading should be the only recreation permitted. These two 
points, reinforced as they are by a record of practical 
experience, go far to demonstrate graduated labour to be a 
valuable form of treatment in pulmonary tuberculosis. 

Dr. Inman's observations on the effect of exercise on the 
opsonic index of patients suffering from pulmonary tubercu¬ 
losis corroborate Dr. Paterson’s clinical results in a remark¬ 
able manner. In his paper he gives a brief review of 
Sir Almroth Wright’s investigations and the principles of 
immunity enunciated by that observer. It has been shown 
-‘that auto-inoculations follow upon all active and passive 
movements which affect a focus of infection and upon all 
vascular changes which activate the lymph-stream in such a 
focus.” It is by the agency of such auto-inoculations 
that nature achieves curative effects in bacterial infections. 
Dr. Inman carried out his researches at the Brompton Hos¬ 
pital sanatorium in a most thorough and praiseworthy 
manner. He very wisely eliminated the personal element so 
far as possible, while he safeguarded himself from the 
possibility of a biased mind by conducting all his observa¬ 
tions with unknown specimens of blood. These were 
obtained from the patients under the necessary conditions. 





Thu Lancet,] 


INGUINAL HERNIA IN CHILDREN. 


[Jan. 25,1908. 241 


but to the experimenter they were simply numbered speci¬ 
mens ; he never knew which patient’s blood he was 
examining, a fact which adds a distinct value to the experi¬ 
ments. Dr. Inman’s charts will be seen to correspond 
in a most remarkable manner with the progress made 
by the patients and we commend a careful perusal 
of his paper to our readers. The practical outcome 
of his investigations is well expressed by Dr. Inman 
at the end of his paper. He points out that the opsonic 
index has shown that the exercise supplies the stimulus 
needed to induce artificial auto-inoculation, and that the 
systematic graduation of the exercise has regulated the 
dose both in time and amount. Further, Dr. Pat4rson 
and Dr. Inman are agreed that with the aid of the opsonic 
index the stimulus can be regulated with scientific accuracy, 
so that the treatment can be carried out more certainly 
and more rapidly. In short, the results of these observa¬ 
tions, both from the clinical and scientific points of view, 
have demonstrated that the treatment of pulmonary tuber¬ 
culosis by graduated labour is successful and founded on 
sound principles. Hitherto it has been assumed that the 
open-air or sanatorium treatment of this disease produces 
its results by improving the general condition and that life 
in the open air was the most important element in the 
therapeutics. Now it is more than suggested that although 
plenty of fresh air is absolutely essential for complete arrest, 
it is necessary that a series of auto-inoculations should be 
produced, and that the safest and most ready method of 
achieving the necessary dosage is graduated labour. This 
graduated labour has to be supervised very carefully or 
harm may result; the amount of exercise and work accom¬ 
plished must be prescribed as carefully by the physician as 
any combination of drugs. The results of graduated labour 
in cases of pulmonary tuberculosis when more generally 
adopted will be watched with interest, meanwhile Dr. 
Paterson is to be congratulated on having introduced 
the method of treatment and Dr. Inman on the careful 
work that supplies the scientific corroboration. 


Inguinal Hernia in Children. 

In the September number of the Practitioner appeared 
a paper by Mr. H. S. Clogg containing an account 
of inguinal hernia in children and as it was based on 126 
cases which bad been submitted to operation the conclu¬ 
sions drawn are likely to be of interest and value. Mr. 
Clogg has never met with what is called direct inguinal 
hernia in a child and all statistics show that it is intensely 
rare before puberty, so that it may be taken that inguinal 
hernia in a child means an oblique hernia. In regard to 
the question as to the relative frequency of the congenital 
and acquired forms of inguinal hernia in children the answer 
is definite. For the production of an acquired hernia some 
weakness of the abdominal wall iB essential but in children 
there is practically always a ready formed sac supplied by 
the unobliterated processus vaginalis. Nearly all cases of 
Inguinal hemia in children are of the congenital variety and 
this is so quite apart from the age of the child, for the sac 
is congenital even though it may not have been occupied by 
bowel until shortly before examination. The classification 
of congenital inguinal hemia which Mr. Clogg prefers is 


undoubtedly the best; it divides these hernias into the total 
funicular hernise, in which the whole of the funicular process 
or processus vaginalis is patent, and those in which the 
funicular process is partly closed ; these are partial funicular 
hernise. Of Mr. Clogg’ s 126 cases 115 were in males and 
of these only 11 were cases of total funicular hernia;, that is, 
about 10 per cent. 

The diagnosis of inguinal hernia in the child seldom 
presents any difficulty. A swelling in the groin, reducible 
on pressure, growing tense when the child cries, and often 
disappearing during sleep, can hardly be anything but a 
hemia, though occasionally a collection of fluid in a patent 
processus vaginalis with a very small opening at the 
internal ring may be mistaken for a hernia. There is another 
error in diagnosis which may prove of some importance. It 
is often thought that the only scrotal swelling which is trans¬ 
lucent is a hydrocele but in young children where there is no 
large amount of fat and the bowel wall is thin an inguinal 
hemia may be translucent and thus it may be mistaken for 
a hydrocele. If on the strength of this mistaken diagnosis 
the swelling should be punctured with a trocar and 
cannula the result would probably be disastrous. The 
correct diagnosis having been made the question of 
the most suitable treatment has to be decided. There 
is a very widespread opinion that circumcision is of some 
value in the treatment of inguinal hernia in children. 
We quite agree with Mr. Clogg that it cannot have the 
slightest effect in curing a hernia, though a tight phimosis 
may have assisted in the original descent of the bowel. As to 
trusses, it is doubtful how often a real “ cure ” of a hemia 
is brought about by a truss. The fact that a hemia has not 
been noticed for some months or years is no evidence that 
it has been really “cured” ; for a perfect cure there must 
be an absolute obliteration of the sac. Now, the use of a 
truss may occasionally in very young children lead to the com¬ 
pletion of the closure of the processus vaginalis when the 
closure has only been delayed, but when several months 
have passed since birth the probability of the obliteration of 
the sac by means of the pressure of a truss is very small 
indeed. Even In young infants when a truss is employed, 
should the bowel only come down once the benefit of the use 
of the trass for weeks may be destroyed and all chance of a 
real cure of the hernia be removed. Even when the employ¬ 
ment of a truss does result in the permanent disappearance 
of the hernia with complete obliteration of the sac it is 
probable, as Mr. Ologo suggests, that the truss takes no 
active part in the closure of the sac but merely permits 
that closure by preventing the descent of the bowel. 
For the past three years he has abandoned the use 
of a truss for inguinal hemia in children except in special 
cases, and even when he uses a truss he always warns the 
parents “that the truss will not cure the rupture." He 
holds that if a hernia has been seen after the first few weeks 
of life the only cure is by operation. 

If, then, an operation is essential for all but the very early 
cases the question arises, At what age should it be done ? 
Mr. Clogg’S answer is that the earlier these cases are 
operated upon the better; he maintains that infants after 
the third or fourth month bear the operation well and make 
a very satisfactory recovery from it, and this is the age at 
which he recommends it unless it entails weaniDg of the 




242 Thu Lancet,] THE MEDICAL OFFICER OF THE LOCAL GOVERNMENT BOARD. 


[Jan. 25,1908. 


infant. In hospital practice an operation at this earl; age 
would almost certainly mean weaning bnt in private prac¬ 
tice it need not do so. Should the child be weaned to allow 
of the performance of the operation it is essential that he or 
she should be allowed to become accustomed to the artificial 
food before being submitted to operation. In some cases 
it may be advisable to operate even before the fourth month, 
as when strangulation has occurred or has threatened, 
or when the hernia cannot be kept up by a truss. 
The operation itself has some peculiarities. The various 
tissues are more difficult to recognise than in the adult and 
the smallness of the structures also renders the operation 
difficult. To expose the deep inguinal ring the external 
oblique has to be divided for a short distance. When the 
sac is of the partial funicular form it is isolated and 
ligatured at the internal ring. When the sac is of the total 
funicular type it is divided where convenient and the upper 
portion is dealt with as already mentioned but no attempt 
is made to close the lower portion which is in connexion 
with the teBtis. In most cases the inguinal canal is 
closed by a couple of sutures which fasten the internal 
oblique to Poupart's ligament. The cut margins of 
the external oblique are united and the wound is closed. 
The results obtained have been good. No fatal case 
occurred ; suppuration was present in six cases; in one of 
these the operation was done for strangulation and in 
several of the others there was some reason for the appear¬ 
ance of suppuration. It was not possible to see the after 
results in all cases but in those that conld be traced the 
result was perfect, there being no recurrence in any case. 
We have devoted some space to a consideration of Mr. 
Cl.OGG'S article, for it embraces all the points of importance 
in a subject of widespread interest to the medical profession. 


The Medical Officer of the Local 
Government Board: a New 
Appointment. 

The announcement made at the end of last week that 
the post of Medical Officer of the Local Government Board 
had been relinquished by Mr. William Henry Power and 
that Mr. John Burns had filled the vacancy by the appoint¬ 
ment of Dr. Arthur Newsholme has come somewhat 
unexpectedly. It was not generally realised that Mr. Power 
had reached the age, 65 years, at which retirement from 
office follows under Civil Service rules ; and hiB successor 
would have been looked for naturally among the many 
distinguished members of the medical staff of the Local 
Government Board. Dr. Newsholme will bring to his 
new duties an ability and industry which are uni¬ 
versally recognised and have been manifested in many 
fields of work, especially in his numerous contributions 
to vital statistics, the prevention of pulmonary tuberculosis, 
and domestic and educational hygiene. Many of these con¬ 
tributions have appeared in our pages, so that we know their 
value to the medical profession. He has presided over or 
organised with conspicuous success the work of many public 
health societies and congresses ; he has edited Public Health 
and the Journal of Hygiene; for many years he has ably 
filled the office of medical officer of health of Brighton, and 
he has there trained many of the younger generation of 


health officers. The Government appointment, which he has 
been called upon to accept, may fairly be described as alike 
the highest and the most onerous of any in the public health 
service of the country and is as exacting as any Civil Service 
appointment of the first rank. We wish him success in his 
new vocation and are certain that he will find himself loyally 
served by those over whom he has been placed. 

In his book ‘'English Sanitary Institutions” Sir John 
Simon, the first man called to the office, has given an 
account of the beginning and subsequent progress of 
the service for which the Medical Officer of the Local 
Government Board is responsible. From these writings it 
is possible to form some estimate of the task which that 
officer has to undertake and of the difficulties with which 
he has to contend in striving for the advancement of 
sanitary science and of sound and well-considered methods 
of sanitary administration. Large conceptions of the part 
to be played by medical considerations, in the wider sense 
of the term, in the proper government of the country 
reoeived little sympathy or practical encouragement from 
the Minister chiefly concerned with the early organisation 
of the Local Government Board. Even in comparatively 
simple matters of administration the initial constitution 
of that Board, with its multifarious detailed functions 
in connexion with Poor-law and other matters to which 
priority of attention was given, formed a dead weight 
against which Simon decided that it was hopeless for him 
to strive—in fact, he has himself told us that he resigned 
because he considered himself defeated in his proper policy. 
In the leisure of after years, however, Simon was able 
to bear testimony to the steady headway in many of 
tbe directions which he had advocated made by his suc¬ 
cessors, notably by Sir G. Buchanan, Sir R. Thorne- 
Thorne, and Mr. Power. In part, no donbt, tbe inore&sing 
influence of successive medical officers has been a natural 
result of the way in which people have now come to demud 
measures to protect the publio health and of the greater 
readiness of Ministers to see advantage in doing something, 
or in professing to do something, to meet this demand. But, 
on the other hand, the central administrative machine to 
which the chief medical adviser of the State is attached 
has continued year by year to take on new dutieB uncon¬ 
nected with public health and to add to its initial cumbrous¬ 
ness, while the reluctance of Ministers seriously to take up 
and to push through any bold or comprehensive scheme 
of public health administration or legislation which entails 
Parliamentary opposition has become more and more obvious 
in recent Parliaments. The Local Government Board and 
its medical department.may properly be credited with much 
sanitary administrative work which is good so far as it goes, 
but it would be interesting to know bow many schemes of 
constructive sanitary policy in matters both large and small, 
which have entailed endless inquiry and work by Simon'3 
successors, could be unearthed from the Board's pigeon-holes. 

It is more profitable to turn to that part of the work 
of the Medical Officer of the Local Government Board 
which is disclosed to the public in the series of annual 
volumes and special reports from the medical department. 
These volumes are systematically reviewed in our columns 
and are well known to all sanitarians. The Medical Officer 
has tbe duty of acting as expert adviser to certain other 




Thb Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Jan. 25,1:908. 243 


departments of State, notably in connexion with foreign and 
colonial affairs. The department supervises, by inspections 
at English ports and otherwise, the system of dealing with 
exotic diseases, such as cholera and plague, and the work 
done has brought much credit to British administration 
abroad and has enabled British representatives to take an 
important position in successive international sanitary con¬ 
ferences. It is hardly necessary to refer to the results of 
special inquiries made by the department year by year into 
conditions of disease prevalence throughout the country ; the 
Medical Officer’s publications may be said to have contained 
many, if not most, of the principal contributions whioh have 
been made to the modern science of preventive medicine 
in England. The work published in these reports under the 
heading of “ auxiliary scientific investigations ” comprises 
bacteriological, physical, and chemical inquiries of a very 
high order, usually on subjects requiring prolonged research 
of the sort which would hardly be attempted by anyone in the 
absence of the facilities given by the department. Present 
knowledge of, among other things, the bacteriology of scarlet 
fever and streptococcal infections, of the production of lead 
poisoning by moorland water-supplies, of the bacteriology of 
polluted soil, and of the penetration of disinfectant gases, 
for example, is largely based on these investigations. 
Many other examples could, of course, be given from 
the publications of the Medical Department of the 
Local Government Board and all would show the high 
standard of scientific and administrative work of the 
department, which during the last eight years has been fully 
maintained by Mr. Power in his capacity of medical 
officer. It is now nearly 30 years sinoe Mr. Power, as 
an inspector of the Board, began the brilliant series of 
investigations regarding the spread of different infectious 
diseases which have since become classic. Long before his 
appointment to the principal post he had already under¬ 
taken the direction of the “field work” and auxiliary 
scientific investigations of his department. His judgment 
and sound scientific insight have been always freely put at 
the disposal of all who wished to consult him. His late chief, 
Sir R. Thorne-Thorne, described him as the “greatest 
living epidemiologist ” and we know no one likely to 
dispute the title. At the end of his official activities and of 
the administrative career of the strong man who has “ done 
his work and held his peace,” Mr. Power can look back on 
services to science and to the State which it is given to few 
men in any country to achieve. 


Tucker v. Wakley and Another. 

The action brought by Mr. Augustus Q. Tucker against 
The Lancet resulted in damages of £1000 being given 
to the plaintiff. A stay of execution was granted. Many 
matters of the first importance affecting as much the 
public as the medical profession were touched upon in 
the course of the four days’ trial, and we shall probably 
consider it our duty to publish a full report of the case. 

Bristol Royal Infirmary.— It has been pro- 

posed to endow a bed in the Bristol Royal Infirmary to the 
memory of the late Mr. 0. J. KiDg, a well-known Bristol 
merchant. The sum required is £1200 and of this amount 
£929 have been already received. 


^niurfaftnw. 

"He quid nlmis." 


THE ADMISSION OF WOMEN TO THE" EXAMINA¬ 
TIONS OF THE ROYAL COLLEGE OF 
PHYSICIANS OF LONDON AND THE 
ROYAL COLLEGE OF SUR¬ 
GEONS OF ENGLAND. 

The proceedings at the Extraordinary Comitia of the 
Royal College of Physicians of London held on Friday last, 
Jan. 17th, have taken the advocates for the admission of 
women to the examinations of the English Colleges one 
step nearer their aim, but the whole question is still in 
considerable confusion. We need not go into the back 
history of the matter; it is sufficient to state that the 
present position is as follows. Petitions have been pre¬ 
sented from the London School of Medicine for Women to 
both Colleges asking that women may be admitted to the 
examinations of the Colleges. The Council of the Royal 
College of Surgeons of England agreed to admit women to 
the examinations for the Membership only, the Fellowship 
being reserved for men ; but the Council undertook before 
coming to a final decision to submit the matter to the 
Fellows and Members of the College, as was only 
right, seeing how drastic a change in constitution 
was contemplated. We presume that in the case 
of a distinct expression of opinion from the con¬ 
stituency the governing body of the College will alter 
its view, but pending the result of the plebiscite the Royal 
College of Surgeons of England is willing to give its Member¬ 
ship to women. The Oomitia of the Royal College of Phy¬ 
sicians of London, which is, of course, a far larger body and 
more representative of corporate views than the Council of 
tbe Royal College of Surgeons of England, has now made 
its reply to tbe petition of the London School of 
Medicine for Women. The Comitia has passed a reso¬ 
lution to admit women to all the examinations of its 
College, bat the effect of this resolution is consider¬ 
ably minimised by tbe adoption of the rider of the 
registrar, Dr. E. Liveing, that it is not intended that 
any, action should be taken under the resolution incon¬ 
sistent with that agreement between the Royal College of 
Physicians of London and the Royal College of Surgeons of 
England by which the Licence of tbe former and the 
Membership of the latter are only granted conjointly. It 
would seem, then, that if the vote of the Fellows and 
Members of the Royal College of Surgeons of England should 
be against the admission of women to the examination for 
the Membership of that College women might still be pre¬ 
vented from being examined for the Licenoe of the Royal 
College of Physicians of London ; they might, however, be 
able to sit for the Membership of that College. We 
conclude as we began—the whole question is in considerable 
confusion. _ 

“RES MEDICA, RES PUBLICA.’’ 

Those of our readers who remember the interesting 
and suggestive address delivered at St. George's Hos¬ 
pital in October last by Dr. William Ewart will welcome 
its publication in pamphlet form by Messrs. Baillii're, 
Tindall, and Cox. Dr. Ewart completely emancipated 
himself from timeworn first of October topics and 
addressed himself to a consideration of some of tbe most 
pressing of the economic evils against which the medical 
profession, as a whole, is called upon to contend. Of some 
of these evils and of the roots from whioh they spring he 
submitted a graphic description to his hearers, and he dis¬ 
cussed in some detail the most serious of the causes which 
interfere with the due recognition and the due remuneration of 



244 The Lancet,] THE ADMINISTRATION OF THE INFANT LIFE PROTECTION ACT. 


[Jan. 25, 1908. 


medical work by the public. He dwelt also upon the remedies 
which might be applied to conditions which all must deplore 
and laid his chief stress upon a higher standard of medical 
education and examination, to be controlled by the State, 
and upon a recognition of the fact that medical services, 
which were formerly rendered chiefly or exclusively to 
individuals suffering from disease or accident, will for the 
future in constantly increasing proportion be rendered to 
the public for the prevention of illness rather than for its 
cure. He called attention to the example set by Harvard 
University in refusing its medical qualifications to students 
who had not graduated in Arts and set aside the question of 
any individual grievances thence arising as being absolutely 
unimportant when compared with the consequent elevation of 
the medical calling. It would, he declared, be an iniquity to 
keep a whole profession in suffering by widening the portals 
for one or two, otherwise able, who happen to lack aptitude 
for drawing, for spelling, or for Greek, or who have been 
misguided in their early education ; and he is evidently of 
opinion that the necessary standards can only be maintained 
and the necessary restrictions enforced by taking the 
business of examination out of the hands of competing 
corporations and by committing it to the State. We cannot 
leave the pamphlet without calling attention to the curioaa 
felicitat of its concluding sentence. Dr. Ewart says of 
Thomas Young, one of the great worthies of the school of 
St. George’s, that he “counted the waves of ether and made 
the Pharaohs speak.” _ 

THE ADMINISTRATION OF THE INFANT LIFE 
PROTECTION ACT. 

At the time of the enactment of the amended Infant Life 
Protection Bill of 1897, which came into operation in the 
following year, we wrote 1 : “Excellent as its provisions are, 
their value is materially diminished by defects in the Act 
which must very seriously diminish its utility. One of these 
consists in the exclusion of single nurse children from the 
Act, the other is the exemption of children for whose 
maintenance a sum exceeding £20 has been paid. The 
effect of these omissions is obvious. The un¬ 

registered orfcche if broken up into its constituent units 
may still continue to flourish unobserved by the eye of 
authority. Nurse children, as is well known, are usually 
illegitimate. They are, as a rule, not desired by their 
parents. If they should be committed to the keeping of 
unscrupulous persons one by one, the law is no longer 
responsible for their safety, which must therefore be at best 
an unknown quantity.' 1 The opinion which we thus strongly 
expressed has not lacked support, as is shown by the fact 
that a further Amendment Bill has been introduced and 
obstructed in the House of Commons in each year since 1901. 
Meanwhile evidence of the urgency of the amendments 
continues to accumulate. Such a piece of evidence is before 
us in the shape of the tenth annual report of Miss Frances 
Zanetti who is inspector under the Act to the Cborlton 
union. She had made visits to various cases in which a 
single child was being reared by foster-parents for a small 
weekly payment. This she had little difficulty in doing 
where the child was being properly looked after, although the 
foster-parents knew that she had no legal right of entry. 
Where her visits were unwelcome she invariably found that 
there was something suspicions about the case. Two of the 
cases which she visited under the Act were sufficiently serious 
to be reported to the National Society for the Prevention 
of Cruelty to Children. One of these was of a terrible 
nature—that of a wasted baby who was found to be the 
fourth illegitimate child of a mother, 22 years old, who had 
been taken home intoxicated the night before the baby 
was born, and since its removal to hospital bad been 

1 The Lancet, Sept. 11th, 1897, p. 675. 


sent to prison for six months for prostitution. It seems 
a moot point whether an asylum for the insane would 
not be a more suitable place for this poor creature. 
Miss Zanetti gives an analysis of 21 cases which she visited 
under the Act, in which 54 children were being tended by 
foster-parents for sums ranging from about 3i. to 7i. weekly. 
Besides these she visited 43 cases which did cot come within 
the provisions of the Act. We hope that many more 
inspectors take so liberal a view of their duties but it ought 
not to be left to the good-will of these officers and the 
consent of the foster-parents for “one child” cases to 
be visited. It is satisfactory to record that a deputation 
to the Home Office of the Poor Law Unions' Association 
has been informed by Mr. Herbert Samuel, M.P., 
that the amendment of the Infant Life Protection Act 
is to be included in the “Children’s Bill” which is to be 
introduced next session. In a matter of common humanity, 
such as this is undoubtedly, we trust that it will be found 
possible to bury the party hatchet for the short space of time 
that would be required to pass it into the statute book. The 
sacrifice of Bills framed in the urgent interest of national 
hygiene to the idol of party feuds takes place with monotonous 
regularity—we need only instance the smothering of the Pure 
Milk Bill of 1907—but when it is a matter of the safeguard¬ 
ing of young children against cruelty and what may almost 
amount to slow murder by neglect we fancy most politicians 
would seek to alter the law if they were thoroughly aware of 
the evils which its present imperfect state tacitly allows. 

TEMPORARY GASTROSTOMY'IN THE TREATMENT 
OF PERFORATION OF THE STOMACH AND 
DUODENUM. 

In the Northumberland and Durham Medical Journal 
for December last Mr. W. G. Richardson has described 
an ingenious modification of the treatment of perforation 
of the stomach or duodenum in cases usually considered 
hopeless. If perforation of a gastric or duodenal ulcer 
occurs the peritoneal cavity is generally flooded with 
the contents of the stomach and death will follow 
if the patient is not relieved by operation. When the 
patient has recovered from the shock there is, as Mr. 
Richardson points out, a good prospect of recovery if 
an operation be performed within from six to nine hours, 
but after nine hours the prospect is almost hopeless. In 
the latter class of cases the patients are nearly dead when 
seen by the surgeon. The usual treatment is to open the 
abdomen, suture the perforation, and thoroughly wash out 
and close the abdomen. Sometimes drainage-tubes are placed 
in the flanks and pelvis. After the operation thirst is insati¬ 
able and is allayed by giving sips of water, generally warm. 
Nutriment is supplied in the form of enemata. Four years 
ago Mr. Richardson adopted the following method. If the 
perforation is on the anterior surface of the stomach he 
passes a large indiarubber catheter through it and secures 
the catheter in position by a surrounding purse-string 
suture. The catheter is passed carefully into the cardiac 
portion of the stomach—a point of great importance, as 
otherwise the stomach cannot be emptied. The operation is 
completed in the ordinary manner, with the exception that 
the stomach is sewn to the incision in the middle line as in a 
case of gastrostomy. Before the patient leaves the table 
his stomach is washed out with hot (bicarbonate of 
sodium solution by placing a funnel in the end of the 
oatheter and pouring in the solution. When nearly 
a pint has been introduced the funnel is lowered 
over the patient’s side and the fluid siphons out. This is 
repeated until the fluid returns quite clear. After being 
put to bed the patient begins to cry out for water 
and is allowed to take it in large quantities. Mr. 
Richardson gives cold water because it is this alone for 








The Lancet,] AN ORGANIC SERUM FOR THE TREATMENT OF SYPHILIS. [Jan. 25, 1908. 245 


which the patient craves. If bo much water is taken that 
the stomach becomes distended the catheter forms a perfect 
safety valve through which the stomach can be emptied at 
once. Thus the most urgent symptom following the opera¬ 
tion can be relieved with safety and what is evidently a want 
of nature supplied. With regard to food, Mr. Richardson 
considers nutrient enemata as a poor substitute for food 
absorbed by the proper organs. When the ulcer is closed 
in the ordinary manner the surgeon dare not feed the 
patient by the mouth because after the operation its 
functions, like those of any injured organ, are im¬ 
paired and it can only partially digest food. Thus food, 
if given, would accumulate, ferment, and do great harm 
unless removed by a stomach-pump—a dangerous operation 
in the circumstances. Therefore nutrient enemata have to be 
relied upon. By making use of the ulcer as a gastrostomy 
opening Mr. Richardson claims that the danger of feeding by 
the stomach is removed and at the same time an amount of 
nourishment is given, which could not be given by the rectum. 
He feeds the patient by the mouth every four hours with 
beef-tea and milk. Thus the pleasure and stimulation 
arising from the act of swallowing are preserved. Before 
each feeding the stomach is washed out with a solution of 
bicarbonate of sodium, so that what remains of the previous 
meal is removed. Moreover, the patient is not disturbed as 
when enemata are given bnt, on the contrary, is afforded 
great comfort. The washing out with bicarbonate of sodium is 
so comforting that the patients often ask the nurse to repeat 
it. After four or five days, when the patient is seen to be 
on the road to recovery, the catheter is withdrawn. The 
opening closes immediately, no leakage takes place, and no 
hernia follows. Mr. Richardson’s experience of this method 
is encouraging bnt not yet sufficient to furnish statistics as 
to its advantages. _ 

AN ORGANIC SERUM FOR THE TREATMENT 
OF SYPHILIS. 

The official bulletin of the Society of Biology of Paris 
in its account of the proceedings of a meeting held on 
Dec. 2lst, 1907, gives a paper by Professor Hallopeau, 
physician to the Hospital of St. Louis and a Member of the 
Academy of Medicine. The paper dealt with the results 
obtained in syphilitic patients under the care of Professor 
Hallopeau by the use of an organic serum prepared 
by Dr. Query who in a paper read before the society 
on March 9th last gave as his conclusion that the 
pathogenic agent of syphilis was a bacillus which repro¬ 
duces itself by spores and of which the spirillum of 
Schaudinn is an involutionary form. Confirmatory evidence 
of the truth of this theory has since been obtained 
by Leuriaux and Geest, Bertarelli and Volpino, Benda, 
Krzyzstalowicz, and Siedlecki. The isolation of the bacillus 
in question has enabled Dr. Qufiry to prepare an organic 
antisyphilitic serum which is prepared and used after the 
same method as the well-known antidiphtheritic serum. 
Professor Hallopeau mentioned that 20 cares had been 
treated with the serum and that a progressive improvement 
had been observed in every one of them. To use his own 
words: “The ameliorations observed should not be laid to 
the account of the normal evolution of the disease, for I have 
noted them as taking place from the very beginning of the 
secondary symptoms and they therefore indicate a definite 
action of the serum upon the evolution of the disease. As to 
whether the ameliorations will be lasting, my studies in the 
question are at present too recent to give a definite answer.” 
Dr. Qufiry in a note which he has sent to us allows that at 
present the word “ cure ” should not be employed with 
regard to the action of the serum upon syphilis, but he has 
had under his personal notice certain patients who were 
treated four yearn ago and in whom there has been no 


apparent relapse. Professor Hallopeau concludes his paper 
by saying that the serum should be used in association with 
atoxyl or mercury and iodide of potassium. There is no 
incompatibility between the treatments and it is necessary 
to make use of every available weapon against such a 
resourceful enemy as syphilis. 

AN AUSTRIAN PROFESSOR'S REMINISCENCES. 

Professor Moritz Benedikt of Vienna has published his 
reminiscences in a lengthy but interesting volume. 1 Bom 
in 1835 in Eisenstadt in Odenburg, now known by its 
Hungarian name of Kis-Marton, his childhood was passed 
under the feudal and autocratic regime which then ruled in 
Austria, his boyhood during the stirring times of the revolu¬ 
tion, while during his student career at Vienna the uni¬ 
versity of that city owned some of the greatest names in its 
history. A man of wide interests, not confined to purely 
professional subjects but embracing literature, art, politics, 
and music, be has been also through two military campaigns, 
those of 1859 and 1866, and has travelled widely in most of 
the European countries, and having in the course of his long 
and active life met many notable personalities on more or 
less intimate terms he has a great many interesting 
reminiscences to record. His descriptions of his early 
school days and of bis later studies at the gymnasium or 
high school afford noteworthy pictures of the educational 
methods of the first half of the nineteenth century in Austria. 
During the time when he was at the gymnasium at Vienna, 
between 1845 and 1853, the revolution occurred, and he 
has various anecdotes of those troubled times to relate. 
Apparently of studious habits from early in his life, he 
studied languages assiduously and acquired a considerable 
knowledge of the literature of Greece, England, and France, 
as well as of the writings of German poets and historians. 
Of the Greeks he liked best Homer, Sophocles, Euripides, 
and Demosthenes. In English he read widely. He states 
that Shakespeare was his poetical and psychological bible, 
and in his anxiety to read his works in the original he bought 
a copy of “Macbeth” after taking a few English lessons 
and looked out over 300 words in the dictionary, writing 
their meaning beside the text in shorthand. By reading this 
play through several times he so increased his vocabulary 
that he was able to read the other plays without any con¬ 
spicuous difficulty. He naturally had a great affection for 
Goethe and Schiller and writes most appreciatively of 
Grillparzer and Kleist. Heine he regards as the greatest 
lyrist since the Psalmist. A most pleasing section of Pro¬ 
fessor Benedikt’s book is that devoted to his years as a 
student at the University of Vienna. His brief character 
sketches of some of the distinguished professors under whom 
he studied serve to bring before us very clearly some of the 
men who helped to give Vienna its great reputation as a 
medical centre. Among these we may mention Hyrtl, 
Briicke, Rokitansky, Skoda, Arlt, and Oppolzer. He also 
came into relation with Semmelweis, whose tragic story he 
refers to in feeling terms, and was intimate with Hebra and 
Karl Ludwig. Hyrtl possessed remarkable abilities as a 
lecturer and in the preparation of anatomical specimens. 
Benedikt describes him as an artist in ail that he undertook. 
He was very popular among his students bnt not among his 
professorial colleagues. Briicke is represented as a man of 
somewhat cynical, unattractive personality whose lectures 
were often beyond the scope of his audience. In spite of 
these characteristics and of his severity at examinations, he 
seems to have acquired the respect of his students. Of 
Rokitansky, Benedikt writes with enthusiasm and extols his 
pioneer work in pathology He was not a great lecturer 
but was a most thorough and illuminating worker. 

1 Aus Melnem Leben Erinneruugen und ErOrterungen, von Dr, 
Moritz. Benedikt. Vienna: Ernst Stulpn&gel. 1906. 



246 The Lancet,] 


THE BARNSLEY DISASTER. 


[Jan. 25,1908. 


Skoda and Oppolzer, both great men, are placed in 
a certain antithesis to one another: the former as a 
great thinker and pioneer, the latter as a fascinating 
personality and a successful practitioner ; the one teaching 
the student to observe and to think, the other to apply his 
knowledge practically. Oppolzer’s clinic was a favourite 
resort for the students; he seems to have been a highly 
instructive teacher. A great impressionist, he observed 
rapidly and arranged his facts with the utmost certainty. He 
was, moreover, extremely fertile in suggestions for treatment. 
Professor Benedikt describes also his experiences at the 
wars, and his subsequent appointment at Vienna, his work 
upon electro-therapeutics, upon the medico-legal relations of 
insanity, and upon ophthalmology and diseases of the nervous 
system. He travelled in Italy, Sicily, France, Turkey, 
Russia, Scandinavia, Holland, Spain, and Great Britain, and 
of all the places be visited he has much of interest to relate. 
Of Great Britain he seems to retain most pleasant memories 
and he confesses that his preconceived notions of 
our country and ourselves he had to modify after his 
visits. Our great national collections Ailed him with wonder 
and admiration. For our various monuments and fountains 
in public places he has much praise and he mentions in par¬ 
ticular the Albert Memorial in London, the Walter Scott 
monument in Edinburgh, that of O'Connell in Dublin, and 
the Knox statue in Glasgow. He acquits us of the hypocrisy 
with which continental nations are fond of accusing us. He 
commends the English manner of writing scientiAc papers 
and confesses to having taken Faraday as his model. He 
thinks that English scientiAc men can differ with less 
rancour than those of some other nations and that they are 
more inclined to wait for evidence before embracing 
novelties. Professor Benedikt’s book is written in an easy, 
chatty style and makes most interesting reading. He is 
evidently a man of strong opinions, but sincere and earnest, 
and can point to a life of good and active work. 


THE BARNSLEY DISASTER. 

A heartrending catastrophe occurred on Jan. 11th at 
Barnsley, resulting in the death of 16 young children. The 
Public Hall, Barnsley, had been rented by the World’s 
Klnematograph Company for a series of entertainments and 
a special matin&e bad been arranged for Saturday, Jan. 11th, 
at very low rates of admission, the charge for a gallery 
tioket being only Id. Apparently over 1000 persons, nearly 
all children, applied for admission to the gallery, the seating 
accommodation of which is 400 adults. When some 433 
children had been admitted and children were still 
mounting the stairs some one apparently at the top 
of the stairs turned the ohildren back and they 
were given the idea that they would be admitted to 
the pit. The children thus trying to descend the stairs 
got jammed with those trying to come up, some of them fell, 
and in a few moments there was a heap of struggling 
children. As a result 16 were killed and some 30 others 
more or less seriously injured. At the inquest, which was 
concluded on Jan. 17th, the jury found that the children 
were suffocated through negligence in not providing 
sufficient staff to regulate the children on the staircase, 
this resulting in a stampede of children on their being 
turned back. The foreman added that the jury did 
not think the negligence criminal or that the con¬ 
struction of the staircase was in any way answerable. 
There is no need to insist upon the horror which such a 
disaster inspires. It is a comfort to know that the con¬ 
struction of the staircase does not seem to have been faulty 
and the blame, if blame can be attributed to anyone, must 
lie Arst with those who seem to have allowed their children 
to go without proper escort, and secondly with the authorities 
of the entertainment in not seeing that there were sufficient 


persons to regulate the entry of would-be sightseers. Of the 
16 children who were killed 10 were under seven years of age, 
the eldest was only 11 years old, and the youngest was 
four. Apparently most of the children who went to the 
show were in charge of other children aged as a rule about 
12 or 13 years, and at least two of the children who were 
killed were in charge of other children aged 12 years. We 
are quite aware of the difficulty which the working classes 
experience in looking after their houses and their children 
too. Mere babies may be seen any day of the week wander¬ 
ing about the London streets and in and out of the traffic, 
and it is a perpetual marvel that there are not more lives 
lost than there are. But if the sad occurrence upon which 
we write will bring home the responsibilities to those who 
have the charge of children the 16 little Barnsley victims 
will not have yielded their lives in vain. 


DISSEMINATION OF ENTERIC FEVER DUE TO 
A “TYPHOID CARRIER.” 

For several months medical authorities have been puzzled 
by outbreaks of enteric fever in a large institution on the 
outskirts of Bristol—the Brentry Home for Inebriates. 28 
cases have arisen and the circumstances have been so peculiar 
that the medical officer of health of Bristol, Dr. D. S. Davies, 
suspected that the cause of the infection must be an 
unsuspected “bacillus carrier '' capable of conveying infec¬ 
tion to others though not suffering from the disease. His 
view has been justiAed by investigation, the source of the 
repeated attacks at Brentry having been traced to a woman 
in the institution who has not recently suffered from enteric 
fever but who has shown herself an effective disseminator 
of the typhoid bacillus. To the Bristol health committee 
recently Dr. Davies made a special report on the oase. It 
is as follows:— 

In consequence of a continuing outbreak of enteric fever at this 
institution, which led to 28 cases and two deaths between September, 

1906, and November. 1907, and as the infection was being introduced 
into the Bristol district, end part of the institution is within the city, I 
took up the investigation of the cause in November, as every effort on 
ordinary lines up to that time had failed to account for, or to stop, the 
spread of the disease. As I advised the chairman on Nov. 13th, the 
circumstances, judged from quite recent pathological work in Germany, 
seemed to me to point to the existence of a '‘carrier*’ case of chronic 
typhoid who was intermittently but unconsciously Infecting the food 
or milk. Acting in conjunction with the Homo Office medical 
inspector, I Instituted a special pathological inquiry into the condition 
of certain inmates, and late in December the inquiry proved that one 
of those to whom the circumstantial evidence had pointed was- 
undoubtedly a typhoid “carrier." This case had been tentatively 
isolated on’Nov, l3th and I ventured to predict that no further cases 
would occur beyond the next incubation period. Tbe last case was on 
Nov, 24th, and from then till now the institution has remained free. 
This new chapter in the history of typhoid infection is of immense 
importance, as we now have the key to many of these intermittent or 
droppiog outbreaks which have hitherto defied explanation. Beyond 
the German cases, one in New York and one in Scotland. I am unaware 
of any other successful investigation of typhoid outbreaks on this line 
of research. 

Mr. G. Wintle, the chairman of the health committee, con¬ 
gratulated Dr. Davies on his success in making this im¬ 
portant discovery, and Dr. Davies, in reply, said that the 
matter was engaging the attention of a special department of 
the Local Government Board. The discovery that a certain 
proportion of those who have suffered from enteric fever 
may continue to harbour bacilli and to discharge them inter¬ 
mittently from the body long after the actual convalescence 
is one of great importance in regard to the spread of the 
disease, since it has now been definitely proved that such 
cases may be the unsuspected sources of widespread infection. 
The recognition and adequate treatment of such persons, to 
whom the name of “ typhoid carriers ” has been applied, is 
obviously a matter of great praobic&l importance. A con¬ 
siderable amount of research has been carried out on this 
subject in Sbrasburg under the auspices of the German 
Imperial Board of Health by Kayser, 1 to whom is due the 

i Arbeiten aus dem Kaiserllchen Gesundheltsamte, Bandxxv., Heft \ 

1907. 




Tot Lanokt,] 


THE TRAFFIC IN OLD HORSES.—A CURIOUS ECONOMY. 


[Jan. 25,1908. 247 


credit of drawing attention to these cases and their import¬ 
ance as centres of infection. He states that 93 per cent, of 
persons convalescent from enteric fever do not discharge 
typhoid bacilli in the stools after the fifteenth day from the 
time when the temperature has fallen to normal, and further 
that of the remainder many soon cease to harbour the bacilli, 
leaving about 3 per cent, of carriers. Klinger after exa¬ 
mining the stools of a large number of cases of persons who 
had suffered from enteric fever found that only 1 ■ 7 per 
cent, became chronic “ typhoid carriers,” a smaller per¬ 
centage than that found by Kayser but the result of a more 
extended examination. From the intermittent character of the 
discharge of bacilli by these “ typhoid carriers ” in the faeces 
it is suggested that it is in the gall-bladder that the 
organisms live and multiply. It is well known that bile is a 
good culture medium for them, that they are not infrequently 
found in gall-stones, and Dehler has treated cases of “ typhoid 
carriers ” by draining the gall-bladder, after which operation 
the bacilli disappeared in the course of a few months. That 
the bacilli may also remain in other situations for long periods 
is proved by the case recorded by Mr. L. S. Dudgeon and 
Dr. R. E. G. Gray 2 in which typhoid bacilli were recovered 
from bone lesions three and a half years after an attack of 
enteric fever. In an annotation 3 commenting upon the case 
we pointed out the necessity for dealing effectively with all 
the discharges from patients suffering from that disease. 
The question of the recognition of these cases is obviously 
one of importance and Kayser suggests that the stools and 
urine of convalescent cases of enteric fever should be 
examined at intervals of a fortnight and three weeks after 
the temperature has fallen, and if these examinations prove 
negative a third trial should be made after several months. If 
any one of the three gives a positive result the examination 
should be repeated at weekly intervals until three consecutive 
negative results are obtained. He also recommends that 
known ' 1 typhoid carriers ” should be kept under bacterio¬ 
logical supervision. Even by such drastic methods it is not 
possible to be certain of discovering all the cases, and 
it is obvious that if such a rigorous control is to be kept 
over the patients who have suffered from enteric fever it 
is quite beyond the province of the ordinary practitioner 
and must come under the control of the health authorities. 
An equally difficult problem is offered in the treatment of 
these cases. Being apparently in perfect health they are 
not likely to submit to treatment by antiseptics or te the 
more drastic surgical procedure adopted by Dehler, even if 
these methods are found to be effective. At present all that 
can be done is to discover them and to prevent them from 
becoming sources of infection, as the instance above quoted 
shows. _ 

THE TRAFFIC IN OLD HORSES. 

Thebe are certain offences against humanity and civilisa¬ 
tion to which we are obliged periodically to refer and the 
brutalities incidental to the shipment of old and worn-out 
horseB have been brought before our readers on many pre¬ 
vious occasions. The latest case of this kind of which we 
have knowledge occupied the attention of Mr. Biron at Old- 
street police court on Jan. 16th when a man named Spratt 
alias Sharpe was charged with cruelty to a horse by leading 
it in a lame condition through the streets under the Cruelty 
to Animals Act. The horse was, as usual, destined to be 
shipped abroad. We pointed out in The Lancet of April 11th, 
1903, p. 1045, that this is the only Act which covers the 
particular offence, for the Order of the Board of Agriculture 
issued at the beginning of 1899 to deal with the matter 
only stated that it should be unlawful to convey from 
any port in the British Isles to any place outside them 
“any horse which, owing to age, infirmity, illness, fatigue, 

1 The Lancet, July 7th, 1906, p. 26. 

* The Lancet, July 7th, 1908, p. 36. 


or any other reason, cannot be so conveyed without cruelty 
during the intended passage and upon landing.” In the 
present case it was proved that the man had been twice 
convicted of cruelty in the same connexion. Mr. Biron 
sentenced him to three months’ hard labour after making 
some remarks such as we have frequently expressed in these 
columns. 1 He said that he could not understand why the 
people behind the men employed to take such poor things 
through the street were not proceeded against. The very 
shippers and people on the boats muBt know that they 
had been exposed to great cruelty to make them travel. 
The trade was shocking, disgusting, and horrible. He 
could only make an example of the prisoner as the 
police said that there were difficulties in the way of 
reaching the men who hired him, though he could not 
understand why. We cannot understand why, either. Surely 
it is desirable that legislation should render the export of 
old horses for foreign food a criminal offence and we urge 
on the present Government the expediency of bringing in a 
small Bill, which would probably become law with little 
controversy, to abolish entirely this traffic. 


THE FOURTH INTERNATIONAL CONGRESS ON 
ELECTROLOGY AND RADIOLOGY. 

The Fourth International Congress on Electrology and 
Radiology will be held at Amsterdam from Sept. 1st to 5th, 
1908. The results of the three former Congresses—at Paris 
in 1900, at Berlin in 1903, and at Milan in 1905—having 
proved their utility and importance, the Fourth Congress 
will be organised on the same lines. The ■ programme 
will comprise electrophysiology and electropathology, electro¬ 
diagnostics and electrotherapeutics, diagnostics and thera¬ 
peutics of roentgen rays, .the study of diverse radiations, 
and medical electrotechnics. In conjunction with the 
Congress an exhibition will be arranged of new or modified 
apparatus used in clinical and laboratorial work and also a 
collection of important radiographs. The Congress and the 
exhibition will be held in the University of Amsterdam, the 
executive committee being Professor Dr. J. K. A. Wertheim 
Salomonson, president, and Dr. J. G. Gohl and Dr. F. S. 
Meijers general secretaries and treasurers. Further informa¬ 
tion can be obtained from the secretaries by addressing them 
at Vondelstraat 53, Amsterdam. 


A CURIOUS ECONOMY. 

The Daily Telegraph of Jan. 10th prints a ourious story of 
Post Office economy contributed by a correspondent. The 
General Post Office, it says, has ceased to supply “dampers’’ 
to the clerks for sorting papers quickly, the official reason 
being that “dampers cost money, and we already pay for the 
use of fingers.” That is well enough but the department 
does not pay for the use of tongues for other purposes than 
talking. The clerks are apparently alive to this and have, 
aocording to our contemporary’s informant, improvised 
dampers by doubling several sheets of blottiDg-paper together 
to avoid the necessity of licking their fingers for the work, 
with the result that the makeshift is likely to cost more than 
the proper appliance. If this story be correct we can only 
hope that the authorities will speedily restore the old dampen 
and will do everything in their power to discourage the 
habit of finger-licking. Not only ie it dirty in itself but 
the fact that the same forms may be handled by the 
licked fingers of different men at a short interval makes 
It a possible source of infection. Tuberculosis is far from 
uncommon in the Post Office service and it is not unlikely 
that the sick-pay given to one man whose lungs became thus 
infected would go a long way towards the provision of 
dampers throughout the department. The principle, too, is a 

i Thk Lancet, April 13th, 1901, p. 1095, and April llth, 1903, p. 1045. 




248 The Lancet,] PLAGUE AT ACCRA.—UNCERTIFIED CAUSES OF DEATH IN 1907. 


[Jan. 25, 1908. 


thoroughly unsound one; what was good enough for our 
fathers is not good enough for us in matters of hygiene, 
seeing how much fuller is our knowledge of the importance 
of little things than was theirs, and in this instance appa¬ 
rently a Government department seeks to deprive its 
employees of a hygienic advantage which even their fathers 
enjoyed. 

PLAGUE AT ACCRA. 

The following telegram from the Acting Governor of the 
Gold Coast was received at the Colonial Office on Jan. 15th : 
“Total number of deaths from plague up to midnight, 14th 
January, fifteen. Thirteen natives in Contagious Diseases Hos¬ 
pital and Isolation Camps, one death reported this morning. 
Garland (Deputy Principal Medical Officer) believes progress 
of plague effectively checked. Sufficient number of medical 
officers here. In order to get into closer touch with natives 
have authorised temporary employment of Papafio, retired 
medical officer, Bruce, native medical practitioner, also 
Fisch, German doctor of some scientific attainments. There 
are now six doctors available at Accra Large number of 
dead rats has been observed, Accra ; every endeavour has 
been made from the beginning to exterminate rodents.” 
The Secretary of State for the Colonies has appointed Dr. 
W. J. R. Simpson, professor of hygiene at King’s College, 
London, and lecturer in tropical hygiene at the London 
School of Tropical Medicine, to proceed to the Gold Coast 
to assist in combating the present outbreak of bubonic 
plague at Accra. He left for the Gold Coast by the 
steamship Mendi on Jan. 18th and was accompanied by 
Dr. J. A. Haran of the medical service of the East 
Africa Protectorate, who hss been selected on account of 
his experience in dealing with plague in that dependency. 
Dr. Simpson’s mission to Accra shows that the Govern¬ 
ment wishes to leave nothing undone that can possibly 
be of service to our Gold Coast Dependency but implies 
no want of confidence in the ability of the medical staff 
now on the spot. Dr. Simpson will probably also viBit 
other towns in West Africa with a view to advising in regard 
to questions of sanitation. Since his departure two official 
telegrams have been received at the Colonial Office show¬ 
ing that on Jan. 20th six, and on Jan. 21st two, deaths 
occurred from bubonic plague. On the latter date the return 
shows 48 cases isolated. _ 

UNCERTIFIED CAUSES OF DEATH IN 1907. 

Although successive Governments have failed to take any 
action for giving effect to the recommendations made in the 
report issued by Sir Walter Foster’s Committee in 1892 on 
the Certification of Causes of Death the nnmber and pro¬ 
portion of uncertified deaths in England and Wales have 
since then constantly declined under the influence of the 
attention given to the subject in the reports of the Registrar- 
General and of the local medical officers of health. In the 
last issued annual report of the Registrar-General (1905) it 
was shown that the proportion of uncertified deaths steadily 
declined from 1 • 81 per oent. in 1900 to 1 ■ 62 in 1905 ; his 
quarterly returns for 1906 showed a further decline to 1 • 53, 
and during the first three quarters of 1907 the percentage 
of uncertified causes of death did not exceed 1'44 
The quarterly and weekly returns for 1907, moreover, 
enable us to consider and to compare the varying proportions 
of uncertified deaths in the 76 large English towns dealt 
with in those returns during 1907. The mean percentage of 
uncertified deaths in these 76 towns was 1 • 1 in 1904 and in 
1905, 1 -0 in 1906, and further declined to 0'9 in 1907. The 
mean proportion of uncertified deaths has thus been con¬ 
siderably lower in these 76 towns than the mean rate in 
the whole of England and Wales in each of the last four 
years, and it is satisfactory to note that the proportions con¬ 
tinue to decline in the large towns as well as in the whole of 


England and Wales. It is, however, still more important 
that attention should be called to the wide variations in the 
reduced proportions of uncertified deaths still prevailing 
among these 76 towns. During 1907 all the causes of 
deaths registered in Croydon, Tottenham, Southampton, 
Wigan, Hornsey, Devonport, Ipswich, and Great Yarmouth 
were duly certified, and all but one of the causes of death 
registered during the year were duly certified in West Ham, 
Brighton, Walthamstow, Plymouth, and Bournemouth. In 
London the proportion of uncertified deaths last year did not 
exceed, as we recently pointed out, 1 per 1000 deaths regis¬ 
tered, whereas the proportion had been equal to 2 per 1000 
in each of the three preceding years. In many other of the 
76 towns, however, there is still a marked excess of un¬ 
certified deaths, showing a want of appreciation of the 
importance of the due certification of all causes of death 
either by a registered medical practitioner who has been in 
attendance during the last illness of the deceased or 
by a coroner after inquest. The proportion of uncertified 
deaths during last year was equal to 2'7 per cent, 
of the deaths registered in Liverpool and in Bootle, 
to 2 ■ 8 per cent, in Sunderland and in Burton-on-Trent, 2 ■ 9 
in Preston, 3-3 in Birmingham, 3’5 in St. Helens, 4-4 in 
Gateshead, 4'5 in Warrington, and 5 • 1 in South Shields. 
It would be useful as well as interesting to have some 
explanation of the fact that while it has been found possible 
to secure the due certification of all causes of death in the 
eight above-mentioned towns, and of all bnt 1 per 1000 in 
very many other towns, the proportion of uncertified deaths 
last year should have exceeded 27 per 1000 in the towns 
referred to above, ranging up to 51 per 1000 in South 
Shields. It is beyond question that even under the present 
legislative arrangements due cooperation between sanitary 
authorities, medical officers of health, and coroners would 
undoubtedly reduce the number of uncertified deaths to an 
inconsiderable minimum. _ 

“IONIC MEDICATION.’’ 

In addition to the discovery of new methods of treatment 
in medicine and surgery it is interesting to note how modern 
scientific ideas bring about the revival of an old method 
which, probably for the want of a better knowledge, had 
been allowed to fall into disuse. An instance of this is the 
local introduction of drugs through the unbroken skin with 
the aid of the electric current. This is generally known 
as cataphoresis, and the method is nearly as old as our 
knowledge of the electrolytic process itself. At one time it 
was employed to a considerable extent both at home and 
abroad, but it was not until Professor Leduc of Nantes 
brought his encyclopaedic knowledge of electrolysis to bear 
on the Bubject that it received a more scientific foundation 
and a fresh lease of life. In the electrolysis of a normal 
saline solution there is a migration of ions; the basic 
(sodium) ions travel from the anode to the cathode, while 
the acid (chlorine) ions move from the cathode to the anode. 
This process is not stopped by the intervention of animal 
membrane or skin. As being more in harmony with 
modern ideas the method is semetimes spoken of as “ ionic 
medication.” As our knowledge and experience increase 
there is every probability that this principle will be employed 
in a gradually increasing degree. It has been found very 
useful, for instance, in the stiffness following a severe 
sprain of the ankle-joint: a pad wet with a watery solution 
of iodine was placed over the part and covered with 
a metal plate connected to the positive pole. Cases of 
trigeminal and supra-orbital neuralgia have been relieved by 
the similar use of quinine or salicylic acid after all other 
methods had failed. Local anaesthesia can be produced with 
a solution of cocaine. Small and superficial rodent ulcers 
are easily cured by anyone who has had a little experience. 
Here a solution of zinc chloride is used and the zinc ions are 




The Lancet,] 


THE LAHORE MEDICAL COLLEGE. 


[Jan. 25, 1908. 249 


driven into the surface of the ulcer which has been pre¬ 
viously cleaned. If the ulcer is small and the application is 
carefully and thoroughly done, once only will be found 
sufficient to canse its disappearance. It is probable that 
it will be applied successfully in other conditions such 
as ringworm, and lupns vulgaris would appear to be one 
likely to be influenced favourably by the local introduction of 
some ion prejudicial to the life of the bacillus. There should 
also be a large field open to investigation in regard to its use 
in gouty and rheumatic deposits. Theoretically an objection 
to this method is that the substance introduced would be 
washed away by the circulation before it had penetrated 
very deeply. While this is no doubt true to a certain extent 
it is none the less true that the process at times enables a 
more pronounced local action to be produced of, say, iodine 
than is possible by the administration of iodides in the usual 
way. _ 

ROYAL COLLEGE OF SURGEONS OF ENGLAND: 

THE LECTURE ARRANGEMENTS FOR 1908. 

The annual course of lectures to be delivered at the Royal 
College of Surgeons of England will commence on Feb. 10th 
and will be continued on each Monday, Wednesday, and Friday 
until March 20th. The lecture hour will be 5 r. m. each day. 
Erasmus Wilson lectures : Mr. S. G. Shattock will deliver 
one lecture on Ovarian Teratomata on Feb. 10th; Dr. 
J. W. H. Eyre, one lecture on the importance (surgically) of 
the Pyogenetic Activities of Diplococcus Pneumonias on 
Feb. 12th ; and Mr. L. S. Dudgeon, one lecture on Infection 
of the Urinary Tract due to Bacillus Coli, on Feb. 14th. 
Hunterian lectures : Dr. Victor Bonney will deliver three 
lectures on a Study of the Connective Tissues in Car¬ 
cinoma and in Certain Pathological Conditions preceding 
its Onset, on Feb. 17tb, 19th, and 21st; Mr. Donald J. 
Armour, three lectures on the Surgery of the Spinal 
Cord and its Membranes, on Feb. 24tb, 26th, and 28th ; 
Dr. F. O. Shrubsall, three lectures on the Physical 
Anthropology of the Pigmy and Negro Races of Africa, 
on March 2nd, 4th, and 6th ; Mr. A. Ralph Thompson, two 
lectures on the Anatomy of the Long Bones relating to 
certain Fractures, on March 9th and 11th ; and Mr. W. S. 
Handley, one lecture on the Natural Cure of Cancer, on 
March 13th. Arris and Gale lectures: Dr. F. A. Bain- 
bridge will deliver one lecture on the Pathology of Acid 
Intoxication, on March 16th, and Mr. M. Greenwood, jun., 
two lectures on the Physiological and Pathological Effects 
which Follow Exposure to Compressed Air on March 18th 
and 20th. _ 

THE LAHORE MEDICAL COLLEGE. 

There is a quaint old saying or proverb to the effect that 
“Soft words butter no parsnips." Doubtless the apothegm 
is an onomatopoetic corruption of another in a different 
language, couched in more dignified terms and possibly 
possessing a different meaning, but be this as it may the 
modern meaning was well exemplified at the annual prize 
distribution of the Lahore Medical College which took 
place some days before Christmas. The Principal of the 
College, Colonel F. F. Perry, I.M.8., in his introductory 
speech said : ‘ ‘ There is no need for me to emphasise the 
fact that medicine is a progressive science and that the 
teaching of medicine becomes daily more elaborate 
and complicated. I will not say that the Lahore 
Medical College and School have been so far faoile 
princeps in India, but I think I can justly claim 
for them that they have been, and are, second to none. 
In order to maintain this position it is necessary that we 
Bhould keep up with the times, and in order to do this im¬ 
provements and changes are essential in the near future.” 
It was cot in this admirable little speech that the soft words 
which do not bntter parsnips made their appearance; they 


became apparent at once in the reply of the Lieutenant- 
Governor of the Punjab, Sir Denzil Ibbetson. “ I have 
always regarded,” he said, “the diffusion of medical and 
surgical knowledge as one of the best things we have done 
in India, and one great advantage attaching to medical educa¬ 
tion in this country is that it stands absolutely apart from 
all political currents. I should like to see the work enor¬ 
mously extended. We have been told by Colonel Perry of 
the growth and development of the College in the last 
50 years, but I should like to see five times the present 
number of students in attendance. I should like to see 
competent medical aid provided for every class of the popu¬ 
lation, and indeed for every individual who desires to avail 
himself of it, but if this is to be achieved we must mainly 
rely upon Indian agency for the expansion. What India 
particularly wants in this direction at present is cot more 
official medical officers but more private medical practi¬ 
tioners. Trained young men in large numbers are wanted 
to set up in medical practice on their own account. The 

process has been begun . but I want to see more of the 

young men who come here to study and to qualify start 
while in their youth upon a career of private practice instead 
of fixing their aims upon official employ.” So far so good. 
Nothing could be more admirable than the sentiments 
which Sir Denzil Ibbetson eloquently expresses. It is 
quite within the range of possibility that among his 
hearers there may have been some who looked forward 
with joy to an announcement that the purse-strings of 
the sympathetic Governor were about to be relaxed. 
If such there were they Boon were sadly disillusioned. 
“Well now, gentlemen,” continued the speaker, “Colonel 
Perry has told us of changes and improvements and has 
asked for my interest and sympathy. I promised him both 

in the fullest measure. But, gentlemen, you are all 

well acquainted with the serious nature of the present 

financial situation. This is a lean year . there is 

practically no hope that the Government will be able to 
provide a large sum of money for improvements in 
this College during the present financial year, and prob¬ 
ably not during the next financial year, but while 
I am obliged to say that let me also say that the 
proposed changes undoubtedly have my sympathy and 
interest, and that when the time comes I will do my best." 
These were soft words but it seems a pity that the leading 
medical college must be starved. 


A telegram from the Acting Governor of the Gold Coast 
received at the Colonial Office on Jan. 18th states that on 
Jan. 17th there were 4 deaths from plague. The total number 
of natives in hospital is 9, while 41 are isolated. A further 
telegram states that on Jan. 18th there was 1 death from 
plague. 17 natives were in hospital and 41 were still 
isolated. The Department of Public Health for Queensland 
in a bulletin dated Dec. 14th, 1907, states that a case of 
plague at Cairns was reported on Nov. 23rd, 1907. The 
patient died on Nov. 30th. The case which occurred 
previously to this one at Cairns was reported on Oct. 8th, 
1907. 


The Medical Inspection of School Children. 

—At a meeting of the Taunton town council held on 
Jan. 14th it was decided to appoint Dr. H. J. Alford, the 
medical officer of health, to be medical inspector of the 
school children of Taunton at a commencing salary of £100 
per annum.—A joint conference between representatives of 
the Monmouthshire education committee and the sanitary 
committee of the Monmouthshire county council was held at 
Newport on Jan. 17th to consider the question of the medical 
inspection of children attending the Monmouthshire schools. 
After some discussion it was decided to recommend the 
appointment of a chief medical officer with two assistants to 
carry out the work. 











250 Tag Lancet,] REPORT FOR 1906 OF THE ADMINISTRATIVE COUNTY OF LONDON. [Jan. 25, 1908. 


ANNUAL REPORT FOR 1906 OF THE 
MEDICAL OFFICER OF HEALTH 
OF THE ADMINISTRATIVE 
COUNTY OF LONDON. 


I. 

Sir Shirley F. Murphy's fifteenth annual report on the 
health of the metropolis has recently been published 
by order of the London County Council. The volume 
occupies, with appendices, 180 folio pages of closely printed 
matter and is illustrated throughout with a series of 
appropriate diagrams. Whilst closely following, in its 
general features, the lines of its predecessors the present 
report contains a large amount of important matter which 
now appears for the first time. To this additional 
matter more especially we propose to refer in detail. 
Nevertheless, as this report is written primarily for 
the benefit of Londoners, we shall endeavour, as far as 
space permits, to notice any serious deviations from the 
normal records of mortality in the metropolis, relating as 
they do to a population closely approaching 5,000,000 in 
number. 

The ordinary statistics of marriages, births, and deaths in 
the metropolis have already been published in the annual 
summary of the Registrar-General. It is, however, worthy 
of more than passing notice that the mortality of London 
both in 1906 and in the year immediately preceding was the 
lowest hitherto recorded. It was only 15’1 in each 1000 
persons living and was below the average rate in the closing 
decade of the nineteenth century by more than 20 per cent. 
The London death-rate in 1906 tallies closely with that of 
England and Wales, the difference in the rates amounting to 
no more than a few tenths of a unit per 1000. It is common 
knowledge that the mortality of dwellers in the several 
districts of the metropolis varies enormously. By calcu¬ 
lating the comparative mortality figure for each of the 29 
metropolitan boroughs, which now correspond to the 
administrative sanitary areas, the county medical officer of 
health gives exact numerical expression to these variations. 
From a table in the report we see that in the quinquennial 
period ending with 1905, 11 of the metropolitan boroughs 
had a mortality in excess and 18 a mortality in defect 
of the average for the administrative county as a 
whole. The table further shows that in 1906 the mor¬ 
tality in the poor and populous district of Finsbury was 
at least double of that in the more highly favoured and 
less populous district of Hampstead. Carrying still further 
his analysis, Bir Shirley Murphy tells us that among the 
21,000 tenants of the dwellings for the working classes 
recently provided by the County Oonncil for the accommoda¬ 
tion of persons displaced by the removal of house property 
for street or sanitary improvements, the rate of mortality 
did not exceed 13 ’7 per 1000, a rate which may be con¬ 
sidered a low one for even the healthy districts of the 
country, and which is less by 1 • 4 per 1000 than the present 
average rate for the metropolis. 

In the year 1906 London mortality from the principal 
epidemic diseases (except diarrhoea) was below the average 
for the preceding deoennium. Small-pox was notified in 
only 31 cases, all of which recovered. Of the cases 
reported, nine occurred in Hackney, six each in Bethnal 
Green and Camberwell, and smaller numbers in other metro¬ 
politan boroughs. Daring the year the services of Mr. W. 
McO.Wanklyn, of the County Oounoil's Public Health Depart¬ 
ment, were required to assist in the diagnosis of 35 cases 
of suspected small-pox. These included a group of four 
patients and another group of three patients, all of whom 
were found to be suffering from genuine small-pox; a group 
of five patients suffering from chicken-pox, and another 
group of five cases affected not with small-pox or chicken-pox 
but with contagious skin diseases. 

Among the common infectious diseases of children neither 
measles nor whooping-cough is inoluded in the schedule of 
the London Notification Act. Nevertheless, these diseases 
give considerable trouble to sanitary as well as education 
authorities by reason of the interference which they cause with 
the regularity of school attendance. The relation of over¬ 
crowding to the prevalence of measles is well shown in the 
present report, from which we learn that the mortality from 
this disease is more than twice as great in districts where 
-over 271 per cent, of the dwellings are overcrowded as it is in 


districts where the overcrowding does not exceed 71 per cent* 
The question of the possible reduction in fatality that might 
be attained by the better nursing at home of cases of measles 
is discussed by the county medical officer as well as by 
certain of his colleagues. Sir Shirley Murphy refers with 
approval to the good services rendered in Woolwich 
by the district nursing institution there, an institution 
that would probably be instrumental in saving many 
of the lives which in present circumstances are sacrificed 
to measles if only the sanitary authorities possessed, 
and utilised, the power to contribute to the expenses 
of the association so as to enable it to employ a sufficient 
staff to cope with local requirements. The county medical 
officer also discusses the question of school closure as an 
expedient for dealing with excessive incidence of measles 
among children of tender age; but although in the year 
1906 not fewer than 52 classrooms and 15 “departments” 
were closed on account of the prevalence of measles, this 
expedient does not appear to have produced the results which 
might have been hoped for ; this is attributed to the fact that 
“there is no satisfactory system by which a teacher becomes 
aware of the cause of absencejof ajpupil.” There appears to 
be some indication that parents nowadays regard measles as 
a more serious malady than was formerly the case and that 
as a consequence a larger proportion of the cases, in certain 
districts at any rate, come under medical care. 

In the behaviour of scarlet fever during 1906 there is 
little abnormal to notice. Both the cise-rate and the 
death-rate of the administrative county corresponded nearly 
to the average, although, as usual, the incidence of attacks 
from scarlet fever varied widely in the several metropolitan 
districts. Almost the same statement may be made concern¬ 
ing diphtheria, except that the prevalence, as well as the 
fatality, of this disease showed a greater defect from the 
average than was observed in the case of scarlet fever. But 
with regard to diphtheria Sir Shirley Murphy gives an 
interesting account of the occurrence of outbreaks among 
school children, in many of the cases the Klebs-Loflier 
bacillus being detected. This account, which will te read 
with interest by all medical men engaged in practical 
sanitation, is too long for reproduction here and scarcely 
admits of condensation. 

As regards the bacteriological examination of ‘ 1 contacts ” 
with cases of diphtheria very interesting particnlars are given 
in the present report. In certain districts the local medical 
officers of health have been able to secure that no " contact” 
should be allowed to return to school after illness from 
diphtheria except after bacteriological examination of the 
fauces. In this connexion the London County Council has 
adopted an important report and resolution submitted to 
it by its Education Committee, from which the following is 
an extract:— 

Our Attention baa bean drawn to the diffieultiej which have atUen 
in districts where diphtheria tiaa been prevaleut, consequent upon 
children who have been excluded from school being certilied as free 
from disease by medical practitioners. With the view, therefore, to 
dealing more thoroughly with the disease, the various medical officers 
of health were asked to adopt the temporary arrangements being 
carried out in Greenwich in the event of there being an outbreak of 
diphtheria in their respective districts. These arrangements involve 
that any children excluded from school on account of diphtheria or 
sore-throat during the prevalence of the disease should not be re¬ 
admitted without a certificate from the medical officer of health that 

they are free from infection. We are of opinion that it would 

greatly strengthen the hands of the various medical officers and do 
much'to redace the present risks of infection if authority were given 
for the refusal. during tho presence of diphtheria in any district, of the 
resdmission of children excluded from school as suffering from diph¬ 
theria or sore-throat until they have obtained a medical certificate of 
freedom from infection based on a bacteriological examination. We 
are informed that such certificates can be given, either by general 
practitioners or by medical officers of health, and would bo free from 
the dangerous errors of medical certificates given merely on the 
inspection of children. 

The Education Committee, alter carefully debating the 
subject, passed the following most important resolution, 
which, as we said before, was adopted by the County 
Council :— 

W'e recommend that the Education Committee be authorised to 
refuse, during the presence of diphtheria in any district, resdmission 
to school of children excluded on account of diphtheria or sore-throat 
until bucIi children shall have obtained a medical certificate of freedom 
from infection, based on a bacteriological examination. 

In our opinion it is difficult to over-estimate the value of this 
far-seeing resolve on the part of the London County Council 
as the supreme educational authority. Probably no step 
oould have been taken that would be more likely thgn this 
to check the spread of infection in elementary schools—that 



The Lancet,] 


ROYAL COLLEGE OF PHYSICIANS OF LONDON. 


[Jan. 25, 1908. 251 


is, of coarse, provided the action of the central authority 
receives the loyal support of the several borough councils. 

Among the fevers formerly designated “continued,” 
typhus fever appears to have caused no deaths in London 
during the year 1906 ; nevertheless, it is clear from the present 
report that were it not for the vigilance of the sanitary 
authorities we should still bear of extensive local epidemics 
of the disease from time to time. For instance, we learn 
that in the period referred to four cases of undoubted typhus 
fever occurred and were removed to hospital, one of which 
cases was notified as suffering from enteric fever and was 
apparently isolated as such. 

The cases of enteric fever in the metropolis were equal to 
a rate of 0 • 3 per 1000 of the population in the year 19C6, a 
rate which corresponds closely to that obtaining in the 
immediately preceding year. In the year first mentioned 
Finsbury had the highest death-rate from enteric fever and 
Chelsea and Stoke Newington the lowest. Of the cases 
notified to be suffering from enteric fever, we learn that 
“ a portion was found, after inquiry by the medical officers 
of health, to be incorrectly diagnosed." With respect to 
those that were accepted as being actual cases of enteric 
fever, effort was made by medical officers of health to dis¬ 
cover the cause of the illness. A considerable number of 
these were believed to have received infection from elsewhere, 
some of them having been infected on the continent, whither 
they had repaired for the summer holiday. Among articles of 
food believed to have been instrumental in conveying infec¬ 
tion cockles are once again frequently mentioned in the 
reports of medical officers of health, Southend and Leigh on- 
Sea being referred to as the source of some of these 
molluscs. Dr. 0. Sanders of West Ham reports an outbreak 
of not fewer than 52 cases of enteric fever during 1906, a 
number of the persons attacked having been found by him to 
have eaten cockles a short time before the onset of the 
disease. After discussing the views of his colleagues as to 
the part played by cockles in the spread of infection, 
Sir Shirley Murphy pertinently remarks: “Whatever view 
is taken as to the sufficiency of the evidence incriminating 
the cockles in these outbreaks, the fact remains that the risk 
of consumption of cockles which have been laid in the Leigh 
Creek is now well recognised, and any further evidence of 
injury to London inhabitants from this source must neces¬ 
sarily raise question as to the steps which should be taken 
in dealing with this matter by public authorities of the 
localities whose inhabitants suffer in this manner.” 

(To be continued.) 


ROYAL COLLEGE OF PHYSICIANS 
OF LONDON. 


AN extraordinary Comitia was held on Jan. 17th, Sir 
Richard Douglas Powell, Bart., K.O.V.O., the President, 
being in the chair. 

The consideration of the petition from the London School 
of Medicine for Women praying for the admission of women 
to the examinations of the College and of the whole question 
involved was resumed. On the previous occasion a motion 
was proposed and seconded 1 ‘ that the petition of the London 
School of Medicine for Women be granted.” To this an 
amendment had been carried “That it is desirable that 
such alterations be made in the by-laws as to allow the 
admission of women to the examination for the Licence only 
of the College.” When this had been put as a substantive 
motion an amendment had been moved and seconded 
“that the word ‘only’ be omitted.” This was discussed 
at some length and the amendment was eventually carried 
by a large majority. On this being put as a substantive 
motion a further amendment was proposed to the effect: 

That it is desirable that such alterations be made in the by-laws as 
to allow the admission of women to the examinations of the College. 

This was carried by 74 votes to 33. 

The Registrar (Dr. E. Liveing) then moved a rider which 
was seconded by the Senior Censor (Dr. D. Ferrier) and 
carried nemine contradicente :— 

That It is not Intended that any action should be taken under the 
resolution just adoptei inconsistent with the agreement between the 
two Royal Colleges under which the Licence of the one and the 
Membership of the other are only granted conjointly. 

The following communications were received :—1. From 
the Secretary of the Royal College of Surgeons of England, 
two lettcrs reporting proceedings of its Council on Nov. 14th 


and Dec. 12th last. 2. From the Marine Department of the 
Board of Trade, inclosing a letter from the Governor of St. 
Helena forwarding a report by Dr. J. J. W. Arnold, the 
Colonial surgeon, on the necessity of issuing farther instruc¬ 
tions respecting the treatment of beri-beri and asking the 
views of the College. The matter wag referred to a com¬ 
mittee consisting of the President, Sir W. S. Church, Dr. 
J. F. Payne, Sir Patrick Manson.and Professor R. T. Hewlett. 
3. From the Royal Sanitary Institute, inviting the College to 
appoint delegates to the annual congress of the institute to 
be held at Cardiff, from July 13th to 18th next. It was 
resolved to appoint two delegates whose names would be 
announced at a future meeting. 4. From the Dean of the 
Faculty of Medicine of the University of Edinburgh, 
announcing the award of the Murchison scholarship (1907) 
to James Sutherland Edwards, M.B. Edin. 

Sir Dyce Duckworth was re-elected a representative of the 
College on the Council of Queen Victoria’s Institnte for 
Nurses. 

A report was received and adopted from the Committee of 
Management recommending that the Mnnicipal Technical 
School, Accrington, should be added to the list of institutions 
recognised by the Examining Board in England for instruc¬ 
tion in chemistry and physics. 

The committee also recommended that the Borough of 
Devonpoit small-pox and fever hospitals should be added to 
the list of fever hospitals recognised by the Examining Board 
in England. 

The President then dissolved the Comitia. 


THE FUTURE OF THE MEDICAL 
PROFESSION : A FRENCH VIEW. 


The Students’ Number of Lt Progres Medical for 1907» 
which was published at the end of the year, contains an 
article by M. J. Noir upon “The Future of the Medical 
Profession ” which will be interesting to all of us. Our 
readers will remember that last year we published articles 
from our Special Commissioner entitled “The Organisa¬ 
tion of the Medical Profession in France. 1 ” We find that 
our French colleagues are oalled upon to deal with much 
the same difficulties in medical politics as have engaged the 
attention of the profession in England, and the abstract 
from M. Noir's paper which we publish below shows 
(as did the previous account by our Special Commissioner) 
how some important ethical questions have been solved 
in France. We learn how our French colleagues, for 
example, deal with " the right of choice of a medical man by 
the patient,” a matter upon which we have often bad to- 
write. We note also “ that a medical examination of an 
injured workman can only take place in the presence of the 
medical man in attendance, who should have notice by letter 
two days beforehand.” This, again, is a point which baa 
received attention from us, and is one of very gTeab 
importance to general practitioners. The general remarks 
of M. Noir on the Socialistic tendencies of modern medical 
practice will also be read with interest by all British practi¬ 
tioners. We, too, on this side of the Channel have seen 
recently great developments of the system of the State 
employment of medicine, and it behoves ns to be aware of its 
professional perils as well as of its advantages. 

“It is not amongst its enemies that the medical pro¬ 
fession should seek the danger which menaces it; it is in the 
transformation which it appears called npon to undergo with 
the times; it is within its own body that the germ of dis¬ 
sociation is likely to arise which will be capable for a time 
of arresting its healthy growth and of compromising its 
success. In proportion as the role of the medical man has 
increased and been ennobled, his material position has 
diminished and has become more and more precarious. The 
consideration and moral influence which he eDjoyed have 
attracted a larger and larger number of yonng men to a 
medical career. The development of general education 
has further unduly increased the number of students. 
Medicine is now, Indeed, an overcrowded profession. In 
consequence of this a crisis has arisen, dangerous without 
doubt, but which will be only transitory, like every crisis, 
and of little importance if it did not threaten to make 
the practice of onr art evolve in a pernicious manner. 

i The Lancet, March 30th (p. 911) and April 27th (p. 1190), 1907. 



252 Thb Lancet,] THE FUTURE OF THE MEDICAL PROFESSION : A FRENCH VIEW. 


[Jan. 25,1908. 


Subject to the economical law of supply and demand the 
medical profession, after passing through a painful period of 
more or less prolonged malaise, will most likely cease to be 
overcrowded. 

But it is a more serious danger which threatens us, a 
danger against which we ought to take immediate steps : it is 
the descent of the physician into the ranks of paid servants 
and (State) functionaries. These terms are synonymous ; a 
physician becomes a paid servant when he enters the employ¬ 
ment of a master or of any society which appoints him with 
the object of using his services at their discretion. If the 
society which employs the physician is the State, the depart¬ 
ment, or the commune, he becomes a functionary. 

This condition of affairs tends to spread because many 
young medical men, like most young men of the middle-class, 
are wanting in initiative, in activity, and in energy, and prefer 
a badly paid appointment to the more laborious and more 
difficult straggle which building up a private practice 
entails. Besides, all those who in any way are at the 
head of any group of men, as owners of factories, company 
directors, presidents of mutual aid societies, clergy, mayors, 
administrators, or politicians, seek to increase medical 
appointments. They hope to succeed in making the practi¬ 
tioner a servant by having him in their pay, and the more 
important his social rule becomes the more they believe it is 
to their interest to enslave him. 

Up to the present the State appointments assigned to 
medical men have been services of public utility in which 
medical cooperation appeared much more appreciated than 
free and independent action. These appointments, connected 
with poor relief, with control, with sanitation, with various 
expert examinations (in which the medical man, poorly paid, 
looked only to his conscience), were considered legitimate 
and caused prejudice to no other medical practitioner. But 
gradually certain of these appointments will be turned into 
veritable administrative offices, the medical men will attend, 
under orders and at a reduced price, the patients on their 
lists. Political and religious struggles will intervene and 
the medical man will be obliged to become an electoral agent 
and to espouse the cause of the political tyrant of his 
district. Cooperation—that useful and fruitful work which 
properly organised and confined to its beneficent role could 
assist greatly in solving appropriately the difficulties of the 
social problem—has too often given the saddening spectacle 
of a brilliantly decorated theatre on the stage of which a 
medical man appears in some badly dissimulated political 
farce. Relegated to a servile condition the medical man can no 
longer fulfil the important role which it seems the evolution 
of science must intrust to him. For such a high mission 
moral qualities are necessary, which complete independence 
can alone assure. But the undignified competition for 
these medical appointments increases daily. Those who 
employ us find a decided advantage in this unbridled com¬ 
petition and seek, without any scruple, to benefit from it. 
This enslaving of the medical man—this degradation of a 
salary substituted for an honorarium—gradually brings about 
in the medical profession the formation of a proletariat, a 
proletariat so much the more dangerous as it is an in¬ 
tellectual proletariat. 

Before these dangers the medical profession has quite 
naturally reacted, and as a means of defence developed the 
entente syndicate. Practitioners have little by little found 
out that isolated they could no longer resist the demands of 
powerful societies. They formed themselves into groups 
and in order to show more clearly the defensive object of 
those groups they gave them the form of syndicates. The 
movement has taken 25 years for its production, but if the 
beginnings of the medical syndicate have been difficult and 
slow we can state with 6ome pride that their progress has 
been constant and that their power of action has been able, 
usefully and vigorously to make itself manifest of late 
years, that at last we are in a position to hope that they 
will be capable of facing the difficulties of the present 
situation. 

Daring many years the medical syndicates resisted the 
abuses of which practitioners complained in their localities, 
but only in an isolated manner and without coordinating 
their efforts. Little by little, however, in the course of 
action by the syndicates a principle was evolved which, if 
successfully applied, will deal a fatal blow to the salaried 
and functionary practitioner. This is the free choice of a 
medical man by the patient. 

The principle of the free choice of a medical man by the 
patient, which we have called 'the liberty of confidence,' is 


not one of those theoretical ideas started for the occasion 
and issue of a dreamer's brain, as Minerva came forth fully 
armed from the head of Jupiter. It is a practical conception 
which the syndicates have only adopted after proving the 
possibility of its application. It began in the organisations 
lor gratuitous medical assistance before the law of 1893. 
Since the application of this law a very liberal organisa¬ 
tion has been established in certain districts allowing 
the pauper to have recourse to the medical practitioner of 
his choice. This organisation, which was started in the de¬ 
partments of Landes and of the Vofges, has removed the 
greatest objections to the ‘ organisation of medical 
assistance ’ (for the poor) and has now been adopted 
by two-thirds of France. It is needless to say that all the 
medical syndicates persistently demand its application. We 
will not enter into the working details of the Vosgian system, 
which requires payment by visit and by kilometre travelled 
and the establishment of control commissions for the pre¬ 
vention of abases which are always possible. 

The legislature, in making employers liable for the cost of 
medical attendance on injured workmen, had to settle the 
conditions under which this attendance should be given. 
After a very lively struggle against the insurance companies 
who wished at any cost to monopolise the attendance re¬ 
quired by the victims of accidents at work; after having 
had to defend themselves against a number of their colleagues 
who, even in the councils of the medical syndicates, defended 
this monopoly, thus sacrificing the general interest for their 
personal advantage, the medical syndicates succeeded in 
having ‘ the liberty of the choice of a medical man ’ recog¬ 
nised by the law. They did better, thanks to the energy, 
devotion, and inflexible tenacity of Dr. Diverneresse who 
devoted himself entirely to this task ; they succeeded in having 
inserted in Article 30 of the law penal provisions against any 
person who offered obstruction to the right of the injured 
person to choose bis medical man. The legislature, at the 
request of the medical syndicates, guided by Dr. Diverneresse, 
even added to the law a regulation of medical etiquette by 
stating in Paragraph 5 of Article 4 that the medical man 
employed to obtain information for the employer or for the 
insurance company as to the condition of the injured work¬ 
man could only do so ‘ in presence of the medical man in 
attendance who should have notice by letter two days before¬ 
hand.’ 

The promulgation of this law of April 9tb, 1898 (amended 
March 22nd, 1902, and March 31st, 1905), was a victory for 
the medical profession the consequence of which may be 
considerable, and which in any case clearly indicates the way 
in which it ought to move in order to insure independence 
and dignity for the practitioner, while preventing his descent 
into the ranks of salaried officials ana functionaries. It is 
thus that the liberty of confidence becomes the corner-stone 
of medical independence. Is there a more solid base than 
this to serve as a rallying point for the work of the medical 
syndicates ! Have not revolutions been started for much less 
worthy liberties 7 

The liberty of confiding his defects and his miseries, his 
health and that of his family to a medical man whom he knows, 
whom be esteems, in whom he has faith : is this not the most 
sacred liberty and that which ought to be the most inviol¬ 
able ? And is it not violated daily, this individual liberty, in 
that which is the most delioate, the most intimate, by public 
and private administrations and by mutual aid societies, 
which impose upon the patient treatment by an official or 
salaried medical man .' Always received with apprehension 
and distrust, this medical man will have to exert prodigious 
devotion, mildness, and tact in order to gain the confidence 
of patients who are forced to receive him. And if, in 
consequence of a death, a family suspects this medical man 
of inability or of negligence what an intolerable position it 
would be for him if bis duties called him again to those who 
believed that they had been victimised by him. He would 
find dark and hostile countenances and anxious glances. He 
would feel that the patient had no confidence in him, that 
he only half harkened to his advice, that in these circum¬ 
stances the best treatment could not be fruitful, and the 
least complication, the least incident would be cast up to 
him as a crime. Intimately convinced that without the con¬ 
fidence of the patient the task of the medical man is incom¬ 
patible with his dignity the associated medical men have 
vigorously proclaimed respect for it. 

When all the medical men of a town or district are united 
they should be able to take up seriously the study of ques¬ 
tions of hygiene and of prophylaxis. Solidly organised 




The Lancet,] 


REPORTS ON PLAGUE INVESTIGATIONS IN INDIA. 


[Jan. 25,1908. 253 


they can provide the practitioner residing far from large 
centres with the laboratories which, left to himself, he could 
not seriously organise and which he would not have the 
leisure to use. Gradually becoming conscious of their power 
we shall afterwards see them found and maintain, with their 
own resources, paying hospitals for people of limited means, 
who require assistance and who often only go into hospital 
with regret. Thus an end will be put to the principal 
argument of those who pretend that the doors of the hospital 
cannot be closed to people of means. Hospital abuse, of 
which the medical profession complains so bitterly and in 
consequence of which the poor Buffer, would disappear. 

But if we ought not to despair of the future of the medical 
profession we ought also not to forget for one instant that it 
is at a dangerous turning point in its history. The diagnosis of 
the disease from which it suffers has been made ; it has been 
given a name, 1 fvnotionarism.' The prognosis is serious. 
But to combat and even to prevent it we have powerful 
specifics, which are mutual cooperation, strict cohesion, pro¬ 
gressive application of the liberty of confidence, and 
demonstration by deeds that the first care of the medical 
syndicates is to put themselves at the service of the sick and 
of the public interest. " 


REPORTS ON PLAGUE INVESTIGATIONS 
IN INDIA 

Issued by the Advisory Committee appointed by the 
Secretary of State for India, the Royal 
Society, and the Lister Institute 
of Preventive Medicine. 1 


The present report is devoted to an account of the epi¬ 
demiological observations of the Commission which were 
made in Bombay city, in four villages in Bombay Island, and 
in two villages in the Amritsar district of the Punjab. In 
all places the primary object of inquiry was the relationship 
of rat plague to human plague. Owing to the necessarily 
complex nature of the data many of the important facts 
brought forward cannot be condensed into a short summary. 

XXI.— Digest of Recent Observations on the Epidemiology 
of Plague. 

This paper contains an abstract of the observations and 
opinions which have been published during the last ten or 
12 years on the connexion between rat and human plague, 
the mode of infection, manner of spread, Ac. 

XXII.— Epidemiological Observations made in Bombay City. 

The Commission made an exhaustive inquiry into plague in 
rats and men in Bombay city over a period of 16 months. 
The period dealt with in this report is the last 12 monthB of 
the whole investigation (October, 1905, to September, 1906). 
With the cooperation of Dr. J. A. Turner and his sanitary 
staff more than 117,000 rats were collected and examined for 
plague infection in the laboratory at Parel ; nearly 18.000 
were found infected. At the same time, nearly all the cases 
of human plague (more than 10,000) in the city were inquired 
into with the view of ascertaining the probable mode and 
place of infection, Ac. The density of both rat and human 
plague in Bombay was, however, so great that the Commis¬ 
sion found itself unable to draw any very definite con¬ 
clusions with regard to these points which were more satis¬ 
factorily investigated in the smaller village communities. 
The large numbers in Bombay, on the other hand, show the 
broad temporal and geograpbical relations between plague 
in rats and in men better than the smaller epidemics in 
limited communities. 

By far the most abundant and important rodents in 
Bombay city are Mns rattus and Mus decumanus. The 
habits and distribution of the two species differ, for while 
Mus decumanus lives for the most part outside houses in 
sewers, stables, Ac., Mus rattus is essentially a house rat and 
abounds in the most intimate relationship with the people. 
Both are subject to plague; but the percentage of Mus 
decumanus (18 • 8 per cent.) found infected was twice as great 
as Mus rattus (9 5 per cent.). The authors point out in this 
connexion that the former species usually harbours twice as 
many fleas as the latter (e.g., in April, 1907, an average of 13 ■ 9 

1 Third report: Journal of Hygiene, vol. vil., pp. 693-986, with 23 
plates, 57 mips, ami 19 charts. Accounts of the previous reports will 
be found in Thk Laackt, Nov. 3rd, 1906, p. 1233, and July 27th, 1907, 


fleas per live rat was found in 306 Mus decumanus examined, 
as against 5'2 per rat on 1911 Mus rattus), while their 
susceptibility to plague experimentally transmitted by fleas 
is the same. The breeding season of both species was 
examined by recording the number of pregnant females and 
the number of young rats caught week by week ; no correla¬ 
tion between the breeding season and epizootic plague was 
obtained. 

Acute plague in both species of rat as well as in man 
occurs in Bombay city throughout the year ; the rat epizootic 
appeared to begin simultaneously in many parts of the city 
and no particular focus of origin could be ascertained for the 
epizootic or the epidemic. It is shown that the general 
intensity of rat plague corresponds to the intensity of human 
plague in the different sections of the city : eight sections 
showed from 10 to 31 plague rats per building actually 
obtained and a plague death-rate from 10 • 7 to 17 per mille, 
while in the other six sections the plague rats per building 
were 0 6 or less and the mortality 3 1 6 to 13 ■ 1 per mille. The 
minute details of the spatial relations between rat and human 
plague were, for reasons already alluded to, difficult to make 
oat; the general coincidence is illustrated by a series of 
monthly maps of one district. 

The close correspondence in time and relative intensity at 
different times of the epizootics and epidemic is well 
shown in a Beries of curves. That for the whole of Bombay 
city shows that the beginning of the epizootic in Mus 
decumanus precedes the epizootic in Mas rattus by about 
16 days, and that the epizootic in Mus rattus comes on some 
25 days before the rise of the human epizootic. This is con¬ 
firmed by a series of similar curves for 12 districts of 
Bombay taken separately. The authors point out that there 
intervals are not inconsistent with the hypothesis that the 
flea is the transmitting agent from rat to rat and from rat 
to man, and they conclude that the epidemic is directly 
attributable to the Mus rattus epizootic which in its turn 
takes origin in the Mns decumanus epizootic. 

In a statistical analysis of these data, printed as an ap¬ 
pendix, Mr, M. Grt enwood shows that the correlation between 
human plagne and plague in Mus rattus is of very high order 
(0■ 8801 + O’0184) ; he also reaches the important con¬ 
clusion that the correlation between plagne in man and 
in Mus decumanus (which reaches the large figure of 
0 7481 + 0 ’ 036) is probably spurious, depending on the 
correlation between plague in Mus decumanus and in Mus 
rattus (which is still higher: 0 ’ 945 + 0 ’ 0C875). 

The paper concludes with a review of the sanitary cir¬ 
cumstances of Bombay city in their relation to the prevalence 
of plague. The authors show that conditions of housing, 
ventilation, conservancy, and the like can only be considered 
factors of importance in so far as they encourage the rat 
population and briDg it into more intimate relationship with 
the people. Even when the people live in well-constructed 
buildings free from sanitary defects (as in the municipal 
tenement buildings) they suffer severely from plague owing 
to their being perfectly agreeable to allow rats to live and 
to breed in their rooms. 

XXIII.— Observations made in Four Ullages in the 
Neighbourhood of Bombay. 

The villages of Sion, Wadhala, Parel, and Worli in Bombay 
Island were kept under continuons close observation and 
were systematically trapped for rats. In Parel there is a 
sewerage system and Mus decumanus occurs occasionally ; 
Mus rattus, however, greatly predominates and is the only 
species found in the other three villages. No oases of 
human plague occurred outside the epidemic season. In 
Sion, Parel, and Worli no plagne rats were found during the 
same period ; in Wadhala (where some of the attendants at 
the Parel laboratory were living) a single rat suffering from 
acute plague was caught in August. The inhabitants of all 
four villages are in more or less constant communication 
with Bombay city. 

1, Sion Milage (population 950).—The origin of plagne in 
this village in January, 1906, could not be definitely ascer¬ 
tained ; the available evidence pointa to the infection having 
been imported on or about the person of a woman who came 
from an infected quarter of Bombay. Human plague began 
soon after, and in the same block of houses as, the occur¬ 
rence of a dead rat. The inhabitants then evacuated that 
part of the village and were replaced by guinea-pigs in cages 
in each house which were kept under careful observation. 
Plague gradually spread from the oiiginal focus through the 
village, the guinea-pigs dying from plague, plague infected 




254 Thb Lancet,] 


BEPOBTS ON PLAGUE INVESTIGATIONS IN INDIA. 


[Jan. 25, 1908. 


fleas being caught in the houses and plague rats being found 
from time to time. In all 45 per cent, of the houses of that 
section of the village were shown to be plague-infected ; by 
the nature of the experiment contact between the guinea- 
pigs in the different houses was excluded. Among the rats 
the infection persisted for two months and took six weeks to 
travel 300 feet. The authors conclude that the infecting 
agent was slowly disseminated among the guinea-pigs by 
plague-infected rats. 

2. Wadhala Village (population 1500).—The observations 
made here were incomplete. In the early part of the 
epidemic season two cases of plague were imported from 
Bombay and died in the village without giving origin to any 
other human cases or any epizootic. Subsequently a number 
-of human cases occurred, some of which were in close asso¬ 
ciation with dead rats which conld not be obtained for 
examination or with rats proved to be plague-infected. 

3. Parel Village (population 3525).—Daring tbe period of 
observation 28 cases of human plague occurred in this 
village. Five of these were definitely associated in time 
and place with a limited epizootic among Mus rattus con¬ 
fined to one corner of the village. Ten cases were brought 
to Parel already infected ; in six the probable source of 
infection could not be determined, the diagnosis being 
doubtful in one case, while seven were probably infected 
outside the village as they had recently visited places where 
rat plague was known to be present. An interesting obser¬ 
vation is detailed as follows 

Cases 14, 15, 16, 18, 19, 24, and 25 were all employed at a .cotton 
spinning mill in the Sewri section of Bombay. Dead rats had been 
found In several parts of this mill, but especially In the mixing depart¬ 
ment, where cases Nos. 14, 15, 18, and 19 worked. Two of these men 
3iad throw-n out the rats. Cases 16 and 24 were employed in other 
parts of the same mill. Case 24 lived with her son (25) who occasion¬ 
ally visited the mill with his mother. The wurnsn had noticed dead 
rats in the go-down where she worked. All these cases and three 
others investigated by us who lived in other parts of Bombay but 
worked in this mill were attacked between the30tta April and 10th May. 
An interesting experiment was done in the mixing room in the rolil. 
On the 12th May two guinea-pigs were placed in it; they were 
examine,I for tleas on the 14th May. On one guinea-pig 108 and on the 
-other 150 rat fleas were captured. After the fleas had been removed 
ilie guinea-pigB were taken to the laboratory and isolated. They 
remained healthy. The fleas were transferred te a fresh guinea-pig 
confined in a flea-proof cage In the laboratory. This guinea pig died 
of plague on the 20th May. The mixing room was thus proved to bo 
infective. It iB important to note that these cases lived Indifferent 
parts of Parel village and that we could obtain no evidence of a rat 
-epizootic at their homes which did not prove infective to guinea-pigs. 
The infection therefore may reasonably be attributed to the mill in 
which they worked. 

The infectivity of the houses in which plague cases 
occurred was investigated experimentally by means of 
guinea-pig flea traps. Though one of the imported cases 
infected the bouse in which she died, as shown by the 
capture of plague-infected fleas therein, none of them gave 
origin to any further human cases or to any epizootic among 
tbe rats. A number of interesting data are given relative 
to the prevalence of rats in this village which was very 
thoroughly trapped for nearly 12 months. This systematic 
trapping appeared materially to reduce the rat population. 

4. Worli Village (population 2508).—Systematic trapping 
for a year appeared to reduce the rat population to approxi¬ 
mately one quarter of the original number. No epizootic 
occurred among the rats and only three cases of human 
plagne. It is probable that all these contracted the infec¬ 
tion outside the village. In two of the cases evidence was 
obtained which pointed to infection so introduced having 
spread in one instance to a guinea-pig and in the other 
to a rat. 

XXIV.— General Consideration* lie gar ding the Spread of 
Infection, Infeativity of Homes, <Jo., in Bombay City arid 
Island. 

With regard to the spread of infection within houses the 
authors point out that the universal experience in plague 
hospitals has been that infection is not, except in pneumonic 
cases, communicated from the sick to the healthy attendants 
and others. Their own observations show that guinea-pigs 
running free in the plague wards do not collect rat fleas nor 
do they contract plague ; that guinea-pigs do not contract 
plague when kept in a flea-proof hut in close contact with 
the bedding of plague cases removed daily for several weeks; 
and that the urine and faeces of acute plague cases are not 
infective to guinea-pigs by cutaneous inoculation. Their 
observations in Bombay villages tend to show that infection 
efficient to start an epidemic is not brought to a place in 
the persons of those sick of plague unless it is first 
effective in starting an epizootic. They also point out 


that in Bombay city comparatively few houses yield 
more than one or two cases, ltecalling the experiments 
already published, - showing that plague is by no means easily 
transmitted from rat to rat by means of the human flea and 
that the degree of septicaemia found in the human cases is 
much less than in infected rate, they conclude that the trans¬ 
mission of infection from man to man by Pulex irritans is 
probably a very infrequent occurrence. The observations 
made in the village of Sion show that a widespread dis¬ 
semination of infection in houses may result from an 
epizootic in the rats when direct contact with sick occupants 
of the house is rigidly excluded. In general, therefore, they 
reach the conclusion that contact with plague cases plays no 
part in the spread of the epidemic. 

Plague is admittedly a place infection—i.e., a house or a 
room in a house may be definitely infective. Seeing that 
persons suffering from plague and their excreta are not 
infective and that, as was previously shown, the air and soil 
of plague-infected houses do not per te convey plague, 
much support is rendered to the view of tbe Commission that 
infection is contracted by man from tbe rat by means of rat 
tleas and that the infectivity of houses is due to the presence 
within them of infected rat fleas. It is also of opinion that 
plague may easily be transmitted to a distance by the same 
means. 

During the whole of the work in Bombay no evidence was 
obtained suggesting that plague among the common or 
domestic animals (other than rats) was of any practical im¬ 
portance. Natural plague was observed only in guinea-pigs, 
rabbits, and monkeys (a limited epizootic in the Victoria 
Gardens) with one doubtful case in a cat. 

XXV.— Observations in the Punjab Villages of Dhand 
and Basel. 

The villages of Dhand (population 1920) and Kasel 
(population 3938) were kept under close observation for a 
year from December, 1905. The general methods of inquiry 
were the same as those used in Bombay, and these villages 
were selected as representing isolated communities which had 
experienced an epidemic of plague in each year since its 
introdnetion into the district in 1902. An analysis of the 
data showed that plague did not tend to recur In the same 
houses year after year. The rate were practically all Mns 
rattus with a few Nesokia bengalensis; no Mas decumanus 
were found. In these villages Mus rattus is both a house 
and a burrowing rat. No relation was found between the 
breeding season of the rats and the prevalence of epizootic 
plagne. As in the Bombay villages, extensive systematic 
trapping appeared to reduce materially the rat population. 
Of the fleas caught on the rate 98 per cent, were Pulex 
cheopis ; tbe average number taken on each rat varied from 
12 -6 in April during the onset of the plague epizootic to 2'2 
in August and September in the off-plague season. During 
the period November to April about 2 per cent, of the fleas 
were Ceratophyllus fasciat.ua (the common rat flea of 
Europe); none were found during the rest of the year. 

Dhand village .—No definite origin could be ascertained. 
Acute rat plague (28 cases) slightly preceded human plague 
(32 cases) and the two show a close association in time 
during their prevalence from February to May. II rats 
suffering from chronic plague were taken between December 
and June. Of the hnman cases 22 inhabited 18 houses in 
which, or in the vicinity of which, plague rate had been 
found before or at the time of the occurrence of tbe cases. 
The other ten cases inhabited eight bouses and no definite 
association with plague rats was demonstrated. Three of 
these eight houses (four cases) were, however, shown by 
guinea-pig experiments to contain infected rat fleas and two 
more of the cases lived close to these houses. Two of the 
remaining cases were clearly imported (late in the epidemic). 
The authors consider their failure to trace a more intimate 
association between rat and human plague to be largely 
due to the limitations of the available methods of finding 
plague rats. 

Basel village.—Mere again the epizootic appeared to arise 
spontaneously though several of the neighbouring villages, 
including Dhand, were already infected. Acute rat plague 
was first discovered three days before the first indigenous 
human case and the close correspondence in time between 
the epizootic (238 acute plague rate) and the epidemic (75 
cases) from April to July is well shown in a curve. 23 rats 
suffering from chronic plague were caught between April 


4 journal of Hygiene, vol. vi., p. 521, Silt voi. vii., p. 413. 





The Lancet,] ROYAL COLLEGE OF SURGEONS OF ENGLAND.—CENTRAL MIDWIVES BOARD. [Jan. 25,1908. 255 


and December. The 75 human cases occurred in 67 houses 
(total houses in village 806) ; in the houses which furnished 
single cases there were 273 “contacts,” of whom only 18 had 
been inoculated ; none of these 255 susceptible persons con¬ 
tracted plague. 53 of the cases were definitely ascertained 
not to have been in contact with other plague cases. Of the 
75 human cases, four were imported, 25 occurred in houses 
in which plague rats had been found, 36 in houses in the 
immediate vicinity of which plague rats had been found, and 
of the remaining ten cases six had visited at houses in 
which plague rats had been found, three lived in houses in 
the vicinity of which plague rats were found some days after 
they fell ill, and one was a doubtful case of plague. 

Experiment* in plague houses in Dhand and Easel. —A 
number of experiments were carried out in these villages 
similar to those done in Bombay 3 showing that the infective 
agent in the houses was infected rat fleas. In 49 plague- 
infected houses guinea-pigs were allowed to run free for 
about 18 hours ; in nine instances they afterwards died from 
plague. Three times as many lleas were caught on the 
guinea-pigs in plague-infected as in not plague-infected 
houses, and five times as many in houses which proved 
infective to guinea-pigs a6 in those not infective. Fleas 
found on guinea-pigs or rats in plague houses were trans¬ 
ferred to guinea-pigs in flea-proof cages in the laboratory ; 
in 10 out of 31 experiments the fresh guinea-pigs died from 
plague. In 51 experiments guinea-pigs, unprotected and 
protected with fine wire gauze or with “tangle toes,” were 
placed in plague houses ; a single flea was found on four of 
the protected animals, none of which died from plague ; 
from one to 75 fleas were found on 34 of the 51 unprotected 
animals, six of which died from plague. Nearly 90 per 
cent, of the fleas caught on the ‘ ‘ tangle toes ” were rat fleas 
(the rest being cat fleas), and of 65 dissected the stomach 
contained plague bacilli in three. 


ROYAL COLLEGE OF SURGEONS OF 
ENGLAND. 


A quarterly meeting of the Council was held on 
Jan. 16th, Mr. Henry Morris, the President, being in the 
chair. 

It was resolved that the election of the conservator of the 
museum should take place at the ordinary meeting of the 
Council on Feb. 13th. 

It was resolved to approve of the suggested alterations of 
the Standing Rules relating to the conservator of the 
museum. 

It was decided that during the next three months tea should 
be served at a charge of 4 d. per person in the library for 
readers, or in the common room for readers who are Fellows 
or Members of the College. 

A report was received from the committee on the annual 
/eport of the Council, and after consideration it was resolved 
that the first resolution carried at the annual meeting of the 
Fellows and Members should be referred back to the com¬ 
mittee for further consideration. It was further resolved 
that the mover and seconder of the second resolution (which 
reaffirmed the' desirability of admitting Members to direct 
representation on the Council) should be informed that the 
resolution had been laid before the Council and that the 
views of the Council upon the question referred to therein 
would be found in the last annual report of the Council. 
No action was taken with regard to the third resolution. 

It was resolved that the mover and seconder of the fourth 
resolution should be informed that the Council saw no reason 
to adopt the suggestion. The fourth resolution suggested that 
when a poll of the Fellows and Members was taken on the 
question of the admission of women to the diploma of the 
College a similar course should be taken with regard to the 
proposal for direct representation of the Members on the 
Council. 

The fifth resolution was a request that the Council should 
add a hood to the gown already worn by Fellows and 
Members. The Council resolved not to comply with the 
request on the ground that a hood was generally distinctive 
of a degree and was not in general use among colleges of 
similar standing. 

The sixth resolution wished the Council to endeavour to 
join the work of the College with the University of London 
(so as to form an Imperial University of London). In reply 


to this resolution the Council directed that the mover and the 
seconder should be informed that the matter had been much 
discussed in the past and that it still occupied the attention 
of the Council. 

Mr. Henry Morris, the President, was appointed Hunterian 
orator for 1909. 

The President reported that he had given evidence on 
Dec. 20th last before the Home Office Committee on the 
London Street Ambulances. The evidence was based on a 
large amount of information which he had obtained from 
Paris, Berlin, and Boston (Massachusetts). A vote of thaDks 
was given to the President. 

Mr. Thomas Bryant was re-elected for three years a repre¬ 
sentative of the College on the council of Queen Victoria’s 
Jubilee Institute for Nurses. 

A committee was appointed to prepare a circular to the 
Fellows and Members asking their opinion as to the desir¬ 
ability of admitting women to the examinations for the 
diplomas of the Royal College of Burgeons of England. 


CENTRAL MIDWIVES BOARD. 


A meeting of the Central Midwives Board was held at 
Caxton House, Westminster, on Jan. 16th, Dr. F. H. 
Champneys being in the chair. 

A deputation from the guardians and directors of the 
Coombe Lying-in Hospital, Dublin, consisting of Dr. M. J. 
Gibson, the Master, a member of the board of the hospital, 
and the honorary secretary, attended on Jan. 9th and pre¬ 
sented a memorial praying the Board to rescind its reso¬ 
lution of Dec. 19th 1 removing the name of the Coombe Hos¬ 
pital from the list of recognised training schools. The 
memorial was supported by letters from the Very Rev. Canon 
Scally, the Rev. J. D. Smylie, and Sir Charles A. Cameron, 
medical officer of health of the city of Dublin, and by a 
statutory declaration made by the registrar of the Coombe 
Hospital as to the circumstances in which the board of 
the hospital first learned of the correspondence between the 
secretary, the late master, and the registrar on Deo. 30th.- 
The members of the deputation spoke in support of the 
memorial and Dr. Gibson made application in due form 
for approval as a teacher. Having fully considered all the 
evidence aDd argument submitted to it by the deputation 
the Board took no action on the memorial but approved 
Dr. Gibson as a teacher. 

Letters were considered from the late Master of the 
Coombe Hospital, Dublin, and from Messrs. D. and T. Fitz¬ 
gerald, his solicitors, asking the Board to reconsider its 
decision not to accept any certificate signed by him in future 
and the following decision was agreed to ; “ That the Board 
declines to reconsider its decision.” 

A letter was considered from Dr. W. Arnold Evans, 
medical officer of health of Bradford, as to advertising by 
midwives and it was decided that Dr. Evans should be 
informed that the Board has no power to prohibit advertising 
by midwives. 

A letter was considered from a midwife approved by 
the Board for the purposes of signing Forms III. and IV., 
inquiring whether her substitute, being a certificated mid¬ 
wife, may supervise cases on her behalf during her absence 
on a holiday. The Board decided that in the circumstances 
stated the substitute may supervise the cases, but that the 
duty and responsibility of signing the certificates remain 
with the midwife approved by the Board. In case of such 
substitute acting in this manner it shall be notified on 
the schedule at the time of signing. The Board then 
adjourned. 

A letter has been addressed to the Lord President 
of the Privy Council by the secretary of the Central 
Midwives Board, giving facts and figures in relation 
to the training of midwives in Poor-law institutions. The 
letter points out that the public utterances of those who 
have advocated the transference of the responsibility for the 
training of midwives in workhouses or workhouse infirmaries 
from the Central Midwives Board to the Local Government 
Board appear to indicate an imperfect knowledge of the facts 
in connexion with the action of the Board in dealing with 
applications for approval from Poor-law institutions, and 
considerable misapprehension as to its causes and results. 
It continues as follows :— 

A conspicuous instance of this occurred at the very meeting of the 
Association of Poor Law Unions at which the resolution referred to in 


> Journal of Hygiene, vol vi., p. 467, and vol. vii., p. 43& 


i Tux Lancet, Dec. 28th, 1907, p. 1881. 





256 The Lancet,] 


THE VACCINATION ORDER OF 1907.—LOOKING BACK. 


[Jan. 25, 19C8. 


your letter of the 25th ult. was passed. Miss E. S. Kerrison, one of 
the guardians of West Ham, stated that “ they had excellent wards, 
and many applications for training could be entertained if they were 
allowed to do so.” “They had the wards and the women, but not the 
authority.” This statement passed unchallenged at the meeting and 
no doubt had it8 influence on the passing of the resolution. The real 
fact was, as pointed out by the medical officer of the union in a letter 
to the Poor Law Officers Journal- of Dec. 7th, that the West Ham 
workhouse had been recognised by the Board as a training school for 
more than two years. 

An analysis of the list of approved training schools as it stands 
at present, differentiating between Poor-law and non-Poor-iaw 
institutions, shows the following result Poor-law: London, 
6; England (except London), 13; Wales, 1 ; total. 20. Non-Poor- 
law : London, 12; England (except London), 21; Wales, 1; total. 34. 
In addition to these the medical officers of the following Poor-law 
institutions have been recognised as teachers of midwifery, thus 
enabling the training of midw ives to be carried on under precisely the 
same condiLions as if the institution itself had been approved as a 
training school: Blackburn, Blandford, Brentford, Burton-on-Treut, 
Christchurch, Epsom, Halifax. Hastings, Kingston-on-Thames, Llanelly, 
Merthyr Tydfil, Newbury, Portsmouth, Prescot, Preston, Heading, 
Kotherhain, Southampton, Swansea, Walsall, Wolverhampton, Wood- 
stock, Worces'.er. 

During the year 1907 the 20 approved Poor law institutions and the 
23 recognised Poor-law teachers have sent up 139 candidates to the 
Board’s examinations. The 34 non-Poor-law institutions and the 64 
teachers have sent up 1626. A scrutiny of the list of candidates shows 
that of the Poor-law institutions one, and of the Poor-law teachers 
seven, have nev er sent up a single candidate for examination. In these 
cases the Board concludes that either the material for training mid 
wives does not exist, or that the facilities already accorded by the 
Board have not been fully utilised. Since Jan. 1st, 1907, 15 Poor-law 
institutions have applied to the Board to be approved as training 
schools. Of these applications three have been granted, ten refused, 
and consideration of the other two is still pending. A list of the 
applications refused, with the number of deliveries per annum in each 
institution, is as follows 

Name of Institution. 

Ashton-under-Lyne Union Hospital . 

Auckland Union Infirmary . 

Dewsbury Union Workhouse Infirmary ... . 

Gateshead Union Hospital . 

Kingston Union Infirmary . 

Lincoln Woikhouse . 

North Blerley Union Infirmary (Bradford) 

Sculcoates Workhouse Infirmary (Hull) ... . 

Stepping Hill Poor-law Hospital (Stockport) . 

Wycombe Union Infirmary . 


* Medical officer recognised as teacher. 

It appears to the Board to be undesirable to accord the name of 
Training School to an institution which cannot within the Kules train 
more than two pupils per annum. In such cases where there is evidence 
of an effective possibility of adequate training, the policy of the Board 
is to recognise the medical officer as a teacher, a course which in no 
way limits the opportunity of the guardians for the purpose of train¬ 
ing. I am to add that, while the Board is deeply conscious of the 
necessity of according due facilities for the training of midwives where 
adequate guarantee exists for compliance with the Kules, it is very 
doubtful whether Poor-law institutions are authorised to undertake 
the training of any pupllB other than their own probationers. If the 
Board had granted all the applications for approval as training schools 
made during the current year by Poor-law institutions the list shows 
that the maximum addition to the number of candidates at the 
examinations would have been 13, trained under conditions inferior to 
the standard which the Board has endeavoured to maintain. 

I am further to submit that, in view of these facts, there is no ground 
for the suggestion that the policy of the Board has operated to limit 
the effective employment of methods and material at present available 
for the training of midwives. In conclusion, I am to state that, in the 
opinion of the Bo^rd, a division of authority, such as is contemplated 
by the resolution of the Association of Poor Law Institutions in England 
and Wales, would be prejudicial alike to the due training of midwives 
and to the public interest. 


Deliveries per 
annum. 

... 23 
... 8 
... 20 
... 34 
... 63* 

... 18 
... 16 
... 37 
... 39 
... 10 

268 


directed me to inquire whether I may be granted the privilege of an 
interview with one of the assistant secretaries or, in the alternative, 
whether I may be honoured with your advice in writing upon the 
following points :— 

1. As to the procedure to be adopted by public vaccinators who 
desire to appeal and 

2. As to the circumstances under which such appeal arises. 

The public vaccinators who desire advice may be divided into the 
following classes :—(a) Those who having been forced by threats of 28 
days' notice to accept what they consider inadequate fees liavo done 
nothing further, (b) Those who have been forced in a similar manner 
but who have also signed new contracts, (c) Those who have, without 
such compulsion, accepted lower fees, but who are not satisfied and 
would like to appeal to the Local Government Board, either at once or 
after an interval, during which they are prepared to give the new 
fees a fair trial, (ci) Those who have not agreed with their guardians 
before Oct. 1st last. 

My council is very anxious to know whether an appeal arises upon 
the issue of the instrument in all of such cases, and if not whether it 
arises in any, and if s) in which of them, and what has to be done by a 
public vaccinator who desires to appeal to the Local Government 
Board. 

In some cases public vaccinators have agreed w ith their guardians for 
a reduced fee on the understanding that it is only for a short period and 
as a trial, and in those cases the public vaccinators are anxious to know' 
whether, if the guardians refuse to reconsider the matter, they (the 
public vaccinators) will have a right to appeal to the Local Government 
Board. 

Apologising for troubling you at this length, 

I am, Sir, your obedient servant, 

(Signedf Chas. Grkenwood, Organising Secretary. 

The Secretary, Local Government Board. 

This letter elicited the following reply :— 

Local Government Board, Whitehall, S.W., Jan. 1st, 1908. 

Sir,—I am directed by the Local Government Board to advert to your 
letter of the 18th ultimo and to state that the appeal to the Board pro¬ 
vided for in Article Ill. of the Vaccination Order, 1907, arises in cases 
in which the vaccination contracts have not been determined and in 
which the guardians and public vaccinators have failed to agree on the 
fees to be paid ; but that a public vaccinator has no ground of appeal if 
he has signed the forms agreeing with the guardians as to the fees or 
has entered Into a new contract with the guardians. . 

A public vaccinator entitled to appeal to the Board should send to 
the Board a detailed statement of his reasons for declining to accept the 
fees offered by the guardians. 

I am, Sir, your obedient servant, 

(Signed) J. S. Davy, 

C. Greenwood, Esq. Assistant Secretary. 

We have carefully studied the Order to which this cor¬ 
respondence refers, which is couched in the usual confusing 
mass of legal verbiage in which Parliamentary documents 
seem to seek the concealment of their real meaning. We 
cannot explain why a document whiich is nominally intended 
for the guidance of the common people of England cannot be 
couched in language which may be readily “ understanded of 
the people,” and we can sympathise with those gentlemen who 
have misapprehended the clause in question, but there is no 
doubt that if they have signed an “instrument” issued 
under its authority they have legally bound themselves to 
accept the conditions of service and remuneration therein 
contained. Pablic vaccinators objecting to the terms of the 
“ instrument ” submitted to them should therefore appeal to 
the Local Government Board before signing it or they will 
find themselves in an unfortunately false position 


Hooking Back. 


FHOM 


THE VACCINATION ORDER OF 1907. 


THE LANCET, SATURDAY, Jan. 23rd, 1830. 


Some difficulty has recently arisen amongst public vac¬ 
cinators in connexion with Article III. of the Vaccination 
Order of 1907 in so far as it affects the contracts entered into 
with their respective guardians. It is well known that the 
Vaccination Order of last year was largely aimed at lowering 
the fees to which these officers were entitled, for it laid down 
that these fees should in future be set forth in an “ instru¬ 
ment ” or legal document having relation to the conditions 
of individual districts and sent to the guardians and public 
vaccinators concerned. It would appear that many of these 
officers have signed such an instrument without fully appre¬ 
ciating its significance, having misunderstood the meaning 
of the section of the Order which governed its issue, and the 
question of appealing to the Local Government Board has 
been raised by a number of them. On their behalf the 
following letter has been sent to that Board by the Associa¬ 
tion of Public Vaccinators of England and Wales:— 

1, Mitre Court Buildings, Temple, E.C., Dec. 18th, 1907. 

Sir, —As public vaccinators are continually Becking advice 
respecting their right of appeal against the “instrument” issued 
under the Vaccination Order of 1907, the members of my council have 


(hin-shot Wounds. —Gan-shot wounds have very commonly 
been considered as altogether different from wounds of other 
kinds, as being very peculiar in their nature. The injury 
which is inflicted by wounds of this nature, is very consider¬ 
able. The inflammation which they produce in the part is 
violent ; their consequences altogether are very serious. 
Hence, when fire-arms were first introduced, the effects of 
these wounds were found so much more serious than those 
which were ordinarily occasioned by the weapons which were 
previously employed, that it was supposed that gun-shot 
wounds were of a poisonous nature. It was suggested that 
the gunpowder, or the heat of the ball, in some measure 
affected the wound, and thus that some highly dele¬ 
terious effect was produced in the injured part. Attempts 
were therefore made to counteract this deleterious influence 
by such applications as were supposed to be capable of 
counteracting heat; the application of turpentine, hot oils, 
and similar hot and stimulating remedies, were resorted to 
for this purpose. Writers of modern times, particularly the 
military surgeons of Europe, have had ample opportunities 
of observing gun-shot wounds, and of investigating their 





The Lancet,] 


VITAL STATISTICS. 


[Jan. 25, 1908. 257 


nature; so that this part of the subject, and the particular 
rules applicable to it, are now very well understood. The 
only peculiarities in gun-shot wounds, arise from the nature 
of the objects by which the wounds are inflicted, and the 
degree of force with which they strike the textures of the 
human body. Balls, bullets, fragments of shells, splinters 
of stone and wood, and various hard substances of these 
kinds, are the objects by which the wounds are made, and 
they are driven with great force against the body ; they 
produce lacerated and contused wounds of the most serious 
kind ; that is, they produce injuries which are attended with 
very serious local inflammation. The degree of violence 
with which these wounds are inflicted, differs in different 
instances. If a gun-shot projectile meets the body directly 
and in full force, it traverses the part if it be small ; or if 
it be larger, and meet a limb, for example, it probably 
carries it away. If a small substance meet the body 
directly, with a less degree of force, it will tear and lacerate 
the part, break and splinter the bone, producing injuries of 
this kind according to the degree of force with which 
it was moving. Sometimes balls or bullets strike the 
body obliquely ; they do not come directly against it. but 
they strike it at various angles, and, in fact, do not 
enter the body, but, having touched it, glance off again. 
Under these circumstances, the soft textures that intervene 
between the skin and the bone may be divided, and effusion 
of blood may take place; tbe bone itself may be broken 
without the skin apparently being injured. It often happens 
in battle, that persons are found dead on the field in whom 
there is no appearance of a wound to account for death ; but 
if the bodies be accurately examined, some injury of this 
kind will be found to have taken place ; and those injuries 
have been very commonly ascribed to the “ wind of the 
ball.” It has been supposed, that a ball which has not 
struck tbe body, but has passed very near to it, produces 
some kind of influence, and that influence has vaguely been 
ascribed to tbe “wind” of the cannon ball. I fancy this 
explanation does not rest on any Bolid foundation ; we have 
no proof for saying that a cannon ball by its wind, in passing 
very near to the body, will commit this injury; in fact, 
if the limb of a person be cut off by a cannon ball, it is 
certain that the ball must go very near to the other, yet you 
do not find that other at all injured. There can be no ground 
then for supposing that these injuries are occasioned by the 
wind of projectiles. In other cases we find that bones may 
be broken, although tbe skin may be uninjured ; tbe state of 
the skin, therefore, is no proof that considerable violence has 
not been offered to a part. 1 


VITAL STATISTICS. 


HEALTH OP ENGL19H TOWNS. 

In 76 of the largest English towns 9139 births and 6227 
deaths were registered during the week ending Jan. 18th. 
The mean annual rate of mortality in these towns, which had 
been equal to 16-9 and 19 "3 per 1000 in the iwo preceding 
weeks, further rose to 20’0 in the week under notice. During 
the first three weeks of the current quarter the death-rate in 
these towns averaged 18 7 per 1000 ; the rate during the 
same period in London did not exceed 18'3. The lowest 
annual death-rates last week in the 76 towns were 9 1 in 
East Ham, 10 • 7 in Walthamstow and in Hornsey, and 11 • 6 
in Tottenham ; tbe rates in tbe other towns ranged upwards 
to 29 3 in Oldham, 30'7 in Warrington, 32 • 2 in Liverpool, and 
33'6 in Bootle. The rate in London last week did not exceed 
19 8. Tbe 6227 deaths registered in the 76 towns during the 
week under notice showed a further increase of 209 upon the 
numbers returned in the two preceding weeks, and included 
501 which were referred to the principal epidemic diseases, 
against 393 and 457 in the two previous weeks; of these, 
164 resulted from whooping-cough, 130 from measles, 63 
from diphtheria, 59 from diarrhoea, 55 from scarlet fever, 
30 from “ fever ” (principally enteric), but Dot one from 
small-pox. The deaths from these epidemic diseases in the 76 
townB were equal to an annual rate of 1 ■ 6 per 1000, the rate 
from the same diseases in London being 15. No death 
from any of these epidemic diseases was registered last week 
in East Ham, Huddersfield, Bouruemouth, St. Helens. 
Hornsey, or in four other smaller ‘.towns; the annual 


1 Excerpt from *' Lectures on Surgery, Medical and Operative, 
delivered at St. Bartholomew's Hospital by Mr. Lawrence. Lecture 
XVII." 


death-rates from these diseases averaged upwards in tbe 
other towns to 4 ‘ 1 in South Shields, 5 • 4 in Merthyr Tydfil, 
5'9 in Warrington, and 6 • 6 in Tynemouth. The fatal cases 
of whooping-cough, which had been 92 and 127 in the two 
preceding weeks, further rose to 164 last week ; the highest 
annual death-rates from this disease were 1'9 in Reading and 
in Aston Manor, 2 7 in South Shields, 3'4 in Merthyr Tydfil, 
and 3'7 in Warrington. The deaths from measles, however, 
which had been 103 and 141 in the two previous weeks, 
declined last week to 130; the highest death-rates from 
this disease last week were 2'1 in Swansea, 2'3 in 
Willesden and Rhondda, 3 0 in Wallasey, and 6 ■ 6 in 
Tynemouth. The 63 fatal cases of diphtheria also 
showed a decline, but included 19 in London, three 
in Portsmouth, three in Liverpool, 11 in Manchester 
and Salford, and two in Gateshead. The deaths 
referred to diarrhoea showed a slight increase and the 55 
deaths from scarlet fever also included those returned in 
recent weeks and included 24 in London, five in Birmingham, 
five in Liverpool, and two in Middlesbrough. The 30 deaths 
referred to “ fever ” also showed a slight increase upon 
recent weekly numbers ; two were returned in Leyton, three 
in Birmingham, four in Nottingham, nine in Manchester and 
Salford, and three in Liverpool. The number of scarlet fever 
patients under treatment in the Metropolitan Asylums Hos¬ 
pitals, which had declined in the six preceding weeks from 
5581 to 4481, had further fallen to 4325 on Jan. 18th. 
No case of small-pox has recently been admitted to 
these hospitals. The deaths in London referred to 
pneumonia and other diseases of tbe respiratory organs, 
which had been 333 and 460 in tbe two previous weeks, 
further rose to 498 during the week under notice, and ex¬ 
ceeded by 112 the corrected average number in the corre¬ 
sponding week of the five years 1903-07. The causes of 57, 
or0'9 per cent., of the deaths registered in the 76 towns 
last week were not certified either by a. registered medical 
practitioner or by a coroner. All tbe causes of death were 
duly certified in Leeds, Bristol, West Ham, Bradford, 
Nottingham, and in 47 other smaller towns ; in London all 
but one of the 1825 deaths were duly certified. No fewer 
than 16 of the causes of death were, however, uncertified in 
Liverpool, six in Birmingham, four in Hull, and three both 
in Manchester and Burnley. 


HEALTH OF SCOTCH TOWNS. 

The annual rate of mortality in eight of the principal 
Scotch towns, which had been equal to 20 • 6 and 24 • 3 per 
1000 in the two previous weeks was again 24-3 in 
tbe weekending Jan. 18th, and exceeded by 4 3 the mean rate 
during the same week in the 76 English towns. Among 
the eight Scotch towns tbe death-rates ranged from 
16 • 1 and 17 • 3 in Aberdeen and Paisley to 28 • 3 in Leith 
and 29'3 in Glasgow. The 857 deaths in these eight towns 
exceeded the number in the previous week by two, and 
included 158 which were referred to the principal epidemic 
diseases, against 127 and 143 in the two preceding 
weeks ; of these, 92 resulted from measles, 30 from 
whooping-cough, 13 from diarrhcea, 12 from “fever,” 
five from diphtheria, five from scarlet fever, and 

one from small-pox. These 158 deaths were equal 

to an annual rate of 4 5 per 1000, which exceeded 
by no less than 2 * 9 the mean rate last week from 
the same diseases in the 76 English towns. The 

fatal cases of measles in the eight Scotch towns, which 
had been 53, 65, and 84 in the three preceding weeks, 
further rose to 92 in the week under notice, of which 73 
occurred in Glasgow, seven in Greenock, and six in Dundee. 
The 30 deaths from whooping-cough also showed a con¬ 
siderable increase upon the numbers returned in recent 
weeks, and included 17 in Glasgow, five in Leith, and four 
in Edinburgh. The deaths attributed to diarTbcca were, 
however, somewhat fewer ; eight were returned in Glasgow 
and three in Dundee. Of the 12 deaths referred to “ fever ” 
in the eight towns nine were certified as cerebro-spinal 
fever (including cases in Glasgow and two in Edinburgh), 
and three as enteric fever, all of which occurred in Glasgow. 
Of the five fatal cases of Bcarlet fever three were returned in 
Glasgow and two in Edinburgh. Diphtheria caused two 
deaths in Dundee ; and the fatal case of small pox occurred 
in Leith. The deaths referred to diseases of the respiratory 
organs in these eight towns, which had been 128 and 205 
in the two preceding weeks, declined to 199 in the week under 
notice, but exceeded by 22 the number from the same 


258 The Lancet,) 


VITAL STATISTICS.—THE SERVICES. 


[Jan. 25, 1908. 


diseases in the corresponding week of last year. The 
causes of 22, or 2 • 6 per cent., of the deaths in these towns 
last week were not certified or not stated; in the 76 
English towns the proportion of these uncertified deaths 
last week did not exceed 0'9 per cent. 


HEALTH OF DUBLIN. 

The annual rate of mortality in Dublin, which had been 
equal to 25 ■ 5 and 26'0 per 1000 in the two preceding weeks, 
further rose to 31 • 2 in the week ending Jan. 18th. During 
the first three weeks of the current year the death-rate in 
the city averaged 27 6 per 1000, the rates during the same 
period not exceeding 18 ■ 3 in London and 18 • 2 in Edinburgh. 
The 236 deaths of Dublin residents registered last week 
showed a further increase of 39 upon the numbers returned 
in recent weeks, and included but three which were referred 
to the principal epidemic diseases, against ten and four in 
the two preceding weeks ; all these three deaths were referred 
to “fever,” probably enteric. These three deaths from 
epidemic diseases were equal to an annual rate of 0 4 
per 1000, the death-rates from the same diseases last 
week being 1'5 in London and in Edinburgh. No death 
in Dublin last week was referred to small-pox, measles, 
scarlet fever, diphtheria, whooping-cough, or diarrhoea. 
The 236 deaths from all causes in Dublin last week included 
37 of infants under one year of age and 76 of persons 
aged upwards of 60 years ; the number of deaths of elderly 
persons showed a marked increase upon the numbers returned 
in recent weeks. Nine inquest cases and seven deaths from 
violence were registered, and 98, or 41 ■ 5 per cent., of the 
deaths occurred in public institutions. The causes of five, 
or 2'1 per cent., of the deaths in Dublin last week were 
not certified ; the proportion of these uncertified causes of 
death last week did not amount to 0 ■ 1 per cent, in London 
but were equal to 2 ■ 4 per cent, in Edinburgh. 


THE SERVICES. 


Royal Navy Medical Service. 

The following appointments are notified : Civil Practitioner 
J. Kirkwood to be Surgeon and Agent at Helmsdale. 

Royal Army Medical Corps. 

Lieutenant-Colonel John 0. Haslett is placed on temporary 
half-pay on account of ill health (dated Jan. 20th, 1908). 

Lieutenant Colin Cassidy, from the Seconded List, to be 
Lieutenant (dated Jan. 1st, 1908). 

Colonel D. Wardrop has been selected to succeed Lieu¬ 
tenant-Colonel H. E. R. James as Commandant and Director 
of Studies, Royal Army Medical College. The under¬ 
mentioned have joined at Aldershot and have been posted 
as follows: Lieutenant H. de V. King and Lieutenant 
J. C. L. Hingston to the Cambridge Hospital for duty, 
and Lieutenant J. B. Hanafin to the Connaught Hospital 
for duty. Lieutenant-Colonel A. E. Tate and Captain 
H. A. Bransbnry have joined the London District 
for duty. Major M. Boyle has been posted to the Station 
Hospital, Lucknow, aDd appointed Specialist in Electrical 
Science, 8th (Lucknow) Division. 

Volunteer Corps. 

Rifle: 3rd Volunteer Battalion, The Northumberland 
Fusiliers : Henry Smurthwaite (late Captain) to be Surgeon- 
Lieutenant (dated Nov. 1st, 1907). The Queen’s Rifle 
Volunteer Brigade, The Royal Scots (Lothian Regiment) : 
The undermentioned Surgeon-Captains to be Surgeon-Majors : 
J. H. A. Laing (dated Oct. 28th, 1907) ; and J. Pirie (dated 
Oct. 29th, 1907). 1st Volunteer Battalion, The Prince 
Albert’s (Somersetshire Light Infantry): Supernumerary 
Surgeon-Major J. M. Harper (Brigade Surgeon-Lieutenant- 
Cylonel, Senior Medical Officer, Cornwall and Somerset 
Volunteer Infantry Brigade) to be Surgeon-Lieutenant- 
Colonel, remaining supernumerary (dated Dec. 21st, 1907). 
1st Herefordshire Volunteer Rifle Corps : Arthur Llewellyn 
Baldwin Green (late Lieutenant) to be Surgeon-Lieutenant 
(dated Deo. 16tb, 1907). 6th Middlesex (West Middlesex) 
Volunteer Rifle Corps: Surgeon-Captain and Honorary 
Surgeon-Major Richard Charles Maron Pooley (late 1st Volun¬ 
teer Battalion, The Duke of Cornwall’s Light Infantry) from 
the Retired List to be Surgeon-Captain, with the honorary 
rank of Surgeon-Major (dated Jan. 1st, 1908). 


Alexandra Military Hospital, Portsmouth. 

The Royal opening of the New Alexandra Military Hos¬ 
pital on the southern slopes of Portsdown Hill, near Ports¬ 
mouth, has been abandoned. The Portsmouth Military 
Hospital staff will enter into occupation of the new buildings 
shortly. 

The New Medical Service for the Territorial Force. 

The Director-General of the Army Medical Service 
addressed a meeting of medical men at the West Kent 
Hospital, Maidstone, on Dec. 17th last, upon the new 
medical service for the Territorial Force. Dr. C. E. Hoar 
was in the chair and invitations had been sent to all medical 
officers of Volunteers in the Home Counties Division of the 
Eastern Command. There was a full and appreciative 
audience, which included amongst many others Colonel 
M. W. Russell, D.A.D.G . R.A.M.C., Surgeon-Colonel H. G. 
Thompson, V.D., Surgeon-Colonel R. T. Csesar, V.D., Colonel 
T. F. MacNeece, A.M.S., and Major C. P. Oliver, whocarried 
out the arrangements for the meeting and who was able to 
announce that although many of the officers invited had not 
been able to attend, yet all bad expressed themselves as 
accepting the scheme as they had read it in the papers. 
Sir Alfred Keogh’s speech was such as we have reported at 
similar meetings during his late autumn campaign and there 
is no occasion to repeat his arguments in detail. He took for 
his text the capital axiom that the function of the medical 
service of an army is to maintain the lighting strength of 
that army in the field and showed the lamentable deficiency 
of the present volunteer medical arrangements in administra¬ 
tion, sanitation, and hospital organisation. He expounded 
his scheme by which he will be able to retain the 
services of the most skilled experts for the troops in 
time of war without burdening them with irksome and 
useless military training and also indicated how medical 
men who are unable actually to join the scheme may 
yet promote it by helping to instruct the members of 
the new force in sanitation, Ac. He called attention to the 
great advantage which the continental powers have over us 
in the medical service of their home forces and submitted 
that we should become equally efficient iu this respect. Sir 
Alfred Keogh very modestly deprecated the general pro¬ 
fessional opinion that the whole credit of the present scheme 
rests with him, pointing oat that volunteer medical officers 
had long recognised the great need for reform and that in 
1901 those in the north put forward a scheme to 
this end. Later the British Medical Association also 
evolved a scheme which was practically the same as that 
which he was advocating. The speaker was well received 
and subsequently replied to a number of questions addressed 
to him regarding administration, discipline, pay, and 
uniform under the conditions of the new service. Surgeon- 
Colonel Thompson proposed a vote of thanks and pointed 
out that although the Director-General disclaimed the credit 
of originating the proposals, yet he had coordinated them 
in a concrete form. The success of this meeting is of good 
augury for the future medical service of the Territorial Force 
in the Home Counties. 

An Indian Editor Punished for Defamation of an 
Offices of the Indian Medical Service. 

Mr Alfred Nundy and Lala Moot Ohand, respectively 
editor and printer of the Tribune, a newspaper published at 
Lahore, have been fined, the former Rs.250 and the latter 
Rs.50, with alternatives of simple imprisonment, for defam¬ 
ing Captain W. E. McKecbnie of the Indian Medical Servioe. 
From a long and elaborate judgment delivered by the judge, 
Mr. Connolly, we learn that one night in May, 1906, a 
punkha coolie was found lying dead at his post outside the 
barracks at Jullundur, and that it was alleged by the 
father of the deceased that his son had died from a kick 
given him by a soldier. At an inquest which was sub¬ 
sequently held the cause of death was found to have 
been double pneumonia, and it wa9 further proved 
after a careful examination that there was not the 
slightest trace of physical injury on the body. The 
presiding magistrate upon this issued an order for the 
arrest of the deceased’s father in order that he might be 
tried for having given false evidence at the iuquest. The 
occurrence excited considerable attention and in a series of 
three articles having reference to it the Tribune made state¬ 
ments which Captain McKecbnie, by whom the post-mortem 
examination was conducted, regarded as libellous. An 
action for defamation was accordingly brought by that officer 
against the above-mentioned persons, who in due course were 





The Lancet,] 


PLEURAL EFFUSION AND ITS TREATMENT. 


[Jan. 25,1908. 259 


found guilty and punished as we have stated. In the course 
of his judgment Mr. Connolly said that he agreed with the 
contention of the prosecution that the meaning conveyed 
to the readers of the paper by the articles was that the 
medical evidence in the case was intentionally and 
deliberately false, and that it was given in order to 
screen from punishment a European soldier who had 
virtually murdered the deceased. The charge was one of 
perjury, of a criminal offence on a particular occasion, 
a charge affecting complainant’s private as well as his 
publio oharacter. There were, however, several factors 
that should be taken into consideration in extenuation. 
These Mr. Connolly proceeded to enumerate at some length, 
adding his belief that there was no proof that Captain 
McKecknie had suffered any material damage. The extenuat¬ 
ing circumstances, said Mr. Connolly in conclusion, "all 
call for a lighter penalty than the serious nature of the 
implication would otherwise demand.” It is certainly 
fortunate for the editor of the Tribune that the learned judge 
was content to listen to the pleadings of mercy. 


Cffmspnhnft 


“ Audi alteram partem.” 

PLEURAL EFFUSION AND ITS 
TREATMENT. 

To the Editor of The Lancet. 

Sin,—I hope the rest of your readers are edilied by 
Dr. Harry Campbell’s letter under the above title in your 
issue of Jan. 11th. I must candidly confess that I am not; 
however, as I hope to get some educational advancement 
in physios I continue this controversy. In my first letter I 
was quite willing to allow an eUutioian of Dr. Harry 
Campbell’s standing to Bettle the meaning of the term 
elasticity, but on further consideration I find that it will not 
be confined either etymologically, physically, or in common 
parlance within the narrow bounds set for it by Dr. Campbell, 
so I therefore revert to my former position stated in my 
Bradshaw lecture. With the Greeks an iXaryp was a driver, 
a hurler, a charioteer, &o. ; {\aweiv to drive, banish, hurl, 
impel, put to flight, row, lead, carry forward, strike, wound, 
harass, beat out; iXaett the act of riding, driving, a military 
expedition, march, pursuit, &c.; hence tXnmnus and elastic 
were applied to any implement, such as a catapult, used for 
hurling missiles by the force of a spring. Possibly David’s 
sling with which he slew Goliath may have been of this 
nature but I shall try a less strenuous method of disposing of 
my antagonist. 

In the “ Century Dictionary, ” which is one of the latest 
references I have at hand on the subject, I find under the 
meanings of elastic :— 

2. Having, as a solid body, the power of returning to the form from 
which it Is bent, extended, pressed, pulled, or distorted, as soon as the 
force applied is removed ; having, as a fluid, the property of recovering 
its former volume after compression. A body is perfectly elastic when 
it has the property of resisting a given deformation equally, however 
that deformation may have been produced, whether slowly or suddenly, 
Ac. All bodies, however, have different elasticities at different 
temperatures, and if the deformation Is so sudden as to change the 
temperature of the body and so alter its resistance to deformation, 
this is not considered as showing it to be imperfectly elastic. 

In contradistinction to the foregoing physical definition 
of elasticity, Dr. Campbell says that when the term is 
applied to the lungs it signifies * ‘ their power of recovering 
their form after being stretched.” This is what the Campbell 
physicist says, it is a mere property of a certain form of matter 
by which it has the power of recovering its original form 
after being stretched, but I prefer the other authority who 
says that it also signifies a resistance to stretching or other 
deformation . 

It is only certain forms of matter which possess this 
property of elasticity , so it is not universal, like gravity. 
Surely Dr. Campbell will admit that we can measure the 
force of elasticity even more easily than we can measure the 
force of gravity. It is not sufficient for him to tell me that 
it is merely a property of matter, that it is a “power of 
recovering form after being stretched.” The same power that 
enables elastic matter to recover form after being stretched 
sorely offers an equivalent resistance to the process of 


stretching. This force of elasticity can be as easily estimated 
by the resistance as by the power of recovery. We can 
estimate the force of gravity in different latitudes and at 
different levels above the sea, and it is the force of gravity, 
rather than any abstract idea of it being a property of 
matter, which interests us. The same can be said of 
elasticity. How do I know that a collapsed lung is elastic 
if I do not stretch it? I not only want to know if it 
be clastic but I want to know how perfect is the elasticity. 
If 1 stretch the lung to find this out Dr. Campbell tells me : 
Oh, you are only making the lung taut ; stop your stretching 
and you will see the elasticity. I reply that I am doing 
a great deal more : I am finding out the lung’s capacity 
for being stretched and its resistance to stretching ; con¬ 
sequently I am finding out the elasticity and the force of the 
elasticity. 

“ The elasticity of the lungs does not, as Sir James Barr 
assumes, rise and fall a9 these organs expand and contract 
in respiration, but remains the same. \Y hat does rise and 
fall under these conditions is the pull which the lungs exert 
on the visceral pleura.” If this language means anything it 
means that the lungs contain a certain amount of elastic 
tissue in virtue of which they possess the abstract property of 
elasticity, and as this elastic tissue remains the same whether 
they are stretched or collapsed their state of tension or 
tauoness has nothing to do with their elasticity. He seems 
to forget that if they are overstretched as in emphysema or 
long collapsed as in pleural effusion they lose their elasticity. 
It is not with any abstract property in the lungs called 
elasticity but with the manifestation of the force of their 
elasticity with which we have got to deal. What causes the 
pull which the lungs exert on the visceral pleura but their 
elasticity ? Dr. Campbell says it is their tautne&s. The 
lungs might remain stretched when they lost their elasticity, 
but they would not remain taut without their elasticity. I 
shall deal with his fibroid tissue later. 

Take a perfectly elastic body like air and see how its 
elasticity does not remain constant, but rises and falls under 
varying circumstances; it exercises a force equal to that by 
which it is itself compressed, and with every rise of a degree 
of temperature there is an increase of elastic force, yet, 
reasoning from analogy, I suppose. Dr. Campbell would say 
that the elasticity was a mere property of the air which like 
that of the lungs “remains the same, but the rise and fall 
was only in the tautneas of the atmosphere.” 

Now for some more extraordinary reasoning from this 
writer. He quickly drops the negation called “ suction ” 
which he had elevated into a constant force “which sucks 

blood into the heart.I should not, however, have called 

attention to 8ir James Barr’s ambiguous employment of this 
term—few writers are guiltless of ambiguity—were it not 
that he assumes, or appears to assume, that the suction, or 
let us say traction, which the lungs exert on the circumjacent 
parts is necessarily bound up with their elasticity. Such, as 
I pointed out in my letter, is not the case. This traction 
is in direct proportion to the degree to which the lungs are 
rendered taut—for the more taut the pulmonary tissue the 
greater is the tug exerted on the visceral pleura but com¬ 
paratively non-elastic lungs, such as those seamed with scar- 
tissue, are capable of being rendered more taut, and thus of 
exerting more traction on circumjacent parts than normal, 
highly elastic lungs.” . .. ; , 

This reasoning is that of the academician in his study 
and not that of the clinician who views facts and reasons 
therefrom. I shall now proceed to prick the bubble. 
When a ship is riding at anchor and the strain constant a 
comparatively non-elastic chain answers admirably, but when 
the strain is variable, as when a ship is being moored, the 
hawser is made of highly elastic hemp ; if a. chain were 
used there would be constant danger of it snapping or of the 
ship being damaged by bumps against the quay. The elastic 
rope offers resistance to being stretched and when the tug of 
the ship ceases the elasticity gradually pulls the vessel back 
to its former position. The elastic tension of more or less 
stretched healthy lungs maintains a constant intrapleural or 
intrathoracic negative pressure both during quiet inspira¬ 
tion and expiration and thus allows the blood to be driven 
in at all stages of respiration, but non-elastic fibroid lungs 
cannot be taut both in inspiration and expiration and there¬ 
fore a constant negative pressure cannot thus be maintained. 
The idea of the slow shrinkage of fibroid tissue keeping up a 
constant tautness is too absurd to demand attention ; if the 
cord be shortened it may more readily be made taut, but 
whether short or long there must be an intermittent 



260 The Lancet,] 


PLEURAL EFFUSION AND ITS TREATMENT. 


[Jan. 25. 1908. 


variation in the tautness of those non-elastic lungs during 
each respiration. 

In his former letter he assumed the non-adherence of the 
pleurae and we now get several other assumptions ; I should 
have preferred facts. He thinks his “ purpose is equally 
well served by taking an actual case in which the pleurse are 
adherent. In such a ca6e the traction which the lungs exert 
on surrounding structures is considerably in excess of the 
normal and this excess is partly due to the contraction of the 
scar-tissue but still more to the preponderating action of 
the inspiratory muscles.” I think he might offer some proof 
of all these statements, and this he tries to do by saying 
that “in fibroid phthisis the inspiratory muscles do act 
powerfully, as he can assert from personal observation,” 
but this is no proof that there is increased tantness of 
the lungs and consequent lowered intrathoracic pressure. 
In asthma and emphysema the inspiratory muscles, both 
ordinary and extraordinary, may pull and tug and struggle 
and strive to get air into the chest, but the whole time 
the intrathoracic pressure may be positive, and Dr. Harry 
Campbell might tug and pull and push at Cleopatra’s Needle 
till he was black in the face, but he would not make the 
slightest impression on it. In fibroid lungs there may be a 
slight fall in the intrathoracic pressure during inspiration, 
but in advanced cases there is nearly always a positive 
pressure in expiration and then the blood is not “ sucked in.” 
The variations in such pressures only amount to a few 
millimetres of mercury. What an enormous difference there 
is between this and the “ suction ” of healthy elastic lungs. 
Dr. Campbell ought to be able to produce in Muller's 
experiment a negative intrathoracic pressure of 70 or 80 
millimetres of mercury and a person with fibroid lungs could 
not do a tenth part of this. What is the use of discussing why 
a fish should not displace water or how strongly acting 
inspiratory muscles drag out the chest and with it make taut 
the adherent lungs which thus exert “ more traction on cir¬ 
cumjacent parts than normal highly elastic lungs.” Try and 
you will find that the fish does displace water, and the lungs 
are not taut, and the intrathoracic pressure is not lowered. 
When Sir Frederick Bramwell and some other members of 
the capital sentences committee discovered that ropes 
stretch much more than is usually anticipated, and that 
there is great variation in the stretch of different ropes 
according to their constitution, and the amount of strain to 
which they are submitted, and also in the same rope in 
different circumstances and according to the amount of 
moisture which it contains, I was asked by the Home Office 
if I could devise a method of estimating the elasticity of any 
rope. I did not retire to my study and work out the 
coefficient of elasticity and what should but what probably 
would not happen. I determined the vis viva or energy 
which I considered necessary, and then under a strain of a 
given number of foot-pounds I determined the stretch, and I 
had no difficulty in devising a method of measuring the 
length of unBtretched rope which would allow of a given 
energy. So far as I know, my method is still in force, at 
least, it was when I left the prison service. 

He again says that “ in many cases of fibroid phthisis the 
mean size of the thorax is increased, and this in spite of the 
fact that the lungs are less than normally yielding to a 
stretching force. How could such an increase be effected 
but by supernormal activity of the inspiratory muscles?” 
I always thought that fibroid tissue occupied less space 
than the portion of the lung which it replaced. I am 
afraid there is some confusion in Dr. Campbell’s mind 
between fibroid tissue and the accompanying emphy¬ 
sema. We are not at present discussing the causes of 
emphysema, but only Dr. Campbell’s non-existent increased 
tautness of fibroid lungs, so we need not pursue this point 
further, but I might refer Dr. Campbell to the extremities 
and ask him to inquire why his heightened tautness of the 
lungs should allow the finger ends to become bulbous. 

He says : “ What, I would ask, has the average intra- 
pulmonary pressure got to do with the stretching of the lungs 
when the pleura are adherent ? Manifestly nothing what¬ 
ever.” The question and answer coming from a physicist 
are really very funny. Does he not know that whether the 
pleurae are adherent or not the thoracic parietes intervene 
between the external atmosphere and the lungs, and any 
force which expands the thorax beyond the expansile power 
of the lungs must exercise a power of 15 pounds to the square 
inch, and this the inspiratory muscles could not do over such 
a large surface as the chest though they tugged and pulled 
like Dr. Campbell at Cleopatra’s needle ? The inspiratory 


muscles, like Dr. Campbell, often expend a lot of useless 
energy. How often do we grieve at the struggles of a poor 
asthmatic doing nothing ? Regarding his remarks about the 
piece of cord, the root of the lung, the visceral pleura. &c., 
he forgets that every time the cord is stretched in in¬ 
spiration it is relaxed in expiration ; healthy elastic lungs 
remain always elastic and taut and in direct proportion to 
the manifestation of their elasticity their tautness and the 
intra thoracic negative pressure are increased. 

I shall not now dwell on his remarks on his interesting 
lectures to which I referred, as I shall probably read them 
again when I get more' leisure—not having done so since 
1904—but he need not flatter himself that they have met 
with general acceptance because they have hitherto passed 
uncriticised, though I think this is not strictly accurate, 
because I believe, if my memory serve me rightly, and 
it does not often fail me, that about July, 1904, I ex¬ 
pressed to Dr. Campbell a somewhat similar opinion to 
that recorded by me in your pages. Mine ilia: lachrymte. 
Notwithstanding Dr. Harry Campbell, the tautness of the 
lungs depends on their elasticity and the pressure of 
the air within them, hence I have arrived at the point from 
which I started, the winning post. Magna est veritas, 
et pncralebit. I am, Sir, yours faithfully, 

Liverpool, Jan. 12th, 1908. _ JAMES Barr. 

To the Editor of The Lancet. 

Sir, —In the discussion which haB lately taken place 
under the above heading in your columns between Sir James 
Barr and Dr. Harry Campbell it appears to me, as in so 
many debated subjects, there is something to be said from 
both points of view. The question would, however, be 
materially simplified by defining exactly what is meant by 
“elasticity” before proceeding to discuss it. Elasticity is 
the property of a substance in virtue of which it tends to 
return to its original form and condition after distortion by 
a force ; and it is measured quantitatively by the amount 
of force required to produce a given distortion in a given 
volume, or unit, of the substance. Thus steel is more 
elastic than ivory, and ivory than rubber. Rubber yields 
considerably to a small force and is therefore comparatively 
inelastic. It possesses the quality of elasticity to a striking 
degree but in a low measure. 

It is important to remember that elasticity is a property 
fixed in amount for any substance. Distortion may render it 
evident but does not increase it. Like moral qualities in 
man, temptations may exhibit them, but the tried man was 
a gentleman or honourable before his trials, and if the latter 
be doubled he is not double the gentleman or double the 
saint. Sir James Barr is certainly in error where he says in 
his letter of Dec. 21st, “ The more taut or stretched (the lung) 
the greater will be its elasticity or tendency to recover its 
form after being stretched.” Us elasticity and tendency to 
recover cannot be increased by stretching; it was inherent 
in it and fixed in quantity frbm the first. The tendency of a 
cat to return home is as great when asleep on the hearth as 
when lost in the woods; and the unstretched lung of an 
unborn babe is as elastic as that of the expanded lung of 
the newly born infant. In the one case the elasticity is 
dormant-, and in the other called into play, but increased 
ntver. 

In considering the forces producing a negative pressure in 
the pleural sacs there is less objection to 8ir James Barr’s 
statements : “ In health there is a slight negative pressure in 
the pleurae owing to the elasticity of the lungs,” and “the 
elasticity of the lungs tends to separate the pleural surfaces." 
It is, however, to these statements Dr. Harry Campbell so 
strongly objects, apparently because of the very restricted 
sense in which they are true. When an infant first breathes 
it is the expansion of the chest walls under muscular action 
which tends to create an intrapleural space of lowered 
pressure and into this the lung simultaneously expands, 
because the pressure of the air entering by the windpipe into 
the lungs is greater than the reduced pressure beneath the 
thoracic walls by the amount the muscular inspirations can 
reduce it. In this way the negative pressure in the pleural 
sacs is created by muscular effort and not by elastic recoil 
of the lungs. It would be even greater, as Dr. Oampbell 
contends, if the lungs did not expand. It is their 
expansion which limits the fall of pressure in the pleural 
sacs. By following the chest expansion the lungs allow 
the visceral pleura to press on the parietal with a force 
equal to the whole atmospheric pressure, less that which 
the elastic recoil of the lungs can support and neutralise. 


Thb Lancet,] 


LICENTIATES IN MIDWIFERY.—ACUTE PULMONARY (EDEMA. [Jan. 25, 1908. 261 


"The force of elastic recoil of the luDgs therefore measures the 
limit of pressure fall in the pleural sacs which the thoracic 
expansion can effect. If the lungs have but little elastic 
recoil and stretch easily very little negative pressure can be 
produced by the thorax on inspiration ; if the coefficient of 
elasticity be great and the lungs have considerable elastic 
recoil the inspiratory muscles expanding the thorax have 
something to pull against and can produce greater negative 
pressure ; if the lungs be comparatively rigid the whole 
force of the inspiratory muscles can be directly expended on 
reducing the intrapleural pressure. * In this sense Dr. Camp¬ 
bell’s contention seems to me physically correct. 

On the other hand, there are conditions in which Sir James 
Barr is correct likewise. For oonsider the thorax and its 
respiratory muscles at rest. The lungs remain stretched ; 
they support by their elastic recoil a certain fraction of 
atmospheric pressure to which the intrapleural space (if 
space it may be called) is not subjected in consequence. 
In that sense, as Sir James Barr states, " there is a slight 
negative pressure in the pleurae owing to the elasticity 
of the lungs." Why all new repair elastic substance in 
the lungs is laid down in a stretched condition is difficult 
to see, though the utility of it is obvious. One would have 
imagined that the elastic tissue would have arranged to be 
at rest when the thorax was at rest, but it strangely chooses, 
from birth onwards, never to assume the unstretched con¬ 
dition. There is, therefore, a residual negative pressure for 
which the pleural sacs are indebted to the elasticity of the 
lungs and the opposing rigidity of the thorax. For the reBt, 
the active and greater falls, they are indebted to the mus¬ 
cular efforts of the thorax and diaphragm and are distinct 
losers by the comparatively low elastic recoil of the lungs 
themselves. 1 am, Sir, yours faithfully, 

Mentone, Jan. 16th, 1908. D. W.'SAMWAYS. 


BRITISH SHIP SURGEONS’ ASSOCIATION. 

To the Editor of Thb LANCBT. 

Sib, —May we through jour valuable journal issue a letter 
of welcome to all members of the medical profession interested 
in the formation of the above association.' A meeting has 
been arranged to take place on Monday, Jan. 27th, at 8 P.M., 
at the Medical Graduates' College and Polyclinic, 22, Chenies- 
street, Gower-street, London, W., and we hope for a large and 
representative gathering. The object of such an association 
has been given in former issues and ship surgeons are almost 
unanimous as to its need. As some of us from the north are 
coming at great inconvenience to our practices we do hope 
that ex-ship surgeons and others, now practising in or near 
the metropolis will do their best to attend. 

I am. Sir, yours faithfully, 

G. Metcalfe Sharpe, Hon. Sec., 

«Tao. 20th, 1908. Late Surgeon Cunard and I', and O. Companies. 


LICENTIATES IN MIDWIFERY. 

To the Editor of The Lancet. 

Sib, —The annotation upon this subject in the current 
number of The Lancet suggests that it would not be 
inopportune to relate a stage in the history of medical 
politics in this country, particularly with respect to the 
education of would-be women medical practitioners. In 1852 
the Royal College of Surgeons of England sought and gained 
in a supplementary charter power to examine "persons” 
for a diploma—Licentiate in Midwifery of the Royal College 
of Surgeons of England, commonly abbreviated to "L.M.” 
It is said that the inclusive word "persons"in Clause 17 
of the new charter was introduced deliberately. Under 
Schedule A (4) of the Medical Act, 1858, such persons might 
be "registered ” with this single qualification. It was, how¬ 
ever, urged by some that the " L.M." diploma was only to be 
issued to men who were already otherwise qualified. The 
Medical Act, 1875, sec. 2, did not vary the position. This 
diploma was suppressed in 1876, In 1872 the King’s and 
Queen's Colleges (now the Royal College) of Physicians in 
Ireland made their midwifery licence registrable ; in 1874 
they granted diplomas to midwives. It was not, of course, 
until the Medical Act, 1886, sec. 2, became law that a triple 
qualification in medicine, surgery, and midwifery was 
essential prior to the registration of the name of a would-be 
medical practitioner. 

The Female Medical Society (1862-72) was founded “ to 


provide educated women with proper facilities for learning 
the theory and practice of midwifery and the accessory 
branches of medical science." The Ladies’ Obstetrical 
College (Great Portland-street) was founded in 1873. In 
1876 Miss Sophia Jex-Blake, Miss Edith Peohey, and Mrs. 
Thorne, having been informed of an opinion of counsel given 
to the College of Surgeons as to the scope of Clause 17 of 
their enlarged charter, and having fulfilled all precedent 
requirements, claimed to be “persons" who must be exa¬ 
mined by the Royal College of Surgeons for the licence in mid¬ 
wifery. In this way they hoped to secure admission to the 
Medical Register. The midwifery board of examiners of the 
College, led by the late Dr. Robert Barnes, resigned in protest, 
thus postponing in January, 1876, the examination tine die. 
It haB never since been conducted. The Obstetrical Society of 
London concurred with this practical protest. The late Dr. 
Robert Barnes, writing to me in October, 1906, said with 
respect to this Incident: “I may say that 1 rescued the 
College and the profession from the disgrace of issuing a 
barren midwifery licence.” 

1 am, Sir, yours faithfully, 

Adelpbi-terrace, W.C., Jan. 13th, 1908. STANLEY B. ATKINSON. 


A CASE OF “ DIPHTHERIA OF THE SKIN.” 

To the Editor of The Lancet. 

Sir,—D r. J. G. Hare is to be congratulated in clearing up 
the nature of Dr. Alan B. Slater’s remarkable case of cuta¬ 
neous diphtheria as reported in The Lancet of Jan. 4th. The 
case raises some interesting pathological issues, particularly 
in regard to the underlying cause of a diphtherial infection 
so extensive. It is, however, perhaps unnecessary to infer 
such an unusual course of events as that suggested by Dr. 
Slater in his ingenious explanation. Diphtheria bacilli do 
not spread far and wide via the superficial lymphatics, but 
they are conveyed at times from one abraded surface to 
another by auto-iooculation. Moreover, while neuritis is an 
ordinary and specific feature of diphtheria, herpes of the 
neuritic type is rare in that disease—is, in fact, commoner 
in other infections, notably scarlet fever, which present the 
rash as a pure complication. 

The peculiar characteristics of the case being the wide¬ 
spread distribution of the lesions and their long duration, it 
seems to me that if auto-inoculation be accepted an explana¬ 
tion based on established pathological facts is forthcoming. It 
is well known that nurses with slight abrasions of the fingers 
may, when working in diphtheria wards, develop a localised 
diphtherial infection and that a permanent cure may not be 
obtained for weeks or even months if antitoxin is not given. 
It may happen that more than one finger is infected, and 
there seems to be no reason why this modified form of 
diphtherial lesion should be restricted in distribution where 
the inoculable points are multiple. Given, then, that the 
original conjunctivitis and vulvitis were wholly or partly 
septic in nature, it might well be that the patient developed 
a spreading septic rash such as is often seen nnder such con¬ 
ditions in children. The cutaneous abrasions would offer 
paints of inoculation, and the diphtheria bacillus, established 
anywhere from mixed infection of the eye or vulva or from 
an outside source, would be readily carried in the discharges 
from one area to another. 

Now that Dr. Hare has proved bacteriologically the nature 
of one case, there is the interesting possibility that other 
obstinate Bkin affections of a similar type may also turn out 
to be diphtherial. 

I am, Sir, yonrs faithfully, 

John Biernacki. 

Plaistow Hospital, London, E., Jan. 12th, 1908. 


ACUTE PULMONARY tEDEMA. 

To the Editor of Thb Lanobt. 

Sir. —With reference to the interest lately awakened by 
the able dissertation upon acute pulmonary oedema by Dr. 
Leonard Williams in The Lancet of Dec. 7th, 1907, may I 
be permitted to add my humble testimony of what I consider 
to be a most remarkable and typical example of the con¬ 
dition. At 10 p.m. last night I was summoned to see a man 
who, I was told, had been taken suddenly and severely ill. I 
immediately set out and arrived on the scene within five 
minutes of the summons to find the patient dead. 

The history was as follows. The patient, a maD, aged 
48 years, had been at his work all day apparently in the best 




262 The Lancet,] 


THE CAUSE OF THE PREVALENCE OF ADENOIDS. 


[Jan. 25, 1908. 


of health excepting a slight dry cough from which he had 
been suffering for the past week or ten days. He returned 
home a little after 6 r M. and partook of his usual tea, 
making a good supper a little before 9 previous to turning in 
for the night at about 9 30 P.M., as from the nature of his 
occupation he was obliged to keep early hours. At a few 
minutes to 10 he started out of bed, remarking to his wife 
that he ‘‘felt choked” and ran into the front sitting- 
room. Here he sank on to a chair and evidently still 
experiencing intense agony in this situation rolled on to 
the floor and expired. His intensely cyanosed appearance 
on rising out of bed so alarmed biB wife that I was sent 
for immediately and arrived at the house it is estimated 
less than ten minutes after the time when he left his 
bed. The remarkable severity and rapid dissolution in 
this case call, I think, for special notice as the experience 
must be a very rare one. The appearance of the body when 
first seen by me was as follows. The face was intensely 
livid and wore an expression of agony, the pupils were very 
widely dilated, the body was of a natural warmth, supple, 
muscular, and well nourished and the thorax well formed! 
Even at this time an abundance of white foam was welling 
from the mouth and nostrils and there was an escape of a 
considerable amount of pinkish serous fluid from the 
mouth. I made the necropsy to-day at 3 P.M.,at which 
the following additional appearances were observed. 
Post-mortem lividity was strongly marked and the veins 
all over the surface of the body were greatly distended 
with very dark blood. The frothy material was still 
issuing from the nostrils and mouth but the flow of serous 
fluid had ceased. Each pleural cavity contained about half 
a pint of reddish serous fluid. The lungs were somewhat 
voluminous from commencing emphystma at the apex and 
anterior borders and on division of the bronchi discharged an 
enormous quantity, over three pints, of reddish serous and 
frothy fluid, while this could also be squeezed from the lung 
through the bronchi and all cut surfaces in abundance, the 
lung tissue then assuming a vesicular character. The larger 
bronohi and trachea were clear but somewhat congested and 
otherwise the lung tissue appeared normal. The left 
ventricle was markedly hypertrophied, the heart weighing 
19 ounces, and the aortic valves were somewhat thickened, 
distorted, and incompetent. The other valves were appa¬ 
rently normal. The aorta was the seat of well-marked athe¬ 
romatous changes, while the radial and temporal arteries 
also manifested pronounced thickening and tortuosity. 
The other organs of the body were in an apparently healthy 
condition. Microscopically no characteristic abnormal ap¬ 
pearance can be detected in the lung. The patient had not 
been under any treatment. No history of heart or kidney 
trouble could be obtained. I expressed the opinion that 
death was due to the sudden strain thrown upon the heart 
by the rapid engorgement of the lungs. 

I am, Sir, yours faithfully, 

_ G. H. C. Lumsden, M.B. Aberd. 

Brighton, Jan. 17th, 1908. _ 


To the Editor of The Lancet. 

Sir,— In Zola's powerful book “F6condit6” there is a 
graphic description of the sudden illness of a perfectly 
healthy young woman whose symptoms began at bedtime, 
following a wetting from a rain-storm in the afternoon and 
who died after intense suffering at 7 o’clock in the morning 
“ d’une congestion pulmonaire.” When the book was pub¬ 
lished eight yearn ago a medical friend discussed this case 
with me. As neither of us was familiar with an acute 
pneumonia or pulmonary congestion which would cause 
death in a hitherto healthy adult within seven or eight hours 
we were at first inclined to class this description among the 
errors of novelists writing on subjects of which they are 
ignorant ; remembering, however, the notorious accuracy of 
M. Zola and the mastery of technical detail which he always 
acquired of any subject on which he undertook to write and 
having, moreover, both been in practice sufficiently long to 
have learnt that we did not know everything, we decided 
that the novelist was probably correct and our own limited 
experience at fault. 

I now learn that the case described corresponds accurately 
with those cases of rapidly fatal “acute pulmonary redema” 
which have recently been recorded by correspondents in your 
columns. The clinical picture of the illness drawn by 
M. Zola is most vivid and accurate and is to be found on 
pp. 557 to 559 of the ordinary French edition. Perhaps the 
disease is better known in France than in England for M 


Zola writes of it as of something not very uncommon. *£The 
medical interest, in other respects, of this striking book is 
such, and the moral it teaches so impressive, that all might 
read it with advantage. I am, Sir, yours faithfully, 

Jan. Uth, 1908. C. K. 


THE SOCIETY OF MEDICAL 
PHONOGRAPHERS. 

To the Editor of The Lancet. 


Sir, —It is many years since the Society of Medical 
Phonographers was last mentioned in your columns and we 
shall be glad if you will allow us to direct attention to the 
fact that it still exists and still issues its medical periodical 
in lithographed phonetic shorthand. We believe that many 
students and members of the profession are ignorant of the 
society and its efforts to promote the effective use of short¬ 
hand in medicine, both in practical work and in research. 
The honorary secretary will be glad to furnish particulars of 
the society to any members of the profession or students 
who may desire to join it. 

We are, Sir, yours faithfully, 

William R. Gowers, President. 

Charlbs W. Cathcart, 1 , r . „ .. . 

G. Sims Woodhead, j ^ lce -I residents. 

Oskar C. Gruner, Honorary Secretary, 
Pathological Department, General 
January, 1908. Infirmary, Leeds. 


THE CAUSE OF THE PREVALENCE OF 
ADENOIDS. 

To the Editor of The Lancet. 

Sir, —If reliable statistics were available it would, I 
believe, be conclusively proved that during the last 30 years 
there has been a remarkable increase in the number of 
children affected with adenoids. That adenoids have always 
existed may, no doubt, be correctly inferred from indirect 
evidence, but on the other hand, evidence has been brought 
forward to show that until recent years it must have been 
quite a rare disease. However, as regards what exists at 
present, I would mention that it is difficult to find evi¬ 
dence of many cases indicating the previous existence of 
adenoids among people of 40 years of age and upwards, 
whereas it seems to be comparatively rare to find a family 
of children without at least one of its members having 
suffered from the disease. It is not my intention, however, 
to compare the past with the present. What I want to do 
is simply to state that without any attempt at selection I 
took a number of families whose habits I knew with, 
regard to the keeping of open windows in the sleeping 
apartments of their children. Of those who kept the windows 
shut at night there were five families, having 26 children in 
all, and not one of these 26 children had ever suffered from 
adenoids. While of five families, having 19 children in all, 
who kept open windows at night throughout the year, eight 
of these children bad suffered from adenoids sufficiently 
badly to have required operation. Now I do not put any 
importance on these figures, they are too few to be of any 
particular value beyond being very suggestive, and it was 
not on account of them that I was led to think that open 
windows at night might be an important factor in the 
causation of the prevalence of the disease. I am writing 
because I am not in a position to get as full statistics on the 
subject as seems desirable and I should like particularly to 
know the effect of cold and damp night air, such as we 
usually have in England, in the production of adenoids and 
of its value or otherwise in the treatment of an ordinary 
cold in the head. 

I am, Sir, yours faithfully, 

Wimpole-Btreet, W., Jan. 20th, 1908. J. SlM WALLACE. 

THE INFECTIVITY OF CANCER. 

To the Editor of The Lancet. 

Sir,— I very much regret to find from his letter addressed 
to you in The Lancet of Jan. 18th, p. 188, that I have in¬ 
advertently misrepresented Dr. Bash ford by attributing to 
him instead of to Messrs. Farmer, Moore, and Walker the 
statement reported in the British Medical Journal of 
Jan. 30th, 1904, that “malignant new growths were virtually 
reproductive tissue arising in abnormal situations ” and 1 am 



The Lancet,] DEATH UNDER AN ANAESTHETIC.—CIVIL SANITARY REFORM IN INDIA. [Jan. 25, 1908 . 2 6 3 


very glad to be assured that Dr. Bashford dissociates himself | 
from such a conclusion. I find, however, that four months 
after Dr. Bashford’s and Dr. Murray’s paper, which contained 
the above quotation, was read Professor Farmer at a meeting 
of the Pathological Society of London held on May 17th, 1904, 
and reported in the British Medical Journal of May 21st, 
1904, p. 1196, observed ‘'that although the authors” 
(Messrs. Farmer, Moore, and Walker) “ had been credited 
with the view that they had arrived at an explanation of the 
phenomena of carcinoma they disclaimed this ; the relation 
between heterotype mitosis and the life-history of carcinoma 
they did not profess to explain.” 

I am, Sir, yours faithfully, 

Driffield, E. Yorks, Jan. 18th, 1908. A. T. BRAND. 


DEATH UNDER AN ANAESTHETIC. 

To the Editor of The Lancet. 

Sir,— In The Lancet of Dec. 14th, 1907, p. 1714, is a report 
of an inquest upon a case of death under an anaesthetic upon 
which I gave evidence as to the post-mortem appearances. 
Amongst other remarks I am reported to have said that I 
considered coughing might have acted as a “shock ” to the 
heart. If I used the word “ shock ” it must have been 
thoughtlessly and in ignorance of the fact that the word 
might appear in print. My opinion is that the deep inspira¬ 
tion which follows a forcible expiration may affect the heart 
and that the heart—judging from the clinical evidence— 
was thus affected in this particular case. 

It has never seemed to me that adhesions of the pleura or 
pericardium are important factors in the production of the 
so-called “ pulsus paradoxus.” Yet in this case it may be of 
interest to mention that firm adhesions obliterated both the 
right and the left pleural cavities. The consequent inability 
of the lungs to advance over the heart during inspiration may 
have aided to produce a distension of the heart which, 
weakened by the anaesthetic and defective aeration of the 
blood—owing to the presence of thick muco-pus in the 
bronchial tubes—proved fatal. 

I am, Sir, yours faithfully, 

Jan. 23rd, 1908 a THEODORE FlSHER. 


well able to pay an ordinary fee prefer to present themselvi a 
at the out-patient department of some great hospital. 
Another difficulty with which we have to contend is the fact 
that quackery displays everywhere her various illusions to 
cheat the hopes and prey on the weaknesses of mankind, 
while faith-healing, crystal gazing, and palmistry are 
rampant. We know from the sixth satire of Juvenal that 
pretenders of a like kind existed in ancient Rome 

“ Frontemque manumque 
Praebeblt vatl crebrum poppysma roganti." 

It must not be forgotten that as a profession we are 
placed at a great disadvantage as compared with other 
callings, because the sciences on which our art is based are to 
a considerable extent occult sciences to even the majority 
of the most cultivated of the laity. The proposition that 
with the advance of hygiene disease will fade away is in all 
probability no more than a beautiful dream, “born of hope 
and destined to die of experience.” Preventive medicine 
may indeed arrest the progress of some epidemics ; though, 
as in the matter of the vaccination laws, it seems doubtful 
whether with the advancing wave of democratic ideas there 
will not be an increased disinclination to submit to the 
restraints which the medical profession may recommend for 
the physical welfare of the community. 

In the lives of professions, as in the lives of states, of 
senates, of individuals, there are periods for pause and 
thought. The present time seems to me a desirable one in 
the life of medicine. Never at any period, I believe, have 
the heads of medicine and surgery been more faithful 
workers more true to nature, or have conferred larger 
benefits'on the human race. To their wisdom and guidance 
I trust that the difficulties of the present may be removed 
and that in the future the triumphs of the past may become 
even greater and brighter than before. 

I am, Sir, yours faithfully, 

Jan. 20th, 19C8. INSPECTOR-GENERAL. 


CIVIL SANITARY REFORM IN INDIA. 

(From a Special Correspondent.) 


THE PRESENT PROSPECTS OF THE 
MEDICAL PROFESSION. 

To the Editor of The Lancet. 

Sir,—E very thinking person must feel that the present 
condition of affairs requires serious consideration. Have we 
passed the zenith of our fame and power? Has rapid pro¬ 
gress brought with it the seeds of decay and impotence ? 
If it is true, as has been asserted, that the average income 
of a medical man is under £250 a year, the number of 
parents and guardians anxious to Bend their children and 
wards to the profession is certain to decrease. Young men 
are seldom tempted to a medical career by the fervid 
enthusiasm which determines to an ecclesiastical vocation. 
Medicine shares none of the high prizes of the law. The 
moBt that the majority of its members can hope for is a 
moderate competence with a slender provision for old age. 
It is probable that many causes acting concurrently have 
combined to briDg about the present state of affairs and I 
propose to comment briefly on some of them. 

The agricultural population shows an increasing tendency 
to flock to the towns and, as Canon Jessop has remarked, 
the old village life has all faded away. Even in districts in 
which corn and other crops are still cultivated extensively 
improved agricultural implements have diminished the 
demand for labour and the railways have brought all except 
the remotest districts into touch with towns where patients 
can consult some medical man renowned for special know¬ 
ledge of their ailments. It is therefore clear that large 
districts will require fewer medical men in future and will 
afford poorer remuneration. Here we are face to face with 
causes entirely non-medical and most unlikely to change, 
except for the worse. 

The inevitable growth and development of specialism 
which increased knowledge has produced have aided, no 
doubt, in the reduction of the income of the general 
practitioner, but ottier causes are, in my opinion, as power¬ 
ful, if not more so, in London and other very large towns. 
One of these is the abuse of medical charities, for it is a 
matter of common knowledge that thousands of persons 


A MOST important letter has been addressed by the 
Government of India to all local governments and adminis¬ 
trations for their opinion on the subject of sanitary reforms 
in civil areas. In the past practically no attention to this 
important subject has been paid, if we except the Presidency 
capitals and a few of the larger cities. The letter now 
addressed indicates the nature and direction of the advance 
which in the view of the Government of India (under the 
advice of the new sanitary commissioner who was appointed 
in 1904) should now be made towards the reorganisation of 
the sanitary department. The Government of India now 
suggests that the posts of deputy sanitary commissioners 
should not exclusively be reserved for officers of the Indian 
Medical Services but should bo thrown open to all medical 
jfficers of health who must in all cases possess the D.P.H. 
liploma. The present inadequacy of the staff of medical 
jfficers of health is pointed out and it is suggested that the pro- 

cosed new sanitary service will offer a suitable and congenial 

jareer for educated Indians who have been trained in Europe, 
;he latter essential being absolutely necessary. In towns 
with a population between 20,000 and 100,000, however, it 
will be necessary to accept a lower standard of scientific 
Attainments, and such posts may be suitably offered to 
jducated natives of the assistant surgeon class. Here I 
nay remark lies the greatest pitfall of the scheme, as this class 
)f medical practitioners in India are mainly recruited from 
;he Brahmin caste, which sect according to caste prejudices 
becomes defiled by contact with latrines and the like, so it 
nay be assumed that inspection of such an important source 
>f public health pollution will not be as rigidly performed as 
it would be by European medical officers of health. The 
Government of India also suggests that in future medical 
jfficers of health from the Indian Medical Service will not 
ae appointed deputy sanitary commissioners unless they 
pave more than seven years’ service. Medical officers 
jf health will not be allowed to undertake private practice 
md their salaries will therefore have to be fixed on a more 
liberal scale than would otherwise be necessary 
The supervision of the conservancy establishment m 
municipal towns is in urgent need of reform and it is 
imperative that steps should be taken to provide emcient 


264 Thb Lancet,] 


CIVIL SANITARY REFORM IN INDIA.—BIRMINGHAM. 


[JAN 25, 1908. 


training for sanitary inspectors who should undertake the 
duties of sanitary supervision which are already performed 
by inspectors of nuisances in Great Britain. It is 
rightly urged that medical officers of health will not, 
and cannot be expected to, undertake work of this sub¬ 
ordinate character and that the existing establishments of 
untrained supervisors and overseers are not able to give the 
health officer the assistance which he has a right to 
demand. These men form the connecting link between 
the health officer and the working labourers of low caste 
coolie class. The training of these sanitary inspectors 
is a question that will require very careful considera¬ 
tion. The standard required should be that prescribed 
by the Royal banitary Institute for inspectors of nuisances 
in England and no doubt arrangements can be made 
to obtain and to train specially selected men and to 
issue certificates to successful candidates who must be of 
good physique, satisfactory character, suitable caste and 
social status, the last qualification enabling them to move 
freely among all classes of the population with tome degree 
of authority. To attract men of the right stamp it will be 
necessary to offer good pay and the Government of India 
thinks that a scale of salaries rising from Rs.50 to Rs.150 
(£3 6». 8 d. to £10 English equivalent) will probably prove 
suitable in most provinces. 

Finally, the Government of India discusses the ques¬ 
tion whether the proposed new scheme of medical 
officers of health and sanitary inspectors should be formed 
into a regular provincial sanitary service or whether 
each local authority should be allowed to recruit its 
own staff independently. The objections urged against 
the latter course are that a career which is limited to 
employment by local authorities on uncertain terms and 
without prospect of pension will not attract candi¬ 
dates of the proper stamp, if, indeed, it attracts any at 
all, and that the insecurity of tenure will deter men 
from qualifying for snch appointments. The duties of 
sanitary inspectors of necessity bring them into conflict 
with members of local authorities, their families and 
relatives, and if sanitary inspectors are merely servants of 
local boards they may either neglect their duties in such 
cases or perform them at the risk of losing their appoint¬ 
ments. On the other hand, it may be argued that the 
creation of a provincial service of sanitary officers will 
conflict with one of the main principles of local self 
government and it is urged that in no branch of local 
administration is local control so necessary as in matters 
connected with sanitation. The Government of India is 
convinced that in the case of sanitary officers the certainty 
of tenure during good conduct must be assured. It will 
thus be necessary to provide that no medical officer of 
health or sanitary inspector should be removeable from office 
without the sanction of the local government in the case of 
the former, or the sanitary commissioner, or perhaps the sani¬ 
tary board, in the case of the latter. Regulations somewhat 
similar to these exist in England and Scotland and are neces¬ 
sary to secure the employment of properly qualified men and 
to guarantee protection against arbitrary treatment in 
retaliation for the fearless and efficient performance of duty. 

Another part of the administrative machinery touched on by 
the Government of India in its new scheme is the formation 
of sanitary boards which would consist of from three to five 
members, including a senior member of the Civil Service 
who is in close touch with local administration, the sanitary 
commissioner and the sanitary engineer as experts, and one 
or two natives of India, preferably non-officials. Thus direct 
discussions will be secured between sanitary experts and 
those who are in a position to appreciate and to represent the 
attitude and feelings of the general population. The 
Government of India does not propose to discuss at present 
the thorny question of sanitation in rural areas. Finally, the 
question of providing an efficient staff of sanitary engineers 
has not been overlooked and assurance is given that a 
separate communication will be made on this matter. 

The various suggestions enumerated above are put for¬ 
ward for the careful consideration of local governments and 
suggestions on some are asked for laying down what specific 
action they propose to take in order to give effect to the 
accepted general policy now promulgated of sanitary im¬ 
provement. It is to be hoped that success will attend this 
new scheme, the first thorough attempt on the part of the 
civil authorities in India to place on a sound basis the im¬ 
portant question of civil sanitation in its idle as a prevention 
of disease. Lieutenant-Colonel J. T. W. Leslie, I.M.S., the 


present Sanitary Commissioner with the Government of 
India, is to be congratulated on taking the bull by the horns, 
and it is to be wished that he will in no way be hampered by 
financial considerations. Outsidethe Presidency capitals and 
a few of the larger cities sanitation may be said to be non¬ 
existent, if we except the cantonments of British troops, the 
latter being mere oases of sanitation in the desert, so to 
speak, scattered throughout India, and these in most cases 
are surrounded by mobs of insanitary native bazaars which 
have sprung up mushroom-like to live on the British 
soldiers as parasites, fouling bis food, air, and environment 
and infecting him with enteric fever and malaria. With the 
cooperation of the civil sanitary service as now proposed the 
sanitary officers of the army will reduce these fell diseases 
to a minimum and the health efficiency of British troops in 
India will benefit greatly. 


BIRMINGHAM. 

(From ocr own Correspondent.) 

The Birmingham Housing Reform Association and the Open 
Space s Society. 

During its short but active existence the Birmingham 
Open Spaces and Playing Fields Society has done excellent 
work for the city, for it has secured several areas where it 
was important that breathing space should be acquired, 
but it has been obvious lately that its work would neces¬ 
sarily overlap with that of the Housing Reform Association 
and consequently It has been decided to combine the two 
societies Into one under the title of the Birmingham and 
District Housing Reform and Open Spaces Association. 
Much work still remains to be done and there can be little 
doubt that the larger association will work with even greater 
success than the smaller association attained in the past 
therefore the councils of both associations are to be con¬ 
gratulated on the union of their forces. 

The Birmingham Ambulance Brigade. 

For the third time in succession the Birmingham challenge 
shield has been won by the Midland Railway division of the 
Birmingham Corps of the St. John Ambulance Brigade. 
Councillor Brooks presided at the meeting which was held 
to celebrate the victory, and in presenting the shield he took 
occasion to congratulate the whole brigade upon the value 
and efficiency of its work. The brigade numbers 358 
members, and during last year it succoured whilst on public 
duty 275 cases, and in their private capacities the members 
have rendered aid to 4398 people. This obviously indicates 
a large amount of valuable work done at critical moments. 
215 members of the brigade have passed the third examina¬ 
tion and have received the brigade’s medallion, and 46 men. 
have gained the nursing certificate. 

Infants in Public-houses. 

In addressing a meeting in West Bromwich on social 
questions Dr. A. E. W. Hazel, M.P., once again drew public 
attention to the Chief Constable of Birmingham's statement 
that not a few women take young children into public-houses 
and some of them have been seen to give beer to infants for 
the purpose of making them sleepy and quiet. This is one 
of those glaring disgraces which might be promptly and 
effectively dealt with by legislation, for surely no sane 
person would oppose a measure which would make such 
abominable behaviour illegal, and every right-minded 
individual will hope, with Dr. Hazel, that the Government 
will act quickly in a matter which brooks no delay. 

The Regulations Regarding Brass Castings. 

The proposed regulations drafted with the object of pre¬ 
venting caster’s ague are looked upon with great disfavour in 
Walsall, where it is contended that caster's ague is unknown, 
the conditions being quite different from those existing in 
Birmingham. The manufacturers characterise the regula¬ 
tions as arbitrary and unnecessary so far as Walsall is con¬ 
cerned, and they hope that alternative and more reasonable 
and acceptable regulations will be formulated. 

The Water supply and the Rainfall. 

Apparently we may look forward to a dry summer with 
equanimity, for the rainfall in the Elan Valley during the 
past year has been quite up to the average, 61'36 inches, 
and at Whitton and Whitacre, as we had reason to expect, 
the fall has been above the average, exceeding it at Whitton. 




The Lancet,] 


BIRMINGHAM.—WALES AND WESTERN COUNTIES NOTES. 


[Jan. 25, 1908. 265 


by 3 •27 inches and at Whitacre by 2 -76 inches. To a 
certain extent this satisfactory resalt on the gathering 
grounds whence our water-supply is derived may be con¬ 
sidered as a compensation for the past dreary summer. 

Medical Inspection of School* in Worcestershire. 

If the conditions in Worcestershire are to be taken as an 
indication of the terms on which the medical officers engaged 
for the inspection of school children will have to work and 
of the work which they will have to do, then it may be 
admitted that the pay will not be over-generous and the work 
if it is well done will be heavy. The sanitary subcommittee 
appointed to report upon the best method of carrying out 
the administrative provisions of the Education Act of 
1907 in Worcestershire recommended that the education 
county, which contains 251 public elementary schools, 
should be divided into three districts, in the largest of 
which the school children would average 18,471 and 
in the smallest 12,164. The subcommittee was of 
the opinion that a medical inspector should be appointed 
for each district and that the work should be 
supervised by the county medical officer. It proposed that 
the county medical officer's salary should be increased 
by £100 per annum, that one of the inspectors should receive 
£500 per annum, rising to £600, and the other two £350, 
rising to £400, and it suggested that one of the medical 
inspectors should be a woman. The report was subjected to 
a considerable amount of criticism and opposition and it was 
eventually decided that the education committee should 
recommend the council to appoint three medical inspectors 
who should commence with salaries of £250, rising to £300. 
This does not seem too much for the work to be done, yet the 
cost to the county will be very considerable and there seems 
every probability that the scheme will have to be enlarged if 
satisfactory results of any substantial character are to be looked 
for. Apparently, according to the reports, the scheme makes no 
provision for the fees of specialists, yet numerous cases must 
be met with in which specialists' opinion will be invaluable 
and will no doubt have to be obtained. It will be well to 
expect that the early estimates of cost for all schemes of this 
nature will prove insufficient and to make up our minds to 
face considerably increased taxation, whilst it is to be hoped 
that the results may give a satisfactory return for the 
expenditure. Expression was given to fear of increasing 
expenditure when the report was presented to the council. 
Objection was made to the appointment of whole-time 
inspectors and the report was referred back to the com¬ 
mittee for further consideration. What the committee will 
do is not clear, for no reasonable person can expect that 
the work required by the Act can be properly done by 
district medical officers of health who are already burdened 
with duties. 

Jan. 21st. 


WALES AND WESTERN COUNTIES NOTES. 

(From our own Correspondents. 

Carmarthenshire Water-supply. 

Following the example of the steam coal areas of 
Glamorgan it is proposed in the anthracite district of 
Carmarthen to go away from the coal district for a supply of 
water. This eventuality was foreshadowed in 1904 when the 
Local Government Board refused to sanction a scheme of the 
Llanelly rural district council for the supply of Burry Port, 
where there is a population of about 4500, with water 
obtained from the coal measures. The local authorities 
cannot be accused of being precipitate in the action now 
proposed to be taken, for as long ago as 1901 the 
Carmarthen county council decided to make a representa¬ 
tion to the Local Government Board in accordance with 
the provisions of Section 299 of the Public Health Act, 
1875, to the effect that the Llanelly rural district council 
had made default in enforcing the provisions of that 
Act. 1 In the coming session of Parliament there will be 
promoted two Bills, each concerned with securing a supply of 
water for the district named. In both proposals the supply 
is to be obtained from the head waters of the river Loughor. 
The larger undertaking, which is estimated to cost £95,000, 
is that of the Burry Port urban district council jointly with 


1 The Lancet, Nov. 2nd, 1901, p. 1231. 


the Llanelly rural district council. The second scheme, the 
cost of which is estimated at £32,000, is being put forward 
by the Ammanford urban district council which has under¬ 
taken to supply the adjoining rural district of Llandilo. 

Cardiff Water-supply. 

The inhabitants of Cardiff are supplied with water from 
the old red sandstone of the Breconshire Beacons, and in spite 
of the increase in the size of the town sufficient provision 
has been made to insure an ample amount both for domestic 
and municipal purposes. During last year the average daily 
consumption per head was 27 gallons, of which 11 gallons were 
for trade and municipal requirements. The revenue from 
the undertaking is not yet sufficient to meet all the charges 
and a rate in aid has to be levied. It is anticipated that in 
a few years the latter will not be necessary. The sum of 
£280 is paid yearly for the water supplied to the public 
baths and it has been suggested that when the water in the 
service reservoirs is running to waste a sufficiently increased 
amount of water should be supplied to the baths to enable 
them to be emptied much more frequently than once a week 
as is the case at present. The proposal is one which should 
meet with favourable consideration. 

Cardiff and the Notification of Births Act. 

Notwithstanding the fact that the health committee of the 
Cardiff corporation recommended the city council not to 
adopt the Notification of Births Act, the council after some 
discussion decided that the Act should be adopted. In a 
special report upon the incidence of infantile mortality in 
Oardiff which was made by the medical officer of health in 
January, 1907, Dr. E. Walford urged the employment of quali¬ 
fied health visitors or women inspectors to visit the bouses of 
the poor in which infants are bom. Already one such in¬ 
spector was attached to the health department but her 
work was hampered owing to the length of time which 
usually elapsed between the birth and the time of registration. 
A scheme of voluntary notification of births by the mid¬ 
wives in the town was proposed by Dr. Walford and he sug¬ 
gested a fee of Is. being paid to each midwife who notified 
a birth within 48 hours of its occurrence. The action of the 
corporation in adopting the Notification Act will necessitate 
the appointment of another woman inspector, and that there 
is sufficient work ready to her hand is evident from the high 
rate of infantile mortality in some parts of the city. In the 
third quarter of the four years 1903-06 the rate in the whole 
of Cardiff was 142 per 10C0 births, but in one part of the 
town it was 178 per 1000, and in another part as high as 189- 
per 1000. 

Proposed Cottage Hospital for Pontypridd. 

The populous valleys which spread out almost fan-like 
from Pontypridd are very ill-provided with hospital accom¬ 
modation. In the Rhondda valleys there is only one suoh 
institution situated at Porth and with accommodation for 
13 patients. In the Aberdare valley there are small hospitals 
at Mountain Ash and at Aberdare, while in the Taff valley 
there is at Merthyr a well-equipped hospital of 45 beds. 
Pontypridd has a population approaching 40,000 persons and 
is the centre of an extensive coal mining district so that the 
need of a general hospital is apparent. At a public meeting 
held in the town on Jan. 15th it was decided that the urban 
district council should be asked to build a small accident 
hospital and to support it out of the general rates of the town. 
At Barry the rates have been applied in support of a similar 
institution for many years. 

Medical Ojfioer of Health for Monmouthshire. 

At the next meeting of the Monmouthshire county council 
a proposal will be made to appoint a medical officer of health 
part of whose duties will be the supervision of the medical 
examination of the children attending the public elementary 
schools in the county. The suggested salary is £600 per 
annum, together with travelling and other expenses. The 
area of the administrative county is 345,000 acres. About 
three-fourths of the county is of a rural character and the 
remainder includes the thickly populated districts of the 
eastern and western valleys where coal mining operations 
are extensively carried on. The population of the administra¬ 
tive county is about 250,000 and there is every probability 
that the number of persons employed in the collieries of the 
district will increase in the future. 

Jan. 21st. 




266 Thh Lancet,] 


SCOTLAND.—IRELAND. 


[Jan. 25,1908. 


SCOTLAND. 

(From our own Correspondents.) 


University of Edinburgh. 

The annual report of the University of Edinburgh for the 
year 1907. shows that the total number of matriculated 
students (including 590 women) was 3278, being 79 more 
than the number for last year, and the highest number 
reached for 14 years. Of this number 1478 (including 55 
women) were enrolled in the Faculty of Medicine, 690, or 
nearly 47 per cent., belonging to Scotland. Of the remainder 
310, or 21 per cent., were from England and Wales; 118 
from Ireland; 71 from India; 263, or nearly 18 per cent., 
from British Colonies ; and 26 from foreign countries. 
TheBe figures show that the proportion of non-Scottish 
students of medicine is well maintained. The degrees 
in Arts, Science, and Medicine conferred during 1907 
were as follows Master of Arts (M.A.). 187 (including 
61 women); Bachelor of Science (B.So.), 49 (including five 
women): Doctor of Science (D.Sc.), eight; Bachelor of 
Medicine and Master of Surgery (M.B., C.M.), two ; Bachelor 
of Medicine and Bachelor of Surgery (M.B., Ch.B ), 197 
(including 16 women); Doctor of Medicine (M.D.), 70 
(including three women) ; and Master of Surgery (Cb.M.), 
two. The General Council of the University -now numbers 
10,358. The diploma in Trooical Medicine and Hygiene 
was conferred on five candidates. The total annual 
value of the University Fellowships, scholarships, bursaries, 
and prizes now amounts to about £18,520, including 
in the Faculty of Medicine £3630. In July approval 
by His Majesty in Council was intimated of an ordinance 
of the University Court making important changes in 
regard to the curriculum and periods of examination for 
graduation in medicine and surgery. The outstanding 
features are the increased opportunity given to students 
for taking each of the four professional examinations in 
separate sections, and the holding of degree examinations 
in December as well as in the spring and summer. Another 
change involved in the new ordinance is the opening of the 
winter session of medicine about a fortnight earlier than at 
present—i.e., on or near Oct. 1st. Other two ordinances of 
the University Court—regulations for the degree of 
Bachelor of Pharmacy and regulations as to bursaries, 
—have been transmitted to the Privy Council. The 
only change in the professoriate during the year is that 
due to the lamented death, which occurred suddenly on 
Dec 20th, of Professor Thomas Annandale. Appointed in 
1877 as successor to Professor Lister he has long ranked as 
one of the foremost surgeons and most popular teachers 
of bis time. Dr. W. E. Carnegie Dickson has been 
appointed lecturer in pathological bacteriology in suc¬ 
cession to Dr. J. M. Beattie, now professor of pathology 
in the University of Sheffield, and Dr. James Arnott 
Brigade-Surgeon-Lieutenant-Colonel, I.M.S. (retired), was 
appointed lecturer in diseases of tropical climates in room of 
Dr. Andrew Davidson, retired. In the medical building at 
Teviot-place a new laboratory capable of accommodating 40 
students has been provided for the pathology department. 
Accommodation was again given in August by the University 
authorities for a scheme of vacation courses in modern 
languages ; also in September for a scheme of post-graduate 
courses in medicine, held under the joint auspices of the 
University and the Royal Colleges of Physicians and 
Surgeons. Both of these schemes proved highly successful. 

Lord Lister and the Freedom of Glasgow. 

Lord Lister, with Lord Blythswood and Mr. Cameron 
Corbett, M.P., were enrolled to-day, Tuesday, Jan. 21st 
honorary burgesses of the city of Glasgow. The Lord Provost’ 
Sir William Biisland, having alluded to Lord Lister’s con¬ 
nexion with the city as professor of surgery at the University 
and surgeon to the Royal Infirmary, recalled his lordship's 
eminent services to mankind as the discoverer of antiseptic 
surgery. Sir Hector C. Cameron, professor of clinical surgery 
m the University of Glasgow, one of Lord Lister s former 
students and his lifelong friend, accepted on Lord Lister’s 
Dehalf the casket containing the burgess ticket, and read 
from him a letter recalling his connexion with the 
University and the city, in the course of which he said • 
'■Having in due time been elected by the managers of 
the Royal Infirmary as surgeon to that institution, I 
experienced uniform consideration at their hands when 
applying to the treatment of wounds the great truth which 


had been recently revealed by the illustrious Pasteur regard¬ 
ing the nature of fermentative changes in organic substances. 
That truth, though it seemed to me to shine clear as daylight 
from Pasteur's writings, was for many years not generally 
recognised, and thus it was my privilege to witness in my 
own practice, as the application of the principle became 
gradually improved, the revelation of pathological truths of 
fundamental importance and a revolution in practical 
surgery, and I look upon the years spent in your city as the 
happiest period in my life. The old infirmary is now giving 
place to more commodious buildings and, great as must 
necessarily be the expense in this undertaking, I do not 
doubt that the proverbial liberality of Glasgow will prove 
fully equal to the occasion.” 

Enterio Fever in Glasgow. 

A serious outbreak of enteric fever has occurred in the 
West-end of Glasgow during the latter part of December 
and the present month. On the occurrence of the first few 
cases it was found that the patients were all receiving milk 
from the same dairy. Further investigations revealed the 
fact that the cart from which the milk was procured received 
occasional supplies from a farm in the neighbourhood of 
Glasgow. The medical and sanitary authorities of the city 
and county thereupon visited the farm where they found a 
youDg woman—a member of the household—lying ill in the 
kitchen bed. She had been ailing from the first week of 
December and was once visited by a medical man. At the 
outset she was believed to be suffering from influenza and 
afterwards the cause of the illness was supposed to be 
pneumonia. Her Bymptoms were, however, recognised to 
be those of enteric fever, her blood giving a positive 
Widal reaction, and her removal to hospital was at once 
ordered by the county authorities. Thereafter the farm¬ 
house was thoroughly disinfected and the supply of milk 
from it was prohibited. Up to the time of writing the 
number of cases reported in the city from this source is 69, 
while from the same source cases have been reported in 
Edinburgh, Uddingston, and Falkirk. There have been 
several deaths in connexion with the epidemic, one unfor¬ 
tunate case being that of a young man who, while 
incubating the disease, had gone to Switzerland od holiday 
and there succumbed to his attack. 

Complimentary Dinner to Sir George T. Beatson. 

A complimentary dinner was given to Sir George T. 
Beatson, M.D.Edin., K.C.B., on Jan. 10th. at which there 
was a large representation of the medical profession and other 
public men from Glasgow, Edinburgh, and elsewhere who had 
assembled to do honour to their guest who has recently 
been invested with the distinction of Knight Commander of 
the Bath. The Duke of Montrose, who presided, supported 
the toast of the health of Sir George Beatson, referring to his 
public-spirited work in connexion with the Scottish National 
Red Cross Hospital which went to South Africa in 1900 and 
to his connexion with St. Andrews Ambulance Association 
and the Western Infirmary of Glasgow. 200 gentlemen were 
present at the dinner and the proceedings testified through¬ 
out to the cordial esteem in which Sir George Beatson is 
held by his professional colleagues and his fellow-workers. 

Jan. 21st. 


IRELAND. 

(From our own Correspondents.) 

The Tuberculosis Exhibition. 

On Jan. 15th the Tuberculosis Exhibition was opened in 
Armagh by Sir John Byers, who, in the presence of a crowded 
meeting in the county court house, gave an address on the 
formation, objects, and lessons of the exhibition. 

Health of Belfast. 

The death-rate of Belfast still continues far too high, 
being for the week ended Jan. 11th 28 per 1000, and 
3 • 8 from the principal zymotic diseases (due to the 
large number of deaths from measles and whooping-cough). 
At a meeting of the health committee of the city corpora¬ 
tion held on Jan. 16th the superintendent medical officer 
of health recommended that a steam disinfector should 
be procured, that one more refuse destructor should 
be erected, and that the ashbin system should be adopted. 
A circular has been sent to the butchers of the city by the 
medical officer of health, urging that meat should be hung at 
the outside of their shops at such a height as to be out of 


The Lancet,] 


PARIS.—ITALY. 


[Jan. 25,1908. 26 7 


reach of contamination by dogs, dust, &c., and if this 
cannot be done in certain places it was advised to cover the 
meat with cloth or waterproof covering. It was also decided 
to notify all the milk purveyors in the city as to the dan¬ 
gerous and common practice of leaving cans with milk on 
iootways during the process of delivering milk to consumers, 
the cans and their contents being thus liable to pollution. 
In the future legal proceedings will be taken in such cases. 
It is interesting and satisfactory to see all the suggestions 
made at the Belfast Health Commission gradually adopted 
by the city authorities. 

Jon. 21st. 


PARIS. 

(From oub own Correspondent.) 

The Sohool for Nurses at the Salpetriere. 

A SCHOOL for training certificated nurses has been open 
for two months at the Salpetriere and is the first of the kind 
in France. The building consists of a main block and two 
wings. The course at this institution will be one of two 
years. The pupils live at the school, where each has her 
own room ; they are not allowed to go out on Sundays 
unless their families live in Paris or unless they have friends 
known to the administration ; they have one month's holiday 
in the year besides a few days at New Year and Easter. 
The number is to be 75 in each year, those of the Becond 
year passing out for 75 new ones to take their place. There 
is a general superintendent with two assistants. The pupils 
spend their mornings in the wards of the hospital in learn¬ 
ing their duties practically, working in turn in all the 
wards, the children’s and adults’ and those for maternity, 
infectious, and insane cases. They learn all the details of 
sick nursing, how to make their patients' beds and their 
toilet, how to lift them, and so on. They return to the 
College for dejeuner and in the afternoon attend courses of 
lectures delivered by specially appointed medical men and 
midwives in the theatre ; these courses comprise anatomy, 
physiology, hygiene, massage, invalid cookery, and all that 
is included in hospital nursing. The housework and table 
service are done in turns by the pupils. The uniform is very 
like that of English nurses. At the end of two years the 
young women who have successfully passed out of the school, 
which will be done by examination, will become second-class 
nurses and will be given their board, lodging, and uniform, 
and 600 francs a year pay. An intelligent nurse will be able 
to become a superintendent at the age of 30 years. 

Extension of the Hospital for Charity Children. 

For some time past the accommodation of this institution 
has been unable to cope with the calls upon it. To overcome 
this difficulty the General Council of the Seine has ordered 
the prefectorial administration to obtain near Paris a piece 
of land where an extension might be built rapidly and under 
the best possible hygienic conditions. Such a site has been 
found not far from Sceaux, in the Antony district. It was 
occupied by a religious community which haB been expelled 
and the President of the Republic has signed a decree 
declaring the appropriation of the dwelling of the com¬ 
munity to the purposes stated above to be in the public 
interest. This supplementary building may be opened during 
the course of next year. 

Hamarthrosis of the Knee. 

M. Kochard and M. de Champtaissin communicated to the 
Surgical Society on Dec. 11th last the result of treating a case 
of bmmarthroBis of the knee by puncture followed on the next 
day by active movement against gradually increased resist¬ 
ance. The result was excellent. By increasing progressively 
the resistance the atrophy likely to result from articular 
injuries is most effectively met. The treatment has a 
favourable application to other kinds of effusion into 
joints. 

Resection of the Loner Jan, nith Immediate Mechanical 
Replacement thereof. 

M. Valias brought this subject before the Surgical Society 
on Dec. 13th last. After resection of the lower jaw certain 
complications sometimes occur, such as various forms of 
ulceration and defects in the dental alignment. M. Valias 
has for several yearB been able to prevent these by fitting 
an artificial appliance immediately after the operation. 
This procedure does not give rise to suppuration, and the 
Surgeon can become very expert at fitting suitable appliances 


to various cases. To get a good result as much tissue as 
possible must be left and in particular the orbicularis oris 
which prevents the dribbling of saliva. The classical incision 
should be extended a little backwards, so that the wound and 
the scar may not be irritated by the apparatus, and, most 
important of all, the mouth must ba washed out every two 
hours so that no septic liquid can remain in it. 

The Effect of Nervous Stimulants on the Capacity for Work. 

At the Academy of Sciences on Jan. 13th M. Armand 
Gautier made an interesting communication on this subject. 
He has particularly studied the action of kola on fatigue. 
In the course of experiments made by giving this drug to a 
number of horses he found that it apparently diminished 
fatigue in those that took it. For instance, a horse that 
ordinarily could go 20 kilometres in an hour went 21 in that 
time when he had been given the kola. But it was ascer¬ 
tained that at the same time the horse lost more weight 
than one which had not received any of the stimulant. This 
shows, according to the learned chemist, that kola, like 
alcohol, can give the tissues a lash with a whip, but that 
such energy, artificially provoked, is at the expense of the 
organism. 

A ‘ ‘ Rest House ” for the French Medical Profession. 

For some time past various medical men have had the idea 
of founding a “rest house ” ( maison de retraite) for French 
medical men. The idea is now in a fair way to take shape, 
and upon the initiative of Dr. Courtault and Dr. Nass a 
committee for consideration of the question has been formed 
which will hold monthly meetings. 

Jan. 21st. 


ITALY. 

(From our own Correspondent.) 


“ Madhouse Administration." 

It is ‘‘common knowledge ” that Italy cannot cope either 
with her mendicancy or with her crime. It seems that she 
is not less impotent to maintain order or even personal safety 
in her lunatic asylums. Within a few days of each other 
scenes of violence and even homicide have drawn attention 
to the “madhouse administration ” of two such provincial 
centres of life, academic and civic, as Turin and Rome her¬ 
self. The facts are these. In the great Turinese “ mani- 
comio ” in the Via Giulio, a female inmate, confined to bed 
by means of powerful straps to prevent her from doing injury 
to herself or others, contrived to free herself from restraint 
and at one in the morning, with an iron cross bar taken 
from her bed, proceeded to the cell of another female 
also suffering from acute mania and also strapped to her 
couch, and with two or three well-directed blows fractured 
the wretched woman’s skull and then retired to her own 
dormitory. These cells form two of a series in a vast 
corridor of which the only surveillance is intrusted to 
two women who relieve each other at long intervals. No 
cry, it seems, on the part of the victim reached the 
woman on duty, and when the latter entered the cell 
of the homicide she was suddenly assailed, though provi¬ 
dentially the crossbar had been left in the victim’s cell. 
Assistance arrived not a minute too soon, the furious 
assailant was overpowered and again put under restraint 
(this time effective), while the victim of her previous 
aggression on being removed to the hospital was found 
to have been dead for some hours. The tragic incident 
of which these details have been made public in the 
press is now under judicial investigation, while the 
journals are commenting on the fact that in the 
Turinese asylum, as in others throughout Italy, the per¬ 
sonnel is manifestly insufficient. Almost at the same time 
that this tragedy was in progress the great Roman “ mani- 
comio ” of the Santo Spirito was the scene of another 
which, equally savage in detail, was fortunately not fatal. 
In a ward reserved for the “agitato” (violently excited 
patients) there was a paralytic man, aged 50 years, who had 
been giving the attendants trouble. One of these had gone 
to administer medicine to a patient in another cell, and in 
bis absence a seemingly harmless inmate got access to the 
paralytic’s dormitory and throwing himself upon him with 
maniacal fury bit off the fleshy part of the nose just above 
the lip. The victim's cries drew the attendants to the scene. 
The assailant was overpowered and removed ; while the 
paralytic, if he ever recovers, will bear a hideous disfigure¬ 
ment on his face to his dying day. A week before this deed 



268 Thh Lancet,] 


ITALY.—VIENNA. 


[Jan. 25,1908. 


of violence a patient in the same asylum having sur¬ 
reptitiously got hold of a copper-lid from the refectory, 
inflicted a murderous blow with it on another patient's 
skull, on whom the operation of trephining had to be 
performed, fortunately in time to save his life. Again the 
public press, in anticipation of the results of judicial 
inquiry, iB calling loudly for a more effective personnel, in 
numbers as well as in aptitude, if only to bring the 
“ madhouse administration ” of Italy up to something like 
the standard reached and maintained north of the Alps. 
Dr. Giovanni Mingazzini, professor of neuropathology and 
psychiatry in the University and director of the Manicomio 
of Rome, has j ust intervened in the discussion of this topic 
and with an authority which few of his Italian contem¬ 
poraries can claim. Admitting the deplorable incidents all 
too common in the asylums of Italy he concedes what 
has been pointed out above—the inadequacy of the 
personnel to the surveillance of the patients. The Roman 
Manicomio, in particular, is overcrowded—its inmates 
being far beyoni the control of the official attendance, 
and this he attributes to the practice of the law courts 
in relegating to the purely medical asylums those 
criminals who, undoubtedly insane, are better fitted for 
such special establishments as that of Montelupo in Tuscany 
than for those asylums where patients tire admitted for 
treatment with a reasonable hope of recovery. As to the 
clamour raised in some quarters for more stringent restraint, 
he opposes that system as at once unscientific and ineffective 
—quoting with approval the dictum of an Italian alienist: 
“It is not so much the mental disease that instigates the 
patient to deeds of violence ; it is rather the coercion which, 
depriving him of the power of moving, determines in him a 
reaction abnormal and antagonistic, exploding in aggres¬ 
sion.” Faying a high tribute to Dr. Conolly of Hanwell 
who, nearly 50 years ago, put the non-restraint system 
in practice, he draws a pathetic picture of the risks in¬ 
curred by asylum directors in Italy who, fully convinced of 
the efficacy of non-restraint, have yet to contend with the 
disadvantages due to the defective personnel —to the lack of 
that sufficiency of attendants which alone makes non- 
restraint practicable. Dr. Mingazzini’s letter, written with 
ratiocinative force and literary brio, ought to have a 
salutary effect on “asylum reform”—one of Italy’s most 
urgent desiderata. 

The Italian “ State Quinine ” in Greece. 

The Greek legislature has just approved on the third read¬ 
ing of a Bill for the introduction of “State quinine ” of the 
type of that existing throughout Italy by the Law of 1900. 
The Government at Athens has put itself in communication 
with that of Rome for the supply of the preparation in 
question as manufactured in the If armaria Centrale of Turin. 
Specimens of this product had, it seems, been obtained 
by the Greek Red Cross Society for purposes of experi¬ 
ment. with the result that the Government at Athens has 
not only adopted the Italian law as to its use but is about 
to employ the identical product itself. This imparting of 
“good offices” by Italy to Greece is of gratifying augury 
(so says the leading Roman journal) for the future of the 
two ancient civilisations. 

Science and Surgery at Bologna. 

The “Mater Universitatum ” on the8th inst. lost, within a 
few hours of each other, two of her brightest ornaments. 
One is Professor Domenico Peruzzi, domiciled at Lugo, the 
distinguished surgeon, eetatis 89, known throughout Italy as 
the first operator to perform laparotomy with a successful 
result. A colleague of his at Pisa had indeed the priority in 
the operation but the patient did not recover. The other 
“scienziato,” also an octogenarian, is Professor Paolo Ruflini 
who, after a brilliant career in the Bologna school, became 
professor of the higher mathematics at Modena. He had 
also been a combatant in his country’s cause and for bis share 
in the battle at Governolo in 1848 had been exiled by the then 
ruler of the duchy. 

Jan. 17th. 


VIENNA. 

(From our own Correspondent.) 

The Influence of General Anaesthetics upon the Blood. 

At a recent meeting of the Vienna Gesellschaft der Aerzte 
Dr. Reicher communicated the results of a series of experi¬ 
ments which he had made with a view to ascertain the 
chemical influence of certain aniesthetics (ether, chloroform, 


and A.C.E. mixture) upon the blood. The experiments were 
made on dogs which after having been kept under observa¬ 
tion for several days were anauthetised for 90 minutes. 
Whilst the animals were still under the influence of the 
ansesthetic blood was withdrawn from the femoral artery and 
the amount of lecithin, cholesterin, and fat contained in it 
was ascertained by extraction with a mixture of alcohol and 
ether; the amount of ammonia, nitrogen, and acetone was 
also estimated. The latter substance was, moreover, sought 
for in the expired air. A considerable increase in the amount 
of fat (up to three times the normal quantity) was found 
in the blood and acetone was also present in a higher 
degree, especially in the expired air and in the urine. 
Dr. Reicher believed that the fat in the blood was sent thereto 
from the normal deposits of fat in order to neutralise the 
amesthetic and thus to spare the red cells. If this fat was 
not sufficient then the lipoid bodies from the central nervous 
system were sent into the blood, as was proved by the 
presence of lecithin and cholesterin. Only a few anses¬ 
thetic substances attacked the erythrocytes directly. The 
alkalescence of the blood was lowered, because the red cells 
when disintegrated formed acid substances. In alcoholic 
intoxication oxybutyric acid and acetic acid were demon¬ 
strated in the urine. The acetone was derived from the 
disintegration of fat and albuminoid bodies. Acetonuria and 
lipmmia were closely related to each other, so that diabetic 
persons might easily show the latter condition, and general 
anaesthesia was therefore a dangerous procedure with them. 
Dr. Reicher commented on the similarity of general anaes¬ 
thesia and diabetic coma. 

Cancer of the Stomach Consequent on Swallowing Caustic 
Potash. 

At a recent meeting of the Vienna Medical Society 
Professor Ghon showed some of the viscera of a boy, 13 years 
of age, who died not long ago. In December, 1906, he 
swallowed a quantity of a weak solution of caustic potash, 
whereupon violent vomiting followed. In course of time he 
showed symptoms of stenosis of the (esophagus which neces¬ 
sitated protracted use of bougies, and jejunostomy had ulti¬ 
mately to be performed on account of a stenosis of the 
pylorus. Death was due to intercurrent broncho-pneumonia. 
The necropsy revealed stenosing erosion of the pylorus, two 
external erosions of the transverse colon which also had 
caused secondary stenosiB by contraction, stenosis of one 
ureter, and chronic inflammatory chances of the peritoneum 
originating from the stomach. On the lesser curvature there 
was a perforation in the midst of a tumour-like mass which 
on histological examination proved to be carcinoma. This 
case is interesting on account of the age of the patient, for 
he is one of the youngest persons of whom there is a 
record as suffering from carcinoma, if ovarian and uterine 
neoplasms are not taken into consideration. Another point 
of interest in the case is the connexion between chronic 
irritation and malignant growth. 

A Small Outbreak of Enteric Fever. 

During the last three weeks a number of cases of enteric 
fever have been brought to the notice of the Banitary autho¬ 
rities and this gave rise to some uneasiness, for the Vienna 
water-supply is so pure that no epidemics of this kind have 
occurred for about 25 years. It was soon possible, however, 
to trace the source of infection to contaminated milk and the 
outbreak was quickly stopped. Whilst every care is taken to 
insure the supply of pure fresh milk to the city a certain 
dealer in a village where enteric fever existed unfortunately 
added infected water to the milk. The milk-supply of 
Vienna is to a great extent centralised and the milk is 
subjected to pasteurisation in most of the dairies, but by 
some misadventure the heating process was interrupted on 
these occasions before the milk was sterilised, with the result 
that 35 cases of enteric fever appeared in a certain district 
and two cases have ended fatally. 

Badio active Baths in Bohemia. 

The Government has formed a bathing establishment at 
Joachimsthal, a mining district in northern Bohemia (from 
which the thaler, and consequently thedollar, derived it 5 name), 
where pitchblende containing radium is found, and this estab¬ 
lishment will be supplied with radio-active water directly from 
the mines. Notwithstanding the receipt of many offers from 
Karlsbad, Marienbad, and private persons the Government 
declined to let the control of the water pass out of its hands. 
The establishment will be under the superintendence of a 
medical man and as the water has a very high index of 
radio-activity its effect will have to be watched and studied 





The Lancet,] 


CANADA.—INDIA. 


[Jan. 25, 1908. 269 


carefully. Quite recently it was announced in the news¬ 
papers that three grammes (less than 50 grains) of radium 
bad been obtained at a cost of £2000 from ten tons of pitch¬ 
blende in that place. This is no doubt an exaggeration, for 
it may be said that this amount approaches the total quantity 
of radio-active substance found in Joachimsthal during the 
last few years. However that may be, nearly all physio¬ 
logical and physical laboratories in Austria, as well as some 
clinical stations, possess small quantities of the new element 
which have been placed at their disposal by the Government. 
Legislation as to the Certification and Detention of Lunatics. 

Several oases of grave mistakes and unlawful detention of 
persons in lunatic asylums which have happened within the 
last few years have led to the adoption by a Parliamentary 
subcommittee of a Bill modifying the present conditions of 
admission into these institutions. Thus before a person can 
be put under the control of a trustee on account of his 
mental condition a judge must make an order, after previously 
hearing the opinion of duly qualified medical men, some of 
whom may be selected by the person alleged to be insane. 
No asylum may receive a patient without the written order 
of a judge unless the patient seeks admission voluntarily. 
The detention of a person against his will may not last longer 
than one year and if prolongation is necessary a new exa¬ 
mination of his mental condition by a medical committee is 
again required. 

Jan. 20th. 


CANADA. 

(From our own Correspondent.) 


Sudden and Violent Deaths in Montreal in 1907. 

According to the official report of Coroner McMahon of 
Montreal there were in that city in 1907 785 deaths 
attributable to accidents, ,fcc. This was just 25 more than 
in 1906. There were 83 persons killed by railways, of whom 
23 were killed by street railways. There were 27 suicides and 
50 people met death from drowning. Fire was responsible 
for 44 deaths, which number includes the deaths of 17 school 
children and one teacher which took place in a school. 
There were 12 homicides and 217 sudden deaths. 51 people 
died without medical treatment and one through an auto¬ 
mobile accident. 18 died in gaols, four in the police stations, 
and one in the patrol wagon. Alcohol caused four sudden 
deaths and there were 13 from gas asphyxiation and 17 
from scalding. During the year there was only one case of 
manslaughter. 

Birth Statistics. 

Montreal has a huge birth-rate which is not perhaps 
exceeded by any other city in the world. It is shown 
that the birth-rate for 1907 is in the neighbourhood of 
44- 20 per 1000 of the population. The average of births for 
a period of 19 years has been 37 - 92 per 1000. This was for 
all nationalities, but during this period the birth-rate amongst 
French Canadians was over 40. The birth-rate in Montreal 
is higher than in Toronto by 13 ’ 21 per 1000, and the excess 
in comparison with a number of other cities is as follows : 
Breslau, 5-61; Prague, 13'18 ; Munich, 5'5 ; Vienna, 6'5; 
Milan, 10■ 0 ; Rome, 12-3 ; St. Petersburg, 6'6; London, 
8'7; Paris, 16 4 ; New York, 10 0 ; and Philadelphia, 13 0. 
It is satisfactory to record that the proportion of illegitimate 
children born in the province of Ontario is steadily decreas¬ 
ing. In the year 1900 one out of every 55 of the children 
born there was illegitimate. Gradually year by year the pro¬ 
portion has been diminishing until in 1905 only one out of 
every 74 ■ 2 was of that unfortunate class. In 1899 the total 
number of illegitimate births was 808 ; in 1900, 800 ; in 1901, 
812 ; in 1902, 819 ; in 1903, 782 ; in 1904, 798 ; and in 1905, 
699. The proportion of illegitimates to every 100 children born 
in these years has been as follows : 1 ■ 80, 1 • 73, 1 ■ 76, 1 ■ 72, 
1 • 6, 1 ■ 58, and 1 ■ 34. The comparison with other countries 
is most favourable, for the latest quinquennial periods 
return the illegitimate births to every 100 children born as 
follows: Austria, 14 ■ 55 ; Belgium, 8’51 ; Norway, 7'35; 
England, 4'04; Sweden, 10 80; France, 8'26; Scotland, 
6 1 33 ; Ireland, 2 ■ 65; German Empire, 9 ■ 21; Prussia, 7 • 84; 
and Italy, 6'34. The following statistics are given of the 
multiple births in Ontario. From 1899 to 1905, both years 
inclusive, there have beea in each of the years in the 
Province of Ontario twins as follows : 1899, 296 ; 1900, 401; 
1901, 469 ; 1902, 523 ; 1903, 492 ; 1904, 549; and 1905, 626. 


In thfi Beven years 1899 to 1905 inclusive there have been 
29 births in which triplets have occurred. The proportion 
of male to female births in 1905 shows an increase over the 
preceding year, the proportion being 100 female to 105 male. 

Toronto’s 1 ital Statistics in 1907. 

The total number of births registered in Toronto in 1907 
was 6715, two a day more than in 1906. The marriage 
service was performed 3635 times, almost ten times a day, 
while the messenger of death entered the city 4563 times, 
nearly 13 times a day. The following is Toronto's record for 
the past seven years : 1900 (births, marriages, and deaths) : 
4530, 1789, 3604 ; 1901 : 4445, 2148, 3404 ; 1902 (not given); 
1903 : 5040, 2631, 3730 ; 1904 : 5283, 2867, 3884 ; 1905 : 6816, 
3060, 3915; 1906: 6985, 3108, 3960; and 1907 : 6715, 3635, 
4563. 

Small pox Expensive in Ontario. 

Owing to neglect on the part of municipalities throughout 
the province of Ontario to enforce the Vaccination Act and 
the small-pox regulations it is estimated by Dr. C. A. 
Hodgetts, secretary of the Ontario Board of Health, that it 
has cost the province §2,000,000 in the past ten years. 
During those years the disease has been present throughout the 
province in more or less of an epidemio form but of a mild 
character. At the present time there are several centres and 
just within a few days from 15 to 20 cases were located in one 
of Toronto’s public schools. Ontario now is a largely unvac¬ 
cinated province and the reflection is on the municipal 
authorities themselves. If they had enforced the law as they 
are empowered so to do there would not have been 1 per 
cent, of the cases that have been reported during the past 
decade, for 99 per cent, of the cases have been in unvac¬ 
cinated persons. 

Reorganising the Staff of Toronto General Hospital. 

Work in connexion with the reorganising of the visiting 
stalf of the Toronto General Hospital is proceeding apace 
and it is quite apparent from the appointments which have 
been made and those which are on the tapis that this hospital 
will hereafter be a pure University hospital. There are to be 
three services in medicine and those who have been appointed 
heads are: Dr. A. McPhedran, professor of medicine in the 
University of Toronto ; Dr. W. P. CaveD, associate professor; 
and Dr. Graham Chambers, associate in the same University. 
Mr. I. H. Cameron, M.B., LL.D., F.R.C S. (honorary), pro¬ 
fessor of surgery in the University, will be chief of the 
surgical staff. The heads of the three active services 
will be Dr. George A. Bingham, Dr. A. Primrose, and Dr. 
H. A. Bruce, all clinicians of the University Medical Faculty. 
Dr. R. A. Reeve, dean of the Medical Faculty and Past 
President of the British Medical Association, is head in 
ophthalmology; Dr. George R. McDonagh, head of laryng¬ 
ology, otology, and rhinology ; Dr. J. F. W. Ross, head of the 
gynaecological department ; Dr. Kennedy Mcllraith, head of 
obstetrics and paediatrics ; and Dr. Samuel Johnston, head 
of anaesthetics. The assistants to these and the outdoor 
appointments have yet to be made. The chiefs of medicine 
and surgery are to confine themselves to these specialties 
and not to do any general practice. 

Jan. 12th. 


INDIA. 

(From our own Correspondents.) 


Civil Sanitary Reorganisation. 

AN important communication was issued on Dec. 4th last 
by the Government of India, Home Department, to all local 
governments and administrations upon the subject of sanitary 
reform in civil areas. 1 It indicates a distinct advance towards 
the reorganisation of the civil sanitary department on modem 
lines and will no doubt attract the attention of sanitarians of 
all kinds at home and abroad. 

Snake-bite in Burma. 

.A Local Government circular issued in Burma states that 
in view of the large number of deaths occurring annually in 
Burma from snake-bite it has been decided to distribute as 
widely as possible through the province the lancets designed 
by Sir Lauder Brunton for the treatment of snake-bite with 
permanganate of potassium. The efficacy of this treatment 
if at once applied is now established. The distribution 
will be left to the Commissioner of Divisions through 

l This is dealt with at p. 263 of our present issue.— Ed. L 




•270 The Lancet,] 


INDIA,—MEDICAL NEWS. 


[Jan. 25, 1908. 


whom all local officer* should obtain their supplies accord- | 
ing to requirements before Not. 1st in each year. To 
OoTerument servants lancets will be issued free of 
charge, bat cost price will be charged to municipalities, 
private firms, and individuals. A reserve stock of per¬ 
manganate of potassium crystals will be kept at all hospitals 
and dispensaries for distribution to those who have lancets 
when the supply of permanganate contained in each lancet 
is exhausted. 

Rabies in Jackals. 

Owing to the prevalence of rabies in Simla the health 
officer attached to the Simla municipal council has started a 
campaign against jackals, large numbers.of which exist in the 
vicinity of India’s summer capital. A special man has been 
engaged to exterminate these animals by poison and also by 
shooting them. Bites caused by rabid jackals are always of 
much greater severity and graver prognosis than dog-bites. 

The Serum Therapy of Plague. 

Khan Bahadur N. H. Choksy, M.B., special plague officer, 
Bombay, has just published a valuable pamphlet recording 
recent observations on the serum-therapy of plague in 
India. It has been contended by some people that the serum 
'treatment of plague cases is ineffectual, if not altogether 
useless, and that the results are entirely disappointing. Dr. 
Choksy contends that, having regard to the unfavourable 
conditions that are almost unavoidable in the treatment of 
a disease like plague, the wonder is that serum treatment 
has given such comparatively good results. He supports this 
assertion by an elaborate discussion of over 1600 cases 
'treated at Bombay, Poona, Indore, Calcutta, and Karachi. 
The average mortality in plague cases in Bombay is about 
89 per cent. ; in cases treated with serum the incidence of 
mortality varied from 33 ’ 3 among a small number of 
Europeans, to 40 per cent, among Parsees, 44 • 3 per cent, 
among Mahomedans, and 55 per cent, among Hindus. Dr. 
Choksy contends that “the serum treatment is the only 
method of saving a larger proportion of lives in a 
certain class of patients.” At the same time it cannot 
favourably influence all types of plague; in hospital 
practice where more than half the cases are of the septi- 
ctemic type on admission, and consequently not amenable to 
any specific treatment, it must be of comparatively little 
value. The essence of successful serum treatment is that it 
should be commenced at an early stage of the disease. This 
is rarely possible with hospital patients, most of whom have 
been suffering several days before admission. But in the 
case of private patients who call in a medical man at once 
the results are undoubtedly favourable. Among 468 private 
patients the case mortality was only 39 9 per cent., while 
among 613 specially selected hospital patients it was 57 per 
cent. Again, among first-day patients the case mortality was 
30 3, among second-day patients 62 6, and among third-day 
patients 63 per cent. These figures show, as Dr. Choksy 
contends, favourable results, and if patients could be taught 
to apply for treatment as soon as they were attacked the 
results would be still more satisfactory. 

The Chimura Cholera Cates. 

Three tragic deaths which occurred recently from cholera 
have been the subject of a special investigation by Major 
Clarkson, I.M.S., sanitary commissioner, who traced tbe trans¬ 
mission of the cholera germ to the jharans (cloths used for 
cleaning dinner plates) of one of the servants of the house. 
Mr. Bernard, Commissioner, Mrs. Bernard (his wife), and a 
Miss White, a visitor, were the victims; several others who 
.partook of food with them were also attacked but recovered. 
The jharans were infected by being washed in a portion of a 
river where a cholera corpse of a native had been lying, the 
disease being transmitted to the dinner plates by the infected 
jharans. 

Jan. 4th. 


Deaths of Eminent Foreign Medical Men.— 

The deaths of the following eminent foreign medical men are 
announced Dr. Huethe, formerly surgeon general of the 
German Navy, at the age of 74 years, who had been living in 
retirement since 1894. He was for some time a professor in 
the Naval Military Academy at Kiel. His death took place 
at Capri.—Dr. Donner, formerly professor of physiology in 
the Tours Medical School.—Dr. H. P. Loomis, professor of 
therapeutics and materia medica in Cornell University.— 
.Dr. Karl Schwing, extraordinary professor of gynecology 
in the Bohemian University of Prague. 


Stttal Steins. 


Examining Board in England by the Royal 
Colleges of Physicians of London and Surgeons of 
England —At the first professional examination held on 
Jan. 7th, 8th, 9th, and 10tb, the following gentlemen were 
approved in the subjects indicated :— 

Chemistry and, Physics.— Gilbert Bailey, Manchester University; 
Basil Fraser Beatson, Leys School, Cambridge; William Hackett 
Broughtou, Manchester University; Frederick William Campbell, 
University College, Cardiff; Rowland Burnell Campion, Guy's 
Hospital; Nai Cheune. London Hospital ; Henry Dyer Scott Close, 
St. Thomas’s Hospital; Edward Percy Drabble, London Hospital; 
Charles Alexander Robertson Gatley, Guv’s Hospital; John 
Llewellyn David Lewis, Guy's Hospital; Victor Alfred Luna, 
Guy's Hospital; Leonard Robert Pickett, Tonbridge School; 
Henry Charles Rigg, Charing Cross Hospital; William Andrew 
Thompson, Guy’s Hospital; Claude de Boudry Thomson, Middlesex 
Hospital; Claude William Treherne, St. Thomas's Hospital; 
Arnold Viney, Oundle School; and Sydney Arthur Wilkinson. 

Chemistry. —Ahmed Abdel-AL, Guy's Hospital; Frank Cunninghame 
Oowton, Alexander Kentoul Ksler, and Maberly Squire Kaler, St. 
Thomas's Hospital; Hassell Dyer Field, Battersea Polytechnic; 
Meredydd Foulkes, St. Thomas’s Hospital; Francis Henry Guppy, 
St. Bartholomew's Hospital; Frank Mainw&ritig Hughes. Gerald 
Noel Martin, and David Scott, London Hospital; Ivan Lindley 
Waddell, 8t. Bartholomew's Hospital; and William Neville Pennant 
Williams, Liverpool University. 

Physics.— Allan Stanley Coaloank, St. Bartholomew's Hospital; 
William Trevor Flooks, University College, Cardiff; Owen 
Gwatkin. Manchester University; William Fidler Mason, Leeds 
University; Eugene Andrew Joseph Murphy, King's College: 
Edmund Uniacke Russell, King's College; Charles Pearse 
Crodacott Sargent, Sr. Bartholomew’s Hospital; aud Henry 
Stanley Young, Birkbeck College. 

Biology.— Ramrao Belcrushma Agaskar and George Asplnall-Stivala, 
St. Bartholomew’s Hospital; Gilbert Bailey, Manchester University; 
William Somerset Birch, King's College; Herbert Chorley, Liver¬ 
pool University; Arthur George Bissot Fenwick, St.Thomas's Hos¬ 
pital; Geoffrey Garland, Leeds University; Charles Alexander 
Robertson Gatley. Guy's Hospital; William Edward Hallinan, 
Charing Cross Hospital; Leslie Price Harris, Guy's Hospital; John 
Kollo Hayman, Middlesex Hospital; George Basil Henley Jones, 
Guy’s Hospital; Edmund Thomas Howard Lea, Westminster Hos¬ 
pital ; David Lewis, London Hospital; Victor Alfred Luna, Guy’s 
Hospital; Alexander Macrae, London Hospital; Reginald Victor 
Martin, St. Mary's Hospital; Arthur Geoffrey Morris, University 
College, Bristol; Eugene Andrew Joseph Murphy, King's College 
Hospital; Frank Andrew Miller Nelson, Loudon llospital; Jorabbai 
Bbaibabhai Patel, Bombay University; Montague Peru ami George 
Brentnali Pritchard, Guy's Hospital; Walter Alexander Reynolds, 
St. Mary’s Hospital; Ilenry Charles Rigg, Charing Cross Hospital; 
Charles Pearse Crodacott Sargent, St Bartholomew’s Hospital; 
Jelal Moochool Shah, Bombay University and St. Bartholomew s 
Hospital; Cuthbert Shaw-Crisp, St. Mary’s Hospital; William 
Andrew Thompson, Guys Hospital; Chunilal Bhimbhai Vakil, 
St. Bartholomew's Hospital; William Cuthbert Whitworth, Guys 
Hospital; William Neville Pennant Williams, Liverpool University; 
and William Worger, University College, Bristol. 

At the Preliminary Science Examination for the Licence in 
Dental Sargery held this month the following gentlemen were 
approved in the subjects indicated ;— 

Chemistry and Physics.— Robert Reginald Adams, Guy's Hospital 
Edwin Randolph Bailey and Henry Leonard Bailey, Poly¬ 
technic Institute ; Stanley Maddox Gardner. Tecliuical In¬ 
stitute, Wandsworth; Robert John Harley-Mason, Birkbeck 
College; Guy William Enstone Holloway, Polytechuic Institute; 
Sidney William Ingram, Guy’s Hospital; William Howard Keay, 
Walsall Technical institute; Sidney Saxton, University College, 
Bristol; Herbert Thornton, Guy's Hospital; and Thomas Reginald 
Trounce, Birkbeck and City of London Colleges. 

Chemistry— Ernest Walter Bacon. Alleyn s School; Arthur Raymond 
Goddard, University College, Nottingham; Cyril Arthur Potlard, 
Birkbeck College; James Stacey Robinson, Walsall Technical 
Institute; George Wesley Royle, Modern School, Bedford ; and 
James Beunett Sharp, Charing Cross Hospital. 

Physics.— CharleB Reptou Faulkner, Birmingham University; 
Thomas Leonard Fid-lick, Guy's Hospital; Roy William List, 
Charing Cross Hospital; William Macqueen Potter. Birkbeck 
College; and Frank Percival Sturdee, Northern Polytechnic 
Institute and Birkbeck College. 

At the quarterly examination in Practical Pharmacy held 
on Jan. 16th the following gentlemen were approved :— 

Burgess Barnett, St. Bartholomew's Hospital; Charles Thornton 
Vere Benson, B.A Cantab , Cambridge University and St. Thomas's 
Hospital; John William Bowen, private study ; Frederick William 
Campbell, University College, Cardiff ; Arthur Henry Howard 
Catt, Charing Cross Hospital; Nai Cheune, London Hospital; 
Thomas Bonuor Davies, St. Bartholomew’s Hospital ; Maurice 
Dwyer. Leeds University ; Harold Delf Gillies, Cambridge Univer¬ 
sity and St. Bartholomew’s Hospital; Arthur Oliver Gray, King's 
College Hospital; Claud Anthony Holbum, Sheffield University; 
George Barrowclough Horrocks, Victoria University, Manchester; 
Gilbert Percy Humphry, St. George's Hospital; Colin Mackenzie, 
B A. Cautab., Cambridge University and Middlesex Hospital; 
Dalton Mallam, London Hospital; Samuel Marie, University 
College, Bristol; Guy Harvey Mead, St. Thomas's Hospital; 
Bertram Charles Noble O'Reilly, London Hospital; George Hugh 
Piercy, University College, Bristol; Arthur H&rdwicke Piatt, 




The Lancet,] 


MEDICAL NEWS.—BOOKS, ETC., RECEIVED. 


[Jan. 25,1908. 271 


Westminster Hospital; Kenneth Pretty, Cambridge University 
and St. Bartholomew's Hospital ; John Startln, St. Thomas's Hos¬ 
pital ; Percy Stanley Tomlinson, University College. Bristol; 
William Wijegoonewardena, Ceylon Medical College and King's 
College Hospital; Charles Eustace Williams, Charing Cross 
Hospital; and Stanley Wood, B.A. Cantab., Cambridge University 
and St. Bartholomew’s Hospital. 

University of Cambridge. —The following 
degrees were conferred recently :— 

M.C .—E. W. Sheaf, Downing. 

MB., B.C.—F. O. Arnold. Trinity. 

B.C. —J. H. Ryffel, Peterhouse; B. P. Campbell, Clare; E. Slack, 
Pembroke; I). W. A. Bull. Gonville and ;Caius; B. A. I. Peters, 
JesuB; H. N. Coleman, Clare; N. M. Fergusson, Magdalene and 
W. G. Parkinson, Emmanuel. 

University of Birmingham. —The following 

candidates having passed the necefsary examinations have 
obtained the Diploma in Public Health of this University :— 

Tom William Beazeley and William Henderson Davison. 

Literary Intelligence.— The Walter Scott 

Publishing Co. will shortly issue a work by Dr. R. R. 
Rentoul entitled, “ Enthetic Diseases (or the Young Man's 
Peril).” 

Longevity.— Mrs. Williams of Sophia-street, 
Cardiff, has recently reached the age of 100 years. 

After-Care Association.— The next annual 
meeting of the After-Care Association will be held at 48, 
Wimpole-street, London, W., by the kind permission of Dr. 
G. F. and Mrs. Blandford, on Wednesday, Jan. 29th, at 
3 p.m. The chair will be taken by Mr. Anthony Hope 
Hawkins and after the nsnal business a paper will be read 
by Dr. G. H. Savage upon the subject of Convalescence from 
Mental Disorders. 

Royal College of Surgeons of England.— 
At the ordinary Council on Jan. 16th the diploma of 
M.R.O.S. was conferred upon John Lawrence Graham-Jones, 

B. A. Cantab., Cambridge University and St. Thomas’s Hos¬ 
pital, and Charles Harold Smith, M.B. Liverpool, Liverpool 
University, who have passed the necessary examinations and 
have now complied with the by-laws. Licences to practise 
dentistry were conferred at the same meeting upon Samuel 
Stephenson Parkinson, Charing Cross and Royal Dental Hos¬ 
pitals, and Wilton Thew, Charing Cross and Royal Dental 
Hospitals, who have now complied with the by-laws of the 
College. 

Income Tax Reduction League.— A public 

meeting of the Income Tax Reduction League will be 
held in the Great Hall, Cannon-street Hotel, at 4 o'clock 
on Monday, Jan. 27th, when the Right Hon. Viscount 
St. Aldwyn, the Earl of Kinnonll, the Hon. Herbert 

C. Gibbs, Sir Alexander H. Brown, Bart., Sir Alexander 
Henderson, Bart., Professor H. S. Foxwell, and other gentle¬ 
men will take part. The Right Hon. Lord Avebury will 
preside. The aims of the League are: (1) to organise income 
tax payers for purposes of self-defence ; (2) to obtain in times 
of peace a substantial reduction of the income tax, which 
ought not to stand at a war rate ; and (3) the restriction of 
income tax to profits actually received by shareholders, or 
by individual traders, and to exempt depreciation funds from 
the operation of the tax. 

The Central Poor-law Conference.— The 

thirty-sixth annual central conference of the Poor-law 
authorities of England and Wales will be held in the 
council chamber of the Guildhall on Tuesday. Feb. 18th, 
and following day, the Right Hon. Sir Edward Fry, G.C.B., 
presiding. The Lord Mayor will attend in state and open 
the proceedings. Sir Edward Fry will then deliver his 
presidential address. The first day is to be devoted to a 
discussion on the Relation of Legal Relief and Private 
Charity, which will be opened by Mr. W. A. Bailward, late 
chairman of the Bethnal Green board of guardians. A 
debate is expected on the second day upon the Provision of 
Work for the Unemployed, opened bv Mr. John Kentish 
Wright (Nottingham) and Mr. Robert Waite (King’s Norton), 
with the Rev. P. S. G. Propert, chairman of the Fulham board 
of guardians, as selected speaker. The subject of the Treat¬ 
ment of Tuberculosis nnder the Poor-law will be introduced 
in a comprehensive paper by Dr. Nathan Raw, physician to 
the Mill road Infirmary, Liverpool. Boards of guardians in 
all parts of England and Wales will, as usual, send delegates, 
and in addition the 12 Poor-law districts will be officially 


represented by their members on the central committee, cf 
which Dr. J. Milson Rhodes is chairman, Sir William Chance, 
Bart., honorary secretary, and Mr. W. G. Lewis (barrister- 
at-law), secretary. 

University College, Bristol.— The annual 

dinner of the University College Colston Society was held on 
Jan. 14th under the presidency of Mr. G. A. Wills. The 
chairman announced that his father, Mr. H. Overton Wills, 
had decided to make a gift of £100,000 towards the fund for 
the foundation of a university for Bristol and the West of 
England, provided that a charter be granted within two 
years. It was stated that £197.000 of the £250,000 required 
before the charter can be applied for had been subscribed. 
The guest of the evening was Sir William J. Collins, 
M.P., Vice-Chancellor of the University of London, who in 
an interesting speech alluded to the ideals of higher educa¬ 
tion and added that he considered Bristol had all the 
elements for the constitution of a vigorous and healthy 
university. 

Proposed Consumption Hospital for Here- 
fordshire —At a meeting of the Herefordshire county 
council on Jan. 11th Sir Richard HarriDgton moved :— 

That it be referred to the general purposes committee to Inquire and 
report whether it is practicable to establish a county hospital for 
incipient cases of tuberculosis on the condition of any, and what, pay¬ 
ment by the respective boards of guardians throughout the county for 
pauper patients sent there and to consider the advisability of admitting 
paying patients. 

Sir Richard Harrington said that he thought that a scheme 
might be adopted whfereby the county would not be put to 
any expense. In other words, the hospital might be made 
self-supporting Last year, at a similar hospital in Westmor¬ 
land. a profit of £359 was made. Mr. George Creswell, who 
seoonded the motion, said that in Herefordshire alone there 
were 500 persons suffering from consumption. The motion 
was agreed to. 

University of London : University College.— 
A course of eight lectures on the Chemical Constitution of 
the Proteins will be delivered by Mr. R. H. Aders Plimmer, 

D.Sc., in the Physiological Laboratory of the College on 
Wednesdays at 5 p.m., having been commenced on Jan. 22nd. 
The lectures will deal with the history of the discovery and of 
the determination of the constitution of the amino acids; the 
hydrolysis of the proteins and the quantitative determination 
of the products of hydrolysis ; the synthesis of the proteinB 
and the polypeptides ; and the action of enzymes on the 
polypeptides. A course of eight lectures on the Chemistry 
of the Fats and Carbohydrates will be delivered by Mr. 
S. B. Schryver, D.Sc., Ph.D., in the Physiological Theatre on 
Fridays at 5 P.M., commencing to-day (Friday, Jan. 24th). 
The subject will be considered nnder the following 
headings:—The general chemistry of the fata and carbo¬ 
hydrates and the methods of differentiation ; the enzymeB 
which act on fats and carbohydrates ; the part played by 
fats and carbohydrates in the general economy of nutrition ; 
and their places of origin and synthesis in animal and 
vegetable organisms. Both sets of lectures are open to all 
students of the University of London and also to all qualified 
medical men and other persons who are specially admitted. 


BOOKS, ETC., RECEIVED. 


Arnold, Edward, 41 and 43, Maddox-street, London, W. 

The Chemical Basis of Pharmacology. An Introduction to. 
Pharmacodynamics basedon the Study of the Carbon Compounds. 
By Francis Francis, D.Sc., Ph.D.. Professor of Chemistry, Uni¬ 
versity College. Bristol, and J. M. Fortescue-Brickdale', M.A., 
M.D Oxon., Physician Bristol Royal Hospital for Sick Children, 
Medical Registrar Bristol Royal infirmary. Demonstrator of 
Physiology, University College, Bristol. Price 14s. net. 

BAiLtiiiRE, Tindall, and Cox, 8, Henrietta-street, Covent Garden, 
London, W.C. 

Aids to Surgery. By Joseph Cunning, M.B.. B.S., F.R C.S. Eng., 
Surgeon to the Victoria Hospital for Ohlldren; Assistant Surgeon 
to the Royal Free Hospital. Second edition. Price, cloth, 
4s net; paper. 3s. 6 d. net. 

The Pocket Anatnmy. Sixth edition, revised and edited by C. H. 
Fagge, M.B., M.S. Lond., F.K.C.S. Thirtieth thousand. Price 
3s. 6 d. net. 

The Spectroscope, its Uses in General Analytical Chemistry. An 
Intermediate Text book for Practical Chemists. By T. Thorno 
Baker, F.C.S., F.R.P.S.. Author of *'Spektralphotogiaphle, und 
deren Anwendimg," " Orthochromatic Photography," Ac. Price- 
5s. net. 




272 The Lancet,] 


BOOKS, ETC., RECEIVED.—APPOINTMENTS. 


[Jan. 25, 1908. 


Deuticke, Franz, Leipzig und Wien. 

Atlas der Venerischen Affektionen der Portio Vaginalis Uteri und 
der Vagina. Von I)r. Moriz Oppenheim, Privatdozent fiir 
Dermatologic und Syphilidologlc an der K. K. Universit&t Wien. 
Price M.14. 

Doin, Octave, 8, Place de l’Odeon, Paris. 

Etudes sur la Physlo-Pathologie du Corps Thyroide et de 
l'HypopbyBe. Par lea Doeteurs Leopold-Levi et Henri de 
Rothschild. Preface de M. Ch. Achard, Professeur Agrtige a la 
Faculte de Medecine, Medecin de l’HOpital Necker. Price Fr.8. 
Dvbwad, Jacob (In Kommlssion bel), Christiania. (A. W. Broggers’ 
Buchdruckerei.) 

Pathologisch-anatomische I ntersuchungen iiber Akute Polio- 
myeliiia und verwandte Krankheiten von den Bpidemien in 
Norwegen, 1903-1906. Von Francis Harhitz, Professor der 
Pathol. Anatomic und allgemeinen Pathologic an der Universitiit 
zu Kristiania und Ol&f bcheel, I. Assistant am pathologiach 
anatomischen Institute zu Kristiania. (Udgivet for Fridtjof 
Nansens Fond.) Price not staled. 

Fischer, Gustav, Jena. 

Die zytologische Untersuchungsmethode, ihre Entwicklung und 
ihre klinische Verwertung an den Krgiissen seroser Hohlen. 
Von Dr. Hermann Koniger, Oberarzt an der mediziuischen 
Klinik. Price M.3. 

Handbuch der Orthopkdischen Technik. Fiir zErzte und Banda- 
gisten. Bearbeitet von San.-Rat Dr. A. Schanz. Spezialarzt iur 
Orthopadie in Dresden. Price, paper, M.18.; bound, M.20. 

Fbovyde, Henry, and Hodder and Stoughton, 20, Warwick-square, 
London. K.C. 

Oxford Medical Publications. Fevers in the Tropics; Their 
Clinical and Microscopical Differentiation, including the Milroy 
Lectures on Kala-Azar. By Leonard Rogers, M.D., F.R.C.P., 
F.R.C.S., B.S., I.M.3., Professor of Pathology, Medical College. 
Calcutta; Fellow of the Calcutta University ; Honorary Member 
of the United States Society of Tropical Diseases and of the 
Philippines Medical Society. Price 30$. net. 

Oxford Medical Publications. Life Insurance and General 
Practice. By E. M. Brockbank. M.D. Viet., F.R.C.P., Honorary 
Assistant Physician, Royal Infirmary, Manchester; Lecturer in 
Materia Medica and Therapeutics, Victoria University of 
Manchester. Price 7a. 6 d. net. 

<Jbeen, William, and Sons, Edinburgh and London. 

Essentials of Physiology for Veterinary Students. By D. Noel 
Paton, M.D., B.Sc., F.R.C.P. Elin., Professor of Physiology, 
University of Glasgow. Second edition, revised and enlarged. 
Price 12a. net. 

Hi hsc it wald, August, Unterden Linden 63, Berlin. N.W. 

Atlas der Pathologisch-anatoinischen Sektlonstechnik. Von Prof. 
Dr. M. Westenhoeffer. Price M.2. 

J. B. Lippincott Company, Philadelphia and London. 

International Clinics. Edited by W. T. Longcope, M.D., Phila¬ 
delphia. U.S.A., with collaboration. Volume IV. Seventeenth 
Series. 1907. Price not stated. 

John Bale, Sons, and Daniels9Cn, Limited, 83-91, Groat Titchfield 
street. Oxford-street, London, W. 

The Pyonex : its Theory and Practice. By W. B. Rule, M.R.C.S., 

L. R.C.P. Price 12a. 6d. net. 

Kabitzsch, Curt. (A. Stuber), Wurzburg. 

Die Tierlschen Parasiten des Meuschen. Bin Handbuch fiir 
Studierende und JErzte. Von Dr. Max Braun, O. 0. Professor 
der Zoologie und Vergl. Anatomie, Direktor des Zoologischen 
Museums der Universitat Kdnigsberg i.Pr. Vierte, vermehrte 
und verbessorte Auflage. Mit einem klinisch-thcrapeutischen 
Anhang bearbeitet von Prof. Dr. Otto Seifert in Wlirzburg. Price, 
paper, M 15; bound M.17. 

Keystone Publishing Co., The, 809-811-813, North 19th-street, 
Philadelphia, U.S.A. 

Tests and Studies of the Ocular Muscles. By Ernest E. Maddox, 

M. D., F.R C.S. Edin., Ophthalmic Surgeon to Royal Victoria 
Hospital, Bournemouth; formerly Syme Surgical Fellow, Edin¬ 
burgh University. Second edition, specially revised and enlarged 
by the Author. Price not stated. 

Kimpton, Henry, 13, Furnival-street, Holborn, London, E.C. (Sten- 
hou.sk, Alexander, 40 and 42, University Avenue, Glasgow.) 

A Practical Treatise on Fractures and Dislocations. By Lewis A. 
Stimson, B.A., M.D , LL.D. (Yale), Professor of Surgery 7 in 
Cornell University Medical College, New York ; Surgeon to the 
New York and Hudaon-street Hospitals. Fifth edition, revised 
and enlarged. Price 25 s. net. 

The Principles and Practice of Modern Surgery. By Roswell Park, 
A.M., M.D., LL.D. (Yale), Professor of the Principles and Practice 
of Surgery and of Clinical Surgery in the Medical Departmeut of 
the University of Buffalo, New York. Volume I.. General 
Surgery. Volume II., Regional Surgery. Price of the work 
complete in two volumes, 36$. net. 

Lehmann, J. F., Miinchen. 

Die Entwickltingsgeschlcte des TAlentes und Genies. Von Dr. 
Albert Reibmayr. Erster Band : DieZtichtung <ies indhdduellen 
Talentes und Genies iu Familien und Kasten. Price M 10. 

Drei Jahre Gallensteinchirurgie. Bericht tiber 312 Laparotomein 
am Gallensyatem aus den Jahren 1904-1906. Von Prof. Dr. Hans 
Kehr, Geh. SauitAtsrat in Halberstadt, Dr. Liebold, Aasistenz- 
arztder Klinik und Oberarzt Dr. Neulinc, komoiaudiert an die 
Klinik. Price M.14. 

Schema des Rumpfos. Von Privatdozent Dr. W. Hildebrandt, 
F'reiburg i.B. Taschenausgabe. Price M.l.20. 

Macmillan Company, The, New York. (Macmillan and Co., 
Limited, Londou.) 

Lessons in Hygienic Physiology. By Walter Moore Coleman, A.B., 
Fellow of the Physical Society of London. Price 3$. 


Marlborough, E., and Co., 51, Old Bailey, London, E.C. 

Egyptian Self-Taught (Arabic). By Captain C. A. Thimm. Third 
edition, revised and enlarged by Major R. A. Marriott, D.S.O. 
Price, wrapper, 2$. ; cloth, 2«. 6 d. 

Rkber, Alberto, Libreria della R. Casa, Palermo. 

A. Trambusti, Professore Ordinario di Patologia Generale nella 
R. l.’niversita di Palermo. La Febbre Mediterranea (Setticemia 
del Bruce). Conferenza tenuta nell’ Aula degli Istituti Clinici 
di Perfezionamento a Milano il 33 Maggio, 1907. Price not 
stated. 

Rousset, Jules, 1, Rue Casimlr-Delavigne et 12, Rue Monsieur-le- 
Prince, Paris. 

Traite Clinique des Maladies de l’Estoraac. Par le Dr. Lucien Pron, 
(d'Aiger). Price Fr.12. 

Rueff, J. t 6 et 8, Rue du Louvre, Paris. 

Alimentation et Hygiene des Knfants. Par le Dr. Jules Comby, 
Medecin de l'llopital des Enfants-Maladcs. Troisl&me edition. 
Price Fr.5. 

Society du Mercure de Franck. 26. Rue de Coude. Paris. 

L’Art chez les Foua. Par Marcel Reja. Price Fr.3.50. 

Steinheil, G., 2, Rue Caaimir-Delavigne, Paris. 

Considerations Historiques sur la Blennorragie. Par le Docteur 
Ernest Roucayrol, Medaille de Bronze de ^Assistance Publique, 
Membre de la' Societe Franpalae d'Histoire de la Medecine. Price 
not stated. 

Urban and Schwarzenberg. Berlin und Wien. 

Die Praxis der Hautkrankheiten. Unna's Lehren fiir Studierende 
und yErzte. Zusammengefasst uud dargestellt von Dr. Iwan 
Bloch, Berlin. Mit einem Vorwort von Dr. P. G. L'uua in 
Hamburg Price M.18. 

Prof. Dr. Wilhelm Czerinak. Die Augenarztliclien Operationen. 
Zweite vermehrte. Auflage. Herausgegeben von Dr. Anton 
Elschnig, K.K.O.O. Universitut-sprolesaor und Vorstand der 
Peutaehen Universitutc-Augenklinik in Prag. I. Band, 2 Halite 
Price M. 10. 

Vigot Frkres, 23, Place de l’Ecole-de-Medecine, Paris. 

Le Criminel aux Points de Vue Anthropologique, Psychologique et 
Social. Par le Dr. Emile Laurent. Preface de M. le Proiesseur 
Lacassagne. Price Fr.3 50. 

Traitement de la Tuberculose par la Paratoxine. Base sur 1'Action 
antitoxique du Foie. Par E. Gerard, Professeur de Pharmacie et 
de Pharmacologic it l’Univeraite de Lille, et G. Lcmoine, 
Professeur de Clinique Medicate il l’Unlversite de Lille. Price 
Fr.1.50. _ 


appointments. 

Successful applicants for Vacancies, Secretaries of Public Institutions , 
and others possessing information suitable for this column, are 
invited, to forward to The Lancet Office, directed to the Sub- 
Editor, not later than 9 o'clock on the Thursday morning of each 
week, such information for gratuitous publication. 


Anderson, C. M., M.D. Edin., has been appointed Clinical Assistant to 
the Samaritan Free Hospital for Women. 

Barber, R. A., M.D., M.S K.U.I., has been appointed Certifying 
Surgeon under the Factory and Workshop Act for the Dronfield 
District of the county of Derby. 

Bury. Reginald Frederick. M.R.C.S., L.R.C.P. Load., has been 
appointed Honorary Surgeon to the Warneford Hospital, 
Leamington Spa. 

Culboss, James, M.B., C.M. Glasg., has been appointed to the 
Honorary Medical Staff of the Newton Abbot Hospital. 

Glover, J. A., M.D. Cantab., D.P.H., has been appointed 
Deputy Medical Officer of Health to the Islington Borough 
Council. 

Grimuly, Richard H., M.R C.S., LS.A., has been appointed to the 
Honorary Medical Staff of the Newton Abbot Hospital. 

Haydon, Edgar, MB., C.M. Glasg., has been appointed to the 
Honorary Medical Staff of the Newton Abbot Hospital. 

Hulukki, J. G., Major, I.M.S., M.B., B.C.Cantab., haB been appointed 
Clinical Assistant to the Samaritan Free Hospital for Women. 

Hunt, Ernest, L.R.C P., M.R.C.S . has been appointed to the Honorary 
Medical S aff of the Newton Abbot Hospital. 

Macmillan, Evan. M.B., MS. Edin., has been appointed Certifying 
Surgeon under the Factory and Workshop Act for the Str&thmiglo 
District of the county of Fife. 

Manners, W. F„ M R C.S. Eng-, has been appointed Clinical Assistant 
to the Samaritan Free Hospital for Women. 

Millar, N., LD S. Eng., has been appointed Honorary Dental Surgeon 
to the Newton Abbot Hospi al. 

Nisbkt, A. Thomson, M.D., C.M. Glasg., has been appointed to the 
Honorary Medical Staff of the Newton Abbot Hospital. 

Purnell, R, M.D. St. And., M.RC.S., LS A., J.P., has been 
appointed a Member of the Visiting Committee for Shepton Mallet 
and Bristol Prisons. 

Scott. Walter U., L.R.C.P. Lond., M R.C S., has been appointed 
to the Honorary Medical Staff of the Newton Abbot Hospital. 

Scott, W. Gifford, M B., C.M Edin.. L K.C.S.Edin., has been appointed 
to the Honorary Medical Si aff of the Newton Abbot Hospital. 

Scbask. J. J. S., L.RC.P-. M.R.C.S.. has bee • appointed to the 
Honorary Medical Staff of the Newton Abbot Hospital. 

Shikvell, Edgar A, M.R.C.S., L K.C P. Lond., has been appointed 
Resident Medical Officer at the Royal Alberr. Hospital, Devouport. 

Smith, G. F. Dakwall, B.M., B.Uh. Oxon., F.R.C.S. Eng., has been 
appointed Surgeon to Out-paiieuts at the Samaritan Free Hospital 
for Women. 

Stuart, Frederick. M.B., B S. Durh., haa been appointed Clinical 
Assistant to tne Samaritan Free Hospital for Women. 

Sugdkn, W. A.. L S. V, has oeen appointed Clinical Assistant to the 
Samaritan Free Hospital for Women. 

Watkins, John GkaNDISSon, L.R.C.P. Loud., M.R.C.S., has beea ap¬ 
pointed Medical Officer for the North Curry District by the 
Taunton Board of GuAraiaus. 





274 The Lancet,] NOTES, SHORT COMMENTS, AND ANSWERS TO CORRESPONDENTS. [Jan. 25, 1908. 


DEATH OF A CENTENARIAN IN AUSTRALIA. 

It Is stated in the Australasian lhat John Browne, an inmate of the 
Liverpool Benevolent Asylum, New South Wales, died last month at 
the reputed age of 119 years. About three years ago he lost his hear¬ 
ing and 18 months later he had a paralytic stroke. He formerly 
belonged to the British Navy and landed in New South Wales at the 
age of 32. 20 years ago ho entered the asylum, being then 99 years 
old. His age was fully authenticated by the Asylum authorities. 

ARTIFICIAL NOSES. 

To the Editor of The Lancet. 

Sir, —Can any of your correspondents tell me of any firm making 
artificial noses and recommend the work from personal knowledge ? 

I am, Sir, yours faithfully, 

Jan. 22nd, 1908. M.D. 

A COUNTESS’S CURE FOR SMALL POX. 

To the Editor of The Lancet. 

Sir,—I n the interesting note under the above heading which 
appears in your issue of Jan. 18th a passage In the Countess's recipe 
is given as follows, “ as much refined searved (?) through tlffeny." 
There is evidently a word omitted after “ refined" and the word 
“ searved ” should undoubtedly be " searched "or " searced,” moaning 
put through a sieve. The word “search" is still a common Scots 
word for a sieve, or was so at any rate in the early years of the last 
century. Moreover, the expression " fine searced sugar" will be found 
constantly in the seventeenth century cookery books. 

I am, Sir, yours faithfully, 

Jan. 21st, 1908. Etonensis. 

Communications not noticed in our present issue will receive attention 
in our next. 


METEOROLOGICAL READINGS. 

(Taken daily at 830 a.m. by Steward's Instruments.) 

The Lancet Office, Jan. 23rd, 1908. 


Date. 

Barometer 
reduced to 
8oa Level 
and 32° F. 

Direc¬ 

tion 

of 

Wind. 

1 Solar 
Raln-i Radio 
fall. In 
Vacuo. 

Maxi¬ 

mum 

Temp. 

Shade. 

Min. 

Temp 

Wet 

Bulb. 

lXS. 

Remarks. 

Jan. 17 

30 03 

S.W. 


66 

53 

50 

49 

61 

Cloudy 

.. 18 

30-29 

s.w. 


hi 

48 

43 

42 

43 

Fine 

.. 19 

30 34 

K. 


43 

41 

34 

3b 

36 

Foggy 

.. 20 

30 43 

N.E. 


58 

44 

36 

38 

39 

Cloudy 

.. 21 

30 57 

S.E. 


43 

38 

33 

3b 

36 

Foggy 

„ 22 

30 43 

S. 


43 

42 

33 

3b 

37 

Overcast 

.. 25 

30 50 

S. 

... 

40 

40 

36 

38 

38 

Foggy 


Hlfbiral Ilia nr for fjjc ensuing ($tcdi. 


OPERATIONS. 

METROPOLITAN HOSPITALS. 

MONDAY (27tll>. —London (2 p.m.), St. Bartholomew's (1.30 P.M.), St. 
Thomas’s (3.30 p.m.), St. George’s (2 p.m.), St. Mary’s (2.30 p.m.), 
Middlesex (1.30 p.m.), Westminster (2 p.m.), Chelsea (2 p.m.), 
Samaritan (Gynsecological, by Physicians, 2 p.m.), Soho-square 
(2 p.m.), City Orthopiedic (4 p.m.), Gt. Northern Central (2.30 p.m.). 
West London (2.30 p.m.), London Throat (9.30 a.m.), Royal Free 
(2 p.m.), Guy’s (1.30 p.m.), Children, Gt. Ormond-street '(3 p.m.), 
St. Mark’s (2.30 P.M.). 

TUESDAY (28tll).— London (2 p.m.), St. Bartholomew’s (1.30 p.m A St. 
Thomas's (3.30 p.m.). Guy’s (1.30 p.m.), Middlesex (1.30 p.m.), West¬ 
minster (2 p.m.). West London (2.30 p.m.). University College 
(2 p.m.), St. George’s (1 p.m.), St. Mary’s (1 p.m.), St. Mark's 
(2.30 p.m.), Cancer (2 p.m.), Metropolitan (2.30 p.m.), Loudon Throat 
(9.30 a.m.), Samaritan (9.30 a.m. and 2.30 p.m.), Throat, Golden- 
square (9.30 a.m.), Soho-aquare (2 p.m.), Chelsea (2 p.m.), Central 
London Throat, and Ear (2 P.M.), Children, Gt. Ormond street 
(2 p.m., Ophthalmic, 2.15 p.m.), Tottenham (2.30 P.M.). 

WEDNESDAY (29th).— St. Bartholomew’s (1.30 p.m.), University College 
(2 p.m.), Royal Free (2 p.m.), Middlesex (1.30 p.m.). Charing Cross 
(3 P.M.), 8t. Thomas’s (2 p.m.), London (2 p.m.), King’s College 
(2 p.m.), St. George's (Ophthalmic, 1 p.m.), St. Mary’s (2 p.m.), 
National Orthoprrdic (10 a.m.), St. Peter’s (2 P.M.), Samaritan 
(9.30 a.m. and 2.30 p.m.), Gt. Northern Central (2.30 p.m.), West¬ 
minster (2 p.m.), Metropolitan (2.30 p.m.), London Throat (9.30 a.m.), 
Cancer (2 p.m.), Throat, Golden-square (9.30 a.m.), Guy’s (1.30 p.m.), 
Royal Ear (2 p.m.). Royal Orthopaedic (3 p.m.), Children, Gt. 
Ormond-street (9.30 a.m., Dental, 2 p.m.), Tottenham (Ophthalmic, 
2.30 p.m.). 

THURSDAY (30th).— St. Bartholomew’s (1.30 p.m.), St. Thomas’s 
(3.30 p.m.). University College (2 p.m.). Charing Cross (3 p.m.), 8t. 
George's (1 p.m.), London (2 p.m.). King's College (2 p.m.), Middlesex 
(1.30 p.m.), St. Mary's (2.30 p.m.). Soho-squaro (2 p.m.), North-West 
London (2 p.m.), Gt. Northern Central (Gynaecological, 2.30 p.m.), 
Metropolitan (2.30 p.m.), London Throat (9.30 a.m.), Samaritan 
(9.30 a.m. and 2.30 p.m.). Throat, Golden square (9.30 a.m.), Guy’s 
(1.30 p.m.), Royal Orthopedic (9 a.m.). Royal Ear (2 p.m.). Children, 
Gt. Ormond-street (2.30 p.m. ). Tottenham (Gynecological. 2.30 p.m.) 

FRIDAY (31st).— London (2 p.m.), St. Bartholomew's (1.30 p.m.), St. 
Thomas's (3.30 p.m.), Guy’s (1.30 p.m.), Middlesex (1.30 p.m.). Charing 
Cross (3 p.m.), St. George’s (1 p.m.), King’s College(2 p.m.), St. Mary’s 
(2 p.m.), Ophthalmic (10 a.m.), Cancer (2 p.m.), Chelsea (2 p.m.), Gt. 


Northern Central (2.30 p.m.), West London (2.30 p.m.), London 
Throat (9.30 a.m.), Samaritan (9.30 a.m. and 2.30 p.m.). Throat, 
Golden-square (9.30 a.m.), City Orthopa»dic (2.30 p.m.), Soho-square 
(2 P.M.), Central London Throat and Ear (2 P.M.), Children, Gt. 
Ormond-street (9 a.m., Aural, 2 p.m.), Tottenham (2 30 p.m ), St. 
Peter’s (2 p.m.). 

SATURDAY (1st).— Royal Free (9 a.m.). London (2 p.m.), Middlesex 
(1.30 p.m.), St. Thomas's (2 p.m.). University College (9.15 a.m.). 
Charing Cross (2 p.m.), St. George’s (1 p.m.)', St. Mary’s (10 a.m.), 
Throat, Golden-square (9.30 a.m.), Guy’s (1.30 p.m.). Children, Gt. 
Ormond-street (9.3) a m.). 

At the Royal Bye Hospital (2 p.m.), the Royal London Ophthalmic 
(10 a.m.), the Royal Westminster Ophthalmic (1.30 p.m.), and the 
Central London Ophthalmic Hospitals operations are performed daily. 


SOCIETIES. 

ROYAL SOCIETY OF MEDICINE, 20, Hanover-squaro, W. 

Monday.— (Odontological Section). 7 p.m., Council Meeting. 
8 P.M., The Curator: Recent Additions to the Museum. Mr. 
W. W. James : Some Notes on a Case of Extensive Necrosis of 
the Mandible. (The patient will be in attendance before the 
meeting.) Mr. J. F. Colyer: The Treatment of Children from 
a Dental Aspect (illustrated by the epidiascope). 

Tuesday .—(Medical Section). 5 p.m., Dr. C. Thomson : Demonstra¬ 
tion of the Use of the Kinematograph in Illustration of Disease. 
Dr. A. F. Hertz : Pathology and Treatment of Constipation 
(illustrated by lantern slides). ( Therapeutical and Pharma¬ 
cological Section). (Apothecaries’ Hall, Blackfriars, E.C.) 
4.30 p.m.. Prof. W. E. Dixon: Arteriosclerosis and its Causa¬ 
tion. Prof. A. R. Cushing: Nutmeg Poisoning. 

Thursday .—(Neurological Section). 8 p.m., Cases. 8.30 p.m.. Dis¬ 
cussion on “ Tics.” 

MEDICAL SOCIETY OF LONDON, 11, Ohandos-street, Cavendish- 
square, W. 

Monday.— 8.30 p.m., Mr. C. B. Lockwood: The Use of Chemicals 
in Aseptic Surgery. Dr. S. West: The Nervous Complica¬ 
tions in Acute Pneumonia. 

OPHTHALMOLOGICAL SOCIETY OF THE UNITED KINGDOM. 

Thursday. —8 p.m., Card Cases. 8.30 p.m., Mr. S. Snell: (1) Car¬ 
cinoma of Orbit.; (2) Colobroma of Iris in each Eye occurring 
in Five Generations. Mr. S. Mayou: Microphthalmia resem¬ 
bling Glioma, with Lenticonus and Hypertrophy of the Ciliary 
Body. Mr. L. Paton: Optic Neuritis in Cerebral Tumours. 
Dr. ▲. J. G. Barker : A Case of Suppurative Tenonitis. 

BRITISH BALNEOLOGICAL AND CLIMATOLOGICAL SOCIETY, 
20, Hanover-Bquare. W. 

Wkdnesdat.— 5.30 p.m., Adjourned Discussion on Dr. Edgecombe’s 
paper on Blood Pressure in Spa Practice (introduced by Dr. V. 
Fox) Mr. T. Hawksley: Exhibition of Blood Pressure Instru¬ 
ments. 


LECTURES, ADDRESSES, DEMONSTRATIONS, &c. 

MEDICAL GRADUATES’ COLLEGE AND POLYCLINIC, 22, 
Chenies-street, W.C. 

Monday.—4 p.m., Dr. J. Galloway : Clinique (Skin). 5.15 p.m.. 
Lecture:—Mr. J. Sherren : The Differential Diagnosis between 
Injuries of the Spinal Cord and those of Peripheral Nerves. 
Tuesday.— 4 p.m., Dr. J. B. Squire: Clinique (Medical). 5.15 p.m,, 
LectureDr. D. Sommerville: Muoous Colitis. 

Wednesday. —4 p.m., Mr. P. J. Freyer: Clinique (Surgical). 
5.15 p.m.. Lecture Dr. W. L&ngdon Brown : Some Intestinal 
Intoxications. 

Thursday.— 4 p.m., Mr. Hutchinson: Clinique (Surgical). 5.15 p.m.. 
Lecture :—Dr. L. Williams: The Bogey of Albuminuria. 
Friday.— 4 p.m., Mr. S. Stephenson: Clinique (Bye). 
POST-GRADUATE COLLEGE, West London Hospital, Hammersmith, 
road, W. 

Monday.— 12 noon: Lecture:—Dr. Low: Pathological. 2 p.m., 
Medical and Surgical Clinics. X Rays. Mr. Dunn: Diseases 
of the Eye. 2.30 p.m., Operations. 6 p.m., Lecture:—Mr. 
Bidwell: Clinical. 

Tuesday.— 10 a.m., Dr. Moullin: Gynaecological Operations. 
12 noon: Lecture:—Dr. Pritchard: Practical Medicine. 2 p.m.. 
Medical and Surgical Clinics. X Rays. Dr. Ball: Diseases of 
the Throat, Nose, and Bar. 2.30 i\m.. Operations. Dr. Abraham: 
Diseases of the Skin. 5 p.m., Lecture:—Dr. R. Jones: The 
Relation of Insanity to Allied Neuroses. 

Wednesday.— 10 a.m., Dr. Ball: Diseases of the Throat, Nose, and 
Ear. Dr. Saunders: Diseases of Children. 2 p.m.. Medical and 
Surgical Clinics. X Rays. Dr. Scott: Diseases of the Eye. 
2.30 p.m., Operations. Dr. Robinson» Diseases of Women. 
5 p.m., Lecture:—Dr. Beddard : Practical Medicine. 
Thursday.—12 noon, Lecture:—Dr. Pritchard; Practical Medicine. 
2 p.m., Medical and Surgical Cliuica. X Rays. Mr. Dunn: 
Diseases of the Eye. 2.30 p.m.. Operations. 5 p.m.. Lecture 
Mr. Edwards: Clinical. 

Friday.— 10 a.m., Dr. M. Moullin : Gynecological Operations. 
2 p.m.. Medical and Surgical Clinics. X Kays. Dr. Ball: 
Diseases of the Throat, Nose, and Ear. 2.30 p.m., Operations. 
Dr. Abraham : Diseases of the Skin. 5 p.m., Lecture:—Mr. R. 
Lloyd: An aesthetics. 

Saturday.— 10 a.m.. Dr. Ball: Diseases of the Throat. Nose, and 
Ear. 2 p.m., Medical and Surgical Clinics. X Rays. Di. 
Scott: Diseases of the Eye. 2.30 p.m., Operations. Dr. 
Robinson : Diseases of Women. 

NORTH-EAST LONDON POST-GRADUATE COLLEGE, Prince of 
Wales's General Hospital, Tottenham, N. 

Monday.— Cliniques:— 10 a.m., Surgical Out-patient (Mr. H. 
Kvans). 2.30 p.m., Medical Out-patient (Dr. T. R. Whipham); 
Throat, Nose, and Ear (Mr. H. W. Careon); X Ray (Dr. A. H. 
Pirie). 4.30.P.M., Medical In-patient (Dr. A. J. Whiting). 








The Lancet,] 


DIARY.—EDITORIAL NOTICES.—MANAGER’S NOTICES. 


[Jan. 25, 1908 . 275 


Tuesday.— Clinique10.30 a.m., Medical Out-patient (Or. A. G. 
Auld). 2.30 P.M., Surgical Operations (Mr. Carson). Cliniques:— 
Surgical Out-patient (Mr. Edmunds); Gynaecological (Dr. A. E. 
Giles). 4.30 p.m., Demonstration:—Dr. G. P. Chappel: Selected 
Medical Cases 

Wednesday.— Cliniques :-2-30 p.m.. Medical Out patient (Dr. 
Whipliam); Dermatological (Dr. G. N. Meachen); Ophthalmo- 
logical (Mr. R. P. Brooks). 

Thursday.— 2.30 p.m , Gynaecological Operations. (Dr. Giles). 
CliniquesMedical Out-patient (Dr. Whiting); Surgical Out- 
patient (Mr. Caraon); X Ray (Dr. Pirie). 3 p.m.. Medical 
in-patient (Dr. G. P. Chappel). 4.30 p.m.. Lecture-Demonstra¬ 
tion Dr. A. J. Whiting: Cases of Aneurysm of the Thoracic 
Aorta (at the Mount Vernon Hospital Out-patient Department, 
7, Fitzroy-equare. W.). 

Friday.— 10 a.m., Clinique:—Surgical Out-patient (Mr. H. Evans). 
2.30 p.m., Surgical Operations (Mr. Edmunds). Cliniques: — 
Medical Out-patient (Dr. Auld); Eye (Mr. Brooks), o p.m., 
Medical In-patient (Dr. M. Leslie). 

CONDON SCHOOL OF CLINICAL MEDICINE, Dreadnought 
Hospital, Greenwich. 

Monday.—2.15 p.m.. Sir Dyce Duckworth : Medicine. 2.30 p.m., 
Operations. 3.15 p.m., Mr. W. Turner : Surgery. 4 p.m., Dr. 
StClair Thomson: Ear and Throat. Out-patient Demonstra¬ 
tions .—10 a.m., Surgical and Medical. 12 noon, Ear and Throat. 
4 p.m., Special Lecture:—Dr. StClair Thomson: Mouth 
Breathing. 

Tuesday.—2(15 p.m., Dr. R. T. Hewlett: Medicine. 2.30 p.m., 
Operations. 3.15 p.m., Mr. Car lea 8 : Surgery. 4 p.m., Mr. M. 
Morris -. Diseases of the Skin. Out-patient bemonstr&tions— 
10 a.m.. Surgical and Medical. 12 noon. Skin. 3.15 p.m., Special 
Lecture:—Mr Carless: On Movable Kidney. 

Wednesday.— 2.15 p.m., Dr. F. Taylor: Medicine. 2.30 p.m., 
Operations. 3.30 p.m., Mr. Cargill: Ophthalmology. Out- 

f atient Demonstrations:—10 a.m., Surgical and Medical, 
1a.m., Eve. 

Thursday.—2.15 p.m., Dr. G. Rankin : Medicine. 2.30 p.m., Opera¬ 
tions. 3.15 p.m.. Sir W. Bennett : Surgery. 4 p.m., Mr. M. 
Davidson : Radiography. Out-patient Demonstrations 
10 a.m., Surgical and Medical 12 noon, Ear and Throat. 
Friday. - 2.15 p.m.. Dr. R. Bradford: Medicine. 2.30 p.m.. 
Operations. 3.15 p.m., Mr. McGavtn: Surgery. Out-patient 
Demonstrations:— 10 a.m., Surgical and Medical. 12 noon, 
Skin. 2.15 p.m.. Special Lecture » —Dr. R. Bradford : Diabetes. 
Saturday.—2.30 p.m.. Operations. Out-patient Demonstrations 
10 a.m., Surgical and Medical. 11 a.m., Eye. 

OREAT NORTHERN CENTRAL HOSPITAL, Holloway road. N. 

Monday.—9 a.m.. Operations (Mr. White). 2.30 p.m.. In-patients— 
Medical (Dr. Beevor); Out-patieats—Medical (Dr. Willcox), 
Surgical (Mr. Low), Eye (Mr. Morton and Mr. Coats). 
Tuesday.—2.30 p.m., In-patients Medical (Dr. Beale), Throat and 
Ear (Mr. Waggett); Out patients —Surgical (Mr. Edmunds), 
Throat and Ear (Mr. French); Operations (Mr. Beale). 
Wednesday.—2.30 p.m.. In-patients-Surgical (Mr. Stabb); Out¬ 
patients— Med leal (Dr. Horder), Gynecological (Dr. Lockyer). 
Skin (Dr. Whitfield), Teeth (Mr. Balv); Operations (Mr. Stabb). 
Thursday.-2.30 p.m., In patients—Medical (Dr. Morison). 
Friday.— 3.30 p.m., Lecture-.—Dr. C. Lockver: Cancer of the 
Womb. 

NATIONAL HOSPITAL FOR THE PARALYSED AND EPILEPTIC, 
Queen-square, Bloomsbury, W.C. 

Tuesday.—3.30 p.m., Lecture :—Dr. A. Turner: Cranial Nerve 
Paralysis. 

Friday.— 3.30 p.m. , Lecture:—Dr. J. Taylor: Myopathies. 

ST. JOHN’S HOSPITAL FOR DISEASES OF THE SKIN, 
Leicester-square, W.C. 

Thursday.— 6 p.m.. Lecture:—Dr. M. Dockrell: Syphilis : History 
and Primary Invasion (Constitutional and Local). Eruptions, 
Erythematous (I., Macular; and II., Maculo-Papular). 
CHARING CROSS HOSPITAL. 

Thursday.— 3 p.m.. Demonstration:—Dr. Galloway and Dr. 
MacLeod: Diseases of the Skin. 4 p.m'., Demonstration:— 
Dr. W. Hunter: Medical. (Post-Graduate Course). 

ROYAL INSTITUTION OF GREAT BRITAIN, Albemarle street. 
Piccadilly, W. 

Friday.—9 p.m.. Prof. B. Rutherford: Recent Researches on 
Radio-Activity. 

ROYAL SANITARY INSTITUTE, Parkes Museum, Margaret 
street, W. 

Wednesday.—8 p.m.. Discussion on Rivers Pollution, with Special 
Reference to the Board proposed by the Royal Commission 
(opened by Sir William Ramsay, K.C.B.). 


EDITORIAL NOTICES. 

It is most important that communications relating to the 
Editorial business of Thu Lancet should be addressed 
eiolusively “To THE Editor,” and not in any case to any 
gentleman who may be supposed to be connected with the 
Editorial staff. It is urgently necessary that attention should 
be given to this notice._ 

It it especially requested that early intelligence of local events 
having a medical interest, or which it is desirable to bring 
under the notice of the profession, may be sent direct to 
this office. 

Lectures, original articles, and reports should be written on 
one side of the paper only, and when accompanied 

BY BLOCKS IT IS REQUESTED THAT THE NAME OF THE 
AUTHOR, AND IF POSSIBLE OF THE ARTICLE, SHOULD 


BE WRITTEN ON THE BLOCKS TO FACILITATE IDENTI¬ 
FICATION. 

Letters, whether intended for insertion or for private informa¬ 
tion, must be authenticated by the names and addresses of 
their writers—not necessarily for publication. 

H e cannot prescribe or recommend practitioners. 

Local papers containing reports or nters paragraphs should be 
■marked and addressed “ To the Sub Lditor." 

Letters relating to the publication, sale and advertising 
departments of The Lancet should be addressed "To the 
Manager.” 

We cannot undertake to return MSS. not used. 


MANAGERS NOTICES. 

THE INDEX TO THE LANCET. 

The Index and Title-page to Vol. II. of 1907, which was 
completed with the issue of Dec. 28tb, were given in 
The Lancet of Jan. 4th, 1908. 

VOLUMES AND CASES. 

Volumes for the second half of the year 1907 are now 
ready. Bound in cloth, gilt lettered, price 18s., carriage 
extra. 

Cases for binding the half year’s numbers are also ready. 
Cloth, gilt lettered, price 2s., by post 2s. 3d. 

To be obtained on application to the Manager, accompanied 
by remittance. 

TO SUBSCRIBERS. 

Will Subscribers please note that only those subscriptions 
which are sent direct to the Proprietors of The Lancet at 
their Offices, 423, Strand, London, W.C., are dealt with by 
them ? Subscriptions paid to London or to local newsagents 
(with none of whom have the Proprietors any connexion what¬ 
ever) do not reach The Lancet Offices, and consequently 
inquiries concerning missiDg copies, ka., should be sent to 
the Agent to whom the subscription is paid, and not to 
The Lancet Offices. 

Subscribers, by Bending their subscriptions direct to 
The Lancet Offices, will insure regularity in the despatch 
of their Journals and an earlier delivery than the majority 
of Agents are able to effect. 

The Colonial and Foreign Edition (printed on thin 
paper) is published in time to catch the weekly Friday mails 
to all partB of the world. 

The rates of subscriptions, post free, either from 
The Lancet Offices or from Agents, are :— 

For the United Kingdom. | To the Colonies and Abroad. 

One Year .£1 12 6 . One Year .£1 14 8 

Six Months. 0 16 3 Six Months. 0 17 4 

Three Months . 0 8 2 j Three MonthB . 0 8 8 

Subscriptions (which may commence at any time) are 
payable in advance. Cheques and Post Office Orders (crossed 
“London and Westminster Bank, Westminster Branch”) 
should be made payable to the Manager, Mr. Charles Good, 
The Lancet Offices, 423, Strand, London, W.C. 

TO COLONIAL AND FOREIGN SUBSCRIBERS. 

Subscribers abroad are particularly requested 
to note the rates of subscriptions given above. It 

has come to the knowledge of the Manager that in some 
cases higher rates are being charged, on the plea that the 
heavy weight of The Lancet necessitates additional 
postage above the ordinary rate allowed for in the terms of 
subscriptions. Any demand for increased rates, on this or on 
any other ground, should be resisted. The Proprietors of 
The Lancet have for many years paid, and continue to pay, 
the whole of the heavy cost of postage on overweight foreign 
issues; and Agents are authorised to collect, and generally 
do so collect, from the Proprietors the cost of such extra 
postage. 

The Manager will be pleased to forward copies direct from 
the Offices to places abroad at the above rates, whatever be 
the weight of any of the copies so supplied. Address— 
The Manager. The Lancet Offices, 423, Strand, 
London, England. 


Soring the week marked ooples ot the foUowlng newspapers 
have been received —Morning Advertiser, Manchester Evening 
Chronicle. Edinburgh Erening .Yet vs. Morning Post, Daily Chronicle. 
The Tribune. Daily Graphic, Liverpool Courier, Manchester 
Courier. Daily Express. Birmingham Post, Daily Sews. Manchester 
Dispatch, Northern Whig, Bournemouth Echo, Westminster Caxette, 
Cork Examiner, L'jmington chronicle, Poole Deraid, Coventry 
Times, Sec. 







276 Thb Lancet,] 


ACKNOWLEDGMENTS OF LETTERS, ETC., RECEIVED. 


[JAN. 25, 1908. 


Communications, letters, &c., have been 
received from— 


Letters, each with enclosure, are also 
acknowledged from— 


A*— Augier Chemical Co-, Lond.; 
Addenbrooke's Hospital. Cam¬ 
bridge; Alkuris, Richmond, 
Managing Director of; Advisory 
Committee for Plague Investiga¬ 
tion in India. Lond., Secretary of; 
Ardath Tobacco Co., Lond.; 
Aberdeen Free Press, Manager 
of ; American Medical Associa¬ 
tion, Chicago; Messrs. Allen 
and Hanburys, Lond. 

■ —Mr. A. Benthall, Lond.; 
Blackburn Education Committee, 
Director of; Berry Wood Asylum, 
Northampton, Clerk to the; 
Messrs. J. Bale, Sons, and 
Danielsaon, Lond.; Bradford 
Children's Hospital, Secretary 
of; Mr. O. Berthier. Palis; 
Dr. A. T. Brand, Driffield; 
Dr. T. E. Bradshaw, Liverpool; 
Dr C. Ballabene, Berlin; 
British Ship Surgeons’ Associa¬ 
tion, Leeds, Hon. Secretary of; 
Dr. W. Bain, Lond.; Mr. T. 
Harrison Butler, Coventry; 
Dr. P- Palmer Burrows, Lindsay, 
Ontario, Canada. 

0—Dr. James Corns, Oldham; 
Messrs. Arthur H. Cox and Co., 
Brighton; Dr. N.Campbell, Lond.; 
Messrs. Cassell and Co., Lond.; 
Messrs. J. and J. Colman, Nor¬ 
wich; Messrs. Callard and 
Bowser, Lond.; Messrs. Collyer 
and Davis, Lond.; Mr. D. Cotes 
Preedv, Lond.; Mr. P. W. Clarke, 
Chorlton-cum-Hardy. 

T).— Mr. C. G. Dunne, Lond.; 
Dr. A. W. W. Dowding, Algeciran; 
Mr. F. Diemer, Cairo; Mr. W. G. 
Dickson, Kingskerswell; Sir 
Dyce Duckworth, Lond. 


F —Dr. R- M. Fraser, Belfast; 
Dr. Theodore Fisber, 8idcup; 
Messrs. Fannin and Co., Dublin; 
Mr. Duncan C. L. Fitzwilliama, 
Lond. 

a—Mr. H. Tyrrell Gray, Lond.; 
Mr. W. J. Green, Lond.; Dr. 
Lachlan Grant, Ballachulish; 
Galen Manufacturing Co., Lond.; 
Mr. G. H. Gemmell, Edinburgh; 
GreatYarmouth County Borough, 
Clerk to the ; Sir W. R. Gowers, 
Lond. 

H.— Mr. G. S. Heatley, Edinburgh ; 
Messrs. H. M. Hobson, Lond.; 
Messrs. Hooper and Co., Lond.; 
Mr. K. Hirose, Okayama. Japan ; 
Mr. F. H. Humphns, Ilkley-in- 
Wharfedale; Dr. C. E. Hum¬ 
phreys, Llanfair-Caereinion : Mr. 
W. Sampson Handley, Lond. 

L—Dr. Arnold 0. Ingle, Cam¬ 
bridge; Incorporated Institute of 
Hygiene, Lond., Curator of; 
Interstate Medical Journal, St. 
Louis ; Dr. C. A. Inman, Lond. 
j.—Mr. Walter Jessel, Lond.; J. K. 
ir—Messrs, r. A. Knight and Co., 
Lond.; Mr. Henry Kimpton, 
Lond. 

L— Mr. Thomas Laffan, Cashel; 
Lurgan Union, Clerk to the; 
Messrs. Lewis and Co.,Brighton; 
Dr. G. S. Landon, Carshalton; 
Messrs. Lee and Nightingale. 
Liverpool; L. D. S.; LeedB and 


West Riding Medico-Chirurgical J 
Society, Senior Secretary of; 
Mr. John M. Lyon, Glasgow; 
Leslies, Ltd., Lond.; Local 
Government Board, Lond., Medi¬ 
cal Officer of. 

i M.— Mr. Carl Marhohl, Halle-a-S.; 
Dr. G. H. Mapleton, Goudhurst; 
Motorists’ Purchasing Associa- 
' tion, Lond.; Mr. Allen Mahood, 
Lausanne; Dr. J. G. Salvin 
Moore. Liverpool; M. C.; Miol 
Manufacturing Co.. Lond.; Sir 
John Moore, Dublin; Messrs. 
Mayer and Moltzer, Lond.; 
Mr. C. Mansell Moullin. Lond.; 
Messrs. Mor&ng and Co., Toronto; 
Mr. P. Monti, Lond.; Mr. 
George A. Murray, Lond.; 
Manchester Medical Agency. 

N. -North British Advertising 
Agency. Lond., Manager of; 
National Provident Institution, 
Lond., Actuary and Secretary of; 
New York State Library, Albany, 
Director of; Mr. J. C. Needes, 
Lond.; Mr. H. Needes, Lond. 

O. —Baron d’Oliveira, Lond. ; Mr. 
Joseph Offord, Lond. 

P. —Messrs. A. R. Pillai and Co., 
Trivandrum. India; Mr. J. M. 

I Pearson, Vancouver; Messrs. 

1 Peacock and Hadley, Lond. 

R.—Mr. A. J. Ridge, Douglas; 
Mr. Henry Bomeike, New York ; 
Royal Albert Hospital, Devon- 

E jrt, Secretary of; Mr. C. By all, 
ond.; Mr. A. B. Rufs, Lond.; 

; Dr. R. F. Rorke, Winnipeg; 

Ramsay County Medical Library, 
r St. Paul. 

B.—Mr. H. W. Swann, Lond.; 
Mr. C. H. Stevens, Lond.; Dr. 

; D. W. Samways, ClystSt George; | 

; Salford Corporation, Clerk to 

, the; Dr. J. Snowman, Lond.; 

Mr. H. B. Symons, St. Leonards- 
on-Sea; Dr. G. Scheltema, 

* Groningen; Society of Chemical i 

Industry. Basle, Secretary of; I 

] Messrs. ‘Simson and Co., Lond.; 

. Star Engineering Co., Wolver¬ 

hampton ; The Standard Malt 
i* Extract Co., Lond.; Scholastic, 

Clerical, &c., Association, Lond.; 
Mr. Nathan Straus, Heidelberg. 
T.— Mr. A. G. Troup, Lond.; 
Mr. George Tocher, Lond.; 

; Captain E. F. Gordon Tucker, 

i- I.M.S., Bombay; Mr. F. Topic, 
i- Prague; Mr. R. B. Turner, 

r. Lond.; Mr. A. Ralph Thompson, 
Lond. 

i- U.—University College, Lond., 

Secretary of. 

^ V.— Mr. E. D. Vignon, Gourock. 

W —Dr. F. G. Wallace, Lond.; 
r Messrs. J. Wright and Co., 

Bristol; Mr. H. J. Wheeler, 
High Wycombe; Dr. E. W. 
n, Ainley Walker, Oxford; Dr. 

P. Watson Williams, Clifton; 
1; Mr. F. C. Wallis, Lond.; Mr. 

j; William Woodward, Liverpool; 

i; Messrs. John Wiley and Sons, 

i; New York; Messrs. J. Walker 

e. and Co.. Lond.; Mr. C. Powell 

White, Manchester. 


A.— Dr. T. B. Adam, Brechin; 
Rev. W. J. Webb Anderson, 
Fatshan, China; A. G. K.; 
Automobile Contract Co., Lond., 
Secretary of; A. H. P.; Dr. B. 
Allen, Askrigg ; A. E. S. 


Counties Lunatic Asylum, Car¬ 
marthen, Clerk to the; J. B. N.; 
The Jet ter and Seheerer Co., 
Lond.; J. H., Finsbury Park; 
Dr. A. W. Jagger, Flushing, 
U.S A. 


Alien, ABKrigg ; a. d. a. „ , « , . 

B-Mr. Sherman Bigg, Lond.; K*-Me S srs. Knoll and Co., Lond. 

_ ... , . n __i_ T :_. I VI nr'O.o 171 rwr ,nH Rrtn. T.OTU1. 


». wsso.a**...* —W. ,- 

Mr. W. G. Burcombe, Lincoln; 
Bootle Borough Hospital, Secre¬ 
tary of; Messrs. J. L. Bullock 
and Co., Lond.; Mr. T. W. 
Bartlett, Steeple Bumpstead ; 
Dr. E. Birt, Wakefield; Dr. A. R. 
Bennie, Fitzroy, Australia; 
British Medical Association, 
Brisbane. Hon. Secretary to the 
Queeusl&nd Branch; Mr. W. A. 
Beet. Beaudesert, Australia; 
Dr. A. H. Brehaut, Guernsey; 
Brecon and Radnor Asylum, 
Talgarth. Clerk to the; Messrs. 


Messrs. King and Son, Lond.; 
Messrs. Kiluer Bros., Lond.; 
Messrs. S. Kutnow and Co., 
Lond.; Messrs. Koidzunn and 
Co.. Kyoto, Japan. 

L.—Mr. H. K. Lewis, Lond.; 
Mr. H. Le Soudier, Paris; Mr. 
Little wood, Leeds; Mr. A. 
Leckie, Lond.; Dr. Lewis, Lond.; 
Mr. C. P. Leavy, Gerahlton; 
Mr. H. K. Lacey, Torquay; 
Dr. A. H. N. Lowers, Lond.; 
Mr. W. W. Linnev, West Croy¬ 
don ; Mr. W. H. Lee, Ellesmere. 


Taigarin, uiera lu u«j; mceoio. ” ■ “1 , • — ~—r 

Burroughs, Wellcome, and Co., BL—Mr. M. D. Makuna, Trealaw 


Lond.; Mr. C. Boulange, Paris; 
Mr. B. Baker, Birmingham; 
Dr. J. M. Barbour, Ramsey; 
Dr. M. M. Bowlan, Lond.; 
Dr. M. Blieden, Johannesburg; 
Mr. J. A. Batley, Leeds; 
Messrs. S. E. Banks, Lond.; 
Sir Wm. Bennett, Lond.; Dr. 
F. E. Bailie, Berkeley, Cal., 
U.S. A.; Mr. Heather Bigg, Lond. 
0.—Mr. B. Castoldi, Brescia, Italy; 
Mr. R. Chable. Neuchatel. Swit¬ 
zerland; C. H. O.; C. W. P.; 
Dr. G. S. Carmichael, Edinburgh ; 
Dr. T. Carruthers, Kilbarchan ; 
Messrs. Camacho, Roldan, and 
Van Sickel, New York; Dr. D. A. 
Campbell, Halifax, Nova Scotia. 


Dr. D. L. MorriBon, Lough¬ 
borough ; Mysore Government, 
Bangalore, Senior Surgeon to 
the ; Messrs. J. Menzies and Co., 
Glasgow; Dr. A. Maute, Paris; 
Mr. B. G. A. Movnihan, Leeds; 
Dr. M.; Mr. R. Machin, Lond.; 
Dr. E. W. F. Macnaughton, 
Lond.; Marmite Food Extract 
Co., Lond., Secretary of; 
Mr. John Murray, Lond.; Maltine 
ManufacturiDg Co., Lond.; 
Dr. W. J. McCardie, Edgbaston; 
Manchester Royal Infirmary, 
Secretary of; Manchester Hos¬ 
pital for Consumption, Secretary 
of; Mr. E. Marett, Jersey 
Dr. F. C. Moore. Manchester. 


Campbell, Halifax, Nova Scot-la- N .—Dr.’ M. G. Na’idu. Hyderabad; 
D. —Mr. G. J. Dowse, Lond.; D. R ; Messrs. Neyroudand Sons, Lond.; 


Derbyshire Royal Infirmary, | 
Derby. Secretary of; Denver | 
Chemical Manufacturing Co., 
Lond.; Messrs. Davy, Hill, and 
Hodgkinson, Lond. 

Dr. G. L. Bastes, Lond.; E. A.; 
East Sussex County Asylum, 
Helllngley, Clerk to the; 
Dr. C. R. Bigood, Windsor; 

E. H. R. 

F.— Dr. Nifndor Flescb, Budapest; 
Mr. F. P. Flood, Merthyr Tydfil; 

F. W. B. „ „ 

Q,—Mr. J. Dundas Grant, Lond.; 

G. B ; G. A. C.; General Medical 
Council, Lond., Registrar of; 
Dr. L. G. Guthrie. Lond.; Messrs. 
W. Green and Son, Edinburgh; 
Dr. M. Grabham, Madeira; 
G. M. S.; G. A. 8.; Dr. C. G. 
Gibson, Launceston. 

H.— Mr. A. H. Head, Lond.; 
Dr. Earl Harlan, Cincinnati; 
MessrB. Hastings BroB., Lond.; 
Messrs. J. Haddon and Co., 
Lond.; H. B.; H. S.; H. P.; 
Mr. John Hey wood, Lond.; 
Mrs. Harland, Lond.; Messrs. 
Heffer and Sons, Cambridge; 
Hull Royal Infirmary, Secretary 


Messrs. Neyroudand Sons, Lond.; 
Newport and Monmouthshire 
Hospital, Secretary of; N. C.; 
North East London Post-Gradu¬ 
ate College, Lond., Secretary of. 

O. —Dr. F. Orton, Lond. 

P. —Dr. T. Wilson Parry, Lond.; 
Dr. M. S. PaterBon, Farnborougb ; 
Presbvterian MIesion Press* 
Shanghai, Manager to the. 

R.—Mr.W. C. Rivers, Northwood; 
Royal Halifax Infirmary, Trea¬ 
surer of. 

8,—Dr. B. Norman Sinclair, Loud.; 
State Homeopathic Hospital, 
Gowanda, N.Y., Steward of; 
Messrs. T. and H. Smith, Edin¬ 
burgh; Salford Royal Hospital, 
Secretary of; South Wales 
Argus, Newport, Manager of; 
Messrs. Spiers and Pond, Lond.; 
Surgeon, Chiswick; S. R. M.» 
Mr. M. Smale, Lond.; Sodetd 
Anonyme dee Eaux Minerales, 
Bvian-lea-Bains ; Dr. J. Selkirk, 
Boston Spa; Messrs. Savory and 
Moore. Lond. 

T —Dr. H. H. Thomson, Nottiiig- 
ham; T. J. D.; T. B.; Dr. P. 
Thompson, Lond.; Mr. J. Thin, 


Hull Royal Infirmary, Secretary Edinburgh, 
of; Hartlepools Hospital, Secre- V.—Dr. T. A. Venema, Lond. 
tary of; H. W., Holloway; W.—Dr. W. Webster, Newcastle, 
Messrs. Hogg and Son, Lond.; Staffs; Mr. E. Wahllss, Ixmd.; 


Messrs. Hogg and Son, Lond.; 
H. Me. D P. 

I,— Incorporated Medical Practi- 
tioner.' Association, Lond. 

J —Dr. H. Jarmulowsky, Dresden ; 
Mr. W. James, Milford Haven ; 
J. G. B.; Mr.W. Jones, Liverpool; 
Dr. Ian Jefferiss, Kirkoswald; 
Dr. R. Johnston, Dundee; Joint 


Messrs. Werner, Ptielderer, and 
Perkins, Lend.; Miss C. Wilkin¬ 
son. Bournemouth West; Dr. 
J. H. P. Wilgreas, Folkestone; 
Messrs. H. Wilson and Son, 
Lond.; Dr. W. H. Wilson, 
Whitby ; W. T. S. 

Y —Dr. K. A. Yeid, Lond. 


EVERY FRIDAY, T HE LANCE T. - 

One Year ..£112 8 One Year . 21 « » Trade and Miscellaneous Advertisement* 1 j} tt to 0 4 6 

BIX Month..- 0“ * . 0 8 8 and Situation. Vacant ... g v ery additional Line 0 0 8 

"T time) are payable In tS! Pa^'^S., 

fTT'orteinal and novel feature of ■■ Th* Laackt General Advert!** ” is a Special Index to Advertisement, on page. 2 and 4, which not only 
afford, a ready means of finding any notice but is in itself an additional advertisement. , hou i a be made payable to the Manager, 

“cheques and Post lifhce orders (crossed "London and We.tmlt.ster Ban*. * SJlml'nu to iSrortisementa^ or SubncriptionB should be addressed. 

Uiementa are alio received by them and all other A dvertising Agents. ___ v 

Agent for the Advertisement Department In France—J, ABTIEB, a. Bne Bapit. Aenlere*. Parle. 


PRIOR SRVRNPRNOS. 


ADVERTISING. , M K „ 

Books and Fnbljrallon. ... Seven Lines and under £0 6 0 
Official and General Announcement* Ditto u o u 

Trade and Miscellaneous Advertisement* 1 Ditto 0 4 8 

and Situation. Vacant ... ^'veiT additional Line 0 0 8 
Situations wanted: First 30 words, 2s. 6d.; per additional 8 words, Sd. 
Quarter Page. £110s. _ . ^^“-M^not o^. 





THE LANCET, February 1, 1908, 


%\\ S^rfSS 


INHERITED SYPHILIS. 

Delivered before the Society for the Study of Diseate in 
Children on Nov. 13th, 1907, 

Bv R. CLEMENT LUCAS, B.S., M B. Lond., 
F.R.C.S. Eng., 

CONSULTING 8URGEON TO GUY'S HOSPITAL AND TO THE EVELINA 
HOSPITAL FOR CHILDREN; MKMBHB OF THE COUNCIL OF THE 
ROYAL COLLEGE OF SURGEONS OF ENGLAND. 


Gentlemen,— This discussion upon inherited syphilis 
opens under quite different circumstances from those under 
which it would have done had it been held three or even 
two years ago, for it is now generally accepted that the 
spirochseta pallida discovered by Schaudinn and Hoffmann in 
1905 is the true cause of the disease and that mercury, 
formerly given empirically, is a direct antidote by causing 
destruction of the parasite. 

The Name. 

This leads me to say a word or two on the three terms 
applied to this form of the disease : (1) congenital, 

(2) hereditary, and 3) inherited. Of these three I greatly 
prefer the third. “ Congenital ” besides being objectionable 
in form and suggestion is not universally true ; “ hereditary ” 
suggests something that may be passed on indefinitely, of 
which there is no proof; whilst “ inherited ” implies only 
something derived from the parents which is detachable, 
like a fortune or misfortune, and this more correctly 
expresses the passing on of the spirochsetse to the offspring. 

The Micro organism. 


syphilised before the embryo or infant. The law is that a 
woman giving birth to a syphilitic infant cannot be inocu¬ 
lated with Byphilis by the infant when she is suckling him— 
in other words, though the mother may have shown no 
definite signs of syphilis she is immune ; whereas, the 
syphilitic infant put to the breast of a healthy woman may 
inoculate her nipple and convey syphilis to her. Hitherto, 
Colies’s law has been used as an argument in support of the 
view that the mother may get a mild form of syphilis from 
her syphilitic foetus whose syphilis is supposed to be derived 
entirely from the father. But the law of immunity will 
remain equally true if it be supposed that the mother is first 
inoculated by the fathir, a large dose of the protozoon 
causing an obvious eruptive syphilis, and a small dose a 
syphilis which misses the eruptive stage. 

Syphilis in a man is generally admitted to be capable of 
transmission to a succeeding generation for a much shorter 
time than syphilis in a woman, and this supports the view 
which I have stated—viz., that for transmission, it is 
necessary that the woman be first infected. 

Transmission by Mii.k. 

The question whether the milk of a syphilitic female may 
infect a healthy infant at the breast has been discussed for 
two and a half centuries, since Ambroise Part, in the 
seventeenth century quaintly observed; “Infants suckled 
by syphilitic nurses are infected by them, seeing that the 
milk is nothing but whitened blood, which being infected by 
the virus the child fed with it imbibes the same qualities.” 
Hunter, founding his argument on ineffectual attempts to 
inoculate the blood of a syphilitic person, came to the 
conclusion that not only the blood but every secretion 
derived from it, such as milk, saliva, perspiration, sic., could 
not convey the disease. But his experiments were inconclu¬ 
sive and his deductions incorrect. Pellizzari succeeded in 
inoculating the blood of a Byphilitic person and, if Voss’s 
experiment is to be trusted, milk has been directly inoculated 


The cause of syphilis, whether inherited or acquired, is 
the presence in the blood and tissues of the same organism, 
which can be demonstrated in the various secondary lesions, 
in the blood, and in the internal organs. The spirochmta 
pallida is a protozoon of spiral form from 4 to 20 m in length 
(about half to three times the diameter of the blood cor¬ 
puscle) and ifi in diameter, with a flagellum at either 
extremity. It is very motile, and its motility is of three 
kinds—a lashing, a corkscrew, and a to-and-fro movement. 
It stains pale pink with Giemsa’s fluid, whilst the coarser, 
highly refracting spirochaeta refringens, with which it is 
often associated, stains dark purple. 

The Mode of Transmission. 

The discovery of the cause of the disease necessitates the 
rearrangement of our former views as to its transmission. 
To those who remember the revolution in thought caused by 
the discovery of the tubercle bacillus—how that the long- 
taught diathesis gradually receded into the background and 
the danger of contagion by intercommunication in houses 
and families grew into importance—will be prepared for 
some change of idea in reference to syphilis. 

To my mind inheritance from the father alone is now pot 
entirely ont of court, and it follows that infection of a mother 
by her syphilitic foetus can never occur. For bow is it 
possible that a spirochasta which is highly motile and the 
leDgth of which averages rather more than the diameter of a 
blood corpuscle, can penetrate an ovum j^gth of an inch in 
diameter and multiply without destroying it. 1 lay it down 
as an axiom to be demolished if you will by discussion, that 
inheritance is invarially through the syphilised mother. This 
is supported by Oolles’s law that a syphilitic infant cannot 
cause a. chancre on the nipple of his mother when suckling. 
It would seem that when virulent the spirocbsetaj penetrate 
the chorion or placenta and occasion miscarriages, macerated 
foetuses, or premature births; but when the virus is 
attenuated by time or treatment the placenta forms a com¬ 
plete protection to the developing fcctus and it is the 
separation of the placenta at birth which allows the 
infection to take place through the umbilical vein. Hence 
the regularity of the secondary exanthematous stage from a 
fortnight to three months after birth. In these cate> the 
separation of the placenta it the first stage and corresponds 
to the chancre of acquired syphilis. 


also. 

A remarkable case bearing on this subject I showed 
before the Royal Medical and Cbirurgical Society in 1881. A 
woman, aged 30 years, gave birth to a healthy child on 
Dec. 11th, whom she suckled. During the following Easter¬ 
tide her husband inoculated her with syphilis, but she con¬ 
tinued to suckle the child. She consulted me three months 
later, when she was suffering from severe secondaries, 
squamous eruption, sore-throat, condyloma, and loss of hair, 
but the child showed no sign of infection. The mother was 
then treated with small doBes of mercury. She and the 
child were shown when the latter was ten months old. The 
child had continued to suckle and he remained plump and in 
perfect health, though the mother still had patches of 
circinated squamous syphilide on her arms. During the 
two years that the mother remained under my care for 
treatment the child showed no sign of inherited syphilis. 
The importance of this case rests on the fact that the 
mother had snckled her child for three months after her 
infection before any treatment was commenced, so that it 
cannot he argued that the infant was taking the antidote in 
the mother’s milk with the poison and so escaped a source of 
possible inoculation ; but it proves that the milk of a 
syphilitic woman when received into the alimentary tract 
of an infant need not convey any infection to the child. 

Transmission by Semen. 

It is obvious, as the greater cannot be included in the less, 
that a spirochieta cannot be carried in a spermatozoon ; bnt 
this does not exolnde the possibility of the spirochastm being 
conveyed by the fluid parts of the semen. 

The early experiments of inoculation by Mireur failed, but 
if the recent results obtained by Finger on monkeys be 
correct the semen of syphilitic men is inoculable. It seems 
almost necessary that It should be so to account for the 
cases of inherited syphilis conveyed after the healing of the 
chancre. If the presence of the spiroohietic could be with 
certainty demonstrated in the semen of men suffering from 
recent syphilis much doubt would disappear; and, in the 
cases where no chancre could be traced in the woman, the 
probability of the infection being carried through the uterus, 
after the disintegration of its lining membrane at any 
menstrual period, would be apparent. 

Transmission to the Third Generation. 


Colles’s Latv. 

I alluded to Colles’s law (which was first stated in 1837) 
in support of the argument that the woman was always first 
No. 4405. 


Another question much open to discnssion is whether- 
syphilis inherited is capable of transmission to the third 
generation. If the tertiary symptoms, occurring ten or 20 

E 




278 Thb Lancet,] 


MR. R. CLEMENT LUCAS: INHERITED SYPHILIS. 


[Feb. I, 1908. 


years after inoculation, can be proved to be due to renewed 
activity of the spirochaetre in certain situations there seems 
to be a fair possibility of their being carried to a third 
generation. Bat the question is beset with difficulties, since 
the sexual purity of two persons up to the time of maturity 
must be proved, and these are generally persons in whom a 
tendency to vice is also hereditary ; for it is known that a 
person the subject of inherited syphilis is not immune from 
re-inoculation after a certain period. Hutchinson mentions 
eight cases that had come under his observation of persons 
who presented signs of inherited syphilis and who married 
but whose offspring showed no evidence of the disease. 
On the other hand, Edmond Fournier collected 116 cases, 59 
of which he thought were to be relied upon as showing trans¬ 
mission to the third generation, and R. W. Taylor has 
published others. Dr. D. M. Hutton brought a case before 
this society, which is published in the first volume of our 
reports and is there criticised by Dr. H. Ashby and others. 
My own experience is limited to one case but it is of unusual 
importance as both parents showed most obvious signs of 
inherited syphilis which were unmistakeable. A blind man 
attended a school for the blind where he met a blind woman 
for whom he developed a feeling of affection. They were 
both blind from interstitial comeo-iritis and they both pre¬ 
sented the typical physiognomy of the inherited disease— 
notched teeth and scars around the mouth. They married, 
and at the time that the man came under my care their first 
child was about two months old. The blind wife was brought 
up to visit her husband, and seeing that she was marked by 
the same disease I sent for the infant who presented no 
evidence whatever of syphilis, nor did any symptoms of 
inherited disease develop in the months during which I was 
able to keep the child under observation. This case, in which 
there should have been double inheritance, showed, so long 
as I was able to watch it, complete immunity. 

The Infant Mortality. 

There is probably no disease responsible for such an 
enormous destruction of human life in its earlier stages as 
that caused by syphilitic parentage. But my experience 
shows that this mortality is greatest in those families where 
both parents have suffered from chancre syphilis and obvious 
secondaries. The severity of the infection and ineffective 
treatment, or lack of treatment, are the two factors which 
determine the mortality. I give two illustrations. 

Case 1.—The mother had been married for II years and 
bad suffered three months after marriage from rash and sore- 
throat. The first child was stillborn 12 months after 
marriage and was miscarried at the sixth mouth. The second 
child lived (the mother being at this time under treatment), 
but had severe snufiies and rash, was very delicate, and had 
recurrent sores and eruptions. The third, fourth, fifth, sixth, 
seventh, eighth, and ninth children were all bom at full time 
but they all died from a few minutes to within two or three 
months of birth. The tenth child was brought up for 
treatment suffering severely from snuffles, stomatitis, and 
coppery shiny eruption. Thus two weak children only were 
living out of ten. 

Case 2.—The mother three weeks after marriage suffered 
from sores on the vulva, followed by rash and sore throat, for 
which she had no prolonged treatment. She waB a pale, 
cachectic-looking woman. The first child, ten months after 
marriage, was stillborn at the seventh month. The second 
was prematurely born at the eighth month and lived for a 
day. The third, born at full time, a fortnight later came 
out in large brown spots and had snuffles, and was taken to 
Guy’s Hospital and was there treated by having blue 
ointment rubbed in over the abdomen. This child is still 
living, and at the age of eleven years she shows no notching 
of the incisors or evidence of her inheritance. The fourth 
child did not come out in an eruption until he was five 
weeks old. He died at the age of six weeks. The fifth, a 
boy, came out in an eruption at the age of five weeks and 
died when he was seven weeks old. The sixth was stillborn. 
The seventh, prematurely born at the eighth mouth with an 
eruption upon her, survived for a day. The eighth, a girl, 
bad a rash soon after birth and she died on the eighth day. 
The ninth, also a girl, was born healthy, but an eruption 
came our, at the third week. She was treated but she died 
at the age of II weeks. The tenth child, a fine boy at birth, 
came out in an eruption three weeks after birth and was 
brought up for treatment. He was suffering from sym¬ 
metrical squamous syphilide of the legs, the feet, the arms, 
and the ears, and a little on the body, with ulceration of the 


mouth and the buttocks and severe snuffles. In this series 
again there were two children only living out of ten. 

The Secondary Stage. 

The trite definition that syphilis is a “ fever diluted by 
time ” given by the late Dr. Moxon is applicable to the 
inherited as well as to the acquired disease. I argued that 
the primary stage is the separation of the placenta and the 
infection of the infant through the umbilical vein. The 
secondary or exanthematous stage commences from the 
second week to as late as the third month. It is characterised 
by eruptions which may vary from slight brown macular 
syphilide to pompholyx, by snuffles, stomatitis, condyloma, 
wrinkled skin, and wasting, and enlargement of the spleen 
and liver. Then follow certain changes in the bones, in 
severe cases perhaps epiphysitis (giving rise to pseudo¬ 
paralysis), Parrot’s nodes (causing natiform 6kull and square 
forehead), cranio-tabes, and bent bones. 

It cannot be too strongly insisted upon that the moist 
eruptions and ulcerations about the mouth and arras as well 
as the vesicular skin affections are charged with the spiro- 
chaetse and are highly contagious. From the second to the 
sixth year there is commonly a rest in the symptoms that 
are regarded as characteristic, but the tibise may become 
thickened from periostitis or a joint may become swollen and 
painful and resolve under mercurial treatment. But now the 
characteristic physiognomy has been gradually formed, the 
flattened nose, the square forehead, the radiating lines from 
the mouth, the stunted figure, and the pallid face; and 
then during the second dentition we look for the three signs 
pointed out by our great observer, Jonathan Hutchinson, 
the notched incisor teeth, interstitial corneitis, and syphi¬ 
litic deafness. Associated with such signs or occasionally 
independent of them gummatous destruction of the soft or 
hard palate may occur and ulcerations of the skin and 
cellular tissue. Destruction of the nasal bones, caries of the 
forehead and skull, of the long bones and dactylitis may take 
place as the result of the inherited disease. 

Moon’s Molars. 

The teeth which Mr. J. Hutchinson described as so 
characteristic of the disease are the notched and narrowed 
incisors, especially the central incisors of the upper jaw. 
This defect is brought about by arrest in development of the 
central columella, of which each incisor has three. But I 
wish to draw special attention to the characteristic change 
brought about by the disease in the first molars described by 
the late Mr. Henry Moon many years ago, since this change 
has recently been rediscovered both in America and on the 
continent. The diagram which I show is taken from the 
fourth edition of “ Bryant's Surgery,” published in 1884, 
wherein the article on Teeth is written by Mr. Moon. He 
figures and describes the syphilitic first molar as “reduced 
in size and dome shaped through the dwarfing of the central 
tubercle of each cusp.” He also contrasts these teeth with 
mercurial teeth and syphilitic-mercurial teeth. The change 
in the molar is of some clinical importance, since occasion¬ 
ally it is characteristic when the incisors are normal. 

Eyes and Ears. 

The eyes may become affected at an early stage by a 
choroido-retinitis which may leave permanent changes easily 
recognised by ophthalmoscopic examination, and iritis, 
though rare, may occur during the eruptive stage. Inter¬ 
stitial keratitis is most frequent between the ages of six and 
16 years but may occur much later and rarely earlier. It is 
highly characteristic of the inherited disease. 

Like the eyes, the ears are attacked by different affections 
in the early and late stages. During the eruptive stage otitis 
media may commence as an extension from the inflammation 
of the naso pharynx, whilst during the second dentition a 
progressive deafness of labyrinthine origin may cause 
complete loss of hearing. Specialists in these departments 
will, I hope, give us some new facts relative to the syphilitic 
manifestations in the eyes and ears. 

Inherited Syphilis Attacking the Viscera. 

Much work has been done in demonstrating the disease in 
the various viscera, not one of which appears to be exempt, 
and there is probably a large field still open here for further 
investigation. Enlarged spleen and liver associated with 
rickets may be proved almost invariably to be of syphilitic 
origin. The disease attacks the various organs in two forms, 
as a small cell infiltration usually following the course of the 
vessels, which in its development and decline may lead to 


The Lancet,] DR. G. C. LOW : UNEQUAL DISTRIBUTION OF FILARIASIS IN THE TROPICS. [Feb. 1,1908. 279 


fibrosis and consequent atrophy, and as a gummatous tumour 
which is less common. When the inherited disease attacks 
both testicles or both ovaries at an early age and brings 
about their fibrosis and atrophy, a condition known as 
infantilism is produced at a period when the sexual charac¬ 
teristics should be pronounced. The physicians present will, 
I hope, give us much new information on inherited syphilis 
of the viscera. 

The Nervous System. 

Much difference of opinion exists as to the frequency of 
nervous disease dependent on inherited syphilis. Whilst 
Borne are inclined to attribute every conceivable weakness, 
paralysis, or mental defect to this disease, others regard the 
nervous lesions dependent on it as infrequent. A certain pro¬ 
portion of epileptics, deaf-mutes, and idiots, but not a large 
percentage, show signs of inherited syphilis. On the other 
hand, syphilitic endarteritis of cerebral vessels, gummata on 
nerves, and sclerosis of brain and spinal cord have been 
noticed by competent observers. One of the most interest¬ 
ing observations of late years is that some cases of hydro¬ 
cephalus are dependent on inherited syphilis and are curable 
by mercury. 

The Need op Criticism in Diagnosis. 

In conclusion, I wish to insist on the importance of 
weighing carefully all the evidence before determining that 
a particular affection is due to inherited syphilis. Every 
deformity from dislocated hip to cleft palate, all defects 
such as hernia, infantile paralysis of various kinds, and 
even naevi have been described by various writers as 
dependent on inherited syphilis, and as if better to cover the 
anomalies the term “para-syphilis” has been invented to 
add to the confusion. 

I need scarcely waste time in combating such crude 
generalisations as that “ all rickets takes origin in syphilis,” 
when any puppy taken from a litter and deprived of proper 
food and exercise will certainly develop this disease. Equally 
crude statements have been made as to other diseases. We 
do not deny that persons whose constitutions have been 
weakened by disease are liable to produce degenerates in 
succeeding generations ; but in future the most certain test 
of the disease being syphilis will be the presence of the 
spirochseta pallida in the part affected. This organism has 
an extraordinary persistency, producing local symptoms after 
lengthened periods, but happily we have in mercury and the 
iodides drugs which control its development and bring about 
its destruction. Metchnikoff has recently shown that some 
hours after direct inoculation the application of a calomel 
ointment to the sore is sufficient to kill the organism and 
prevent the occurrence of secondary symptoms. 

Gentlemen, I have now finished my brief sketch of this 
interesting disease as it attacks the second generation. It is 
the merest outline that you may fill in the substance. I ask 
for new facts and new observations ; for now that the cause 
of the disease is definitely known we have a fresh incentive 
for further investigation. There are many diseases still con¬ 
fused under a common name—just as gonorrhoea and syphilis, 
typhus and typhoid fever were confused generations ago— 
that time will unravel. But as we gain more exact, more 
precise, and more definite knowledge of any one disease, we 
shall be the better equipped for appreciating the symptoms 
and distinguishing the effects produced by others. 


THE UNEQUAL DISTRIBUTION OF 
FILARIASIS IN THE TROPICS . 1 

By G. C. LOW, M.B., C.M. Edin., 

LECTUBEB ON' TBOPICAL DISEASES, POST-GRADUATE COLLEGE, 
WEST LONDON HOSPITAL. 


The distribution of any given disease is always a very 
interesting problem and one which of necessity must depend 
on many varying factors. This is specially so in many 
tropical complaints, and such being the case I have hoped 
by introducing one of those to your attention to-night 
to stimulate further work and research in the whole ques¬ 
tion of the unequal distribution of disease throughout the 
tropics. Most of the well known tropical diseases are peculiar 
in this respect—namely, that they require an intermediary 
either in the shape of an animal or an insect to further tbeir 


1 A paper real before the Society of Tropical Medicine and Hygiene 
ou Jan. 17th, 1908. 


proper dissemination, and if theoretically we could remove 
those then the diseases would necessarily come to an end. 
Examples of those are plague with its dependency ou the 
rat and its fleas ; Malta fever with its dependency on the 
goat; sleeping sickness conveyed from man to man directly 
and apparently only by tsetse flies; malaria, yellow fever, 
and fflariasis requiring something more complicated still— 
namely, a definite extracorporeal life cycle in different 
genera of mosquitoes ; and so on. 

The dictum, “ No anopheles, no malaria,” is easy of under¬ 
standing and examples are not far to seek. Barbados, an 
island in an intensely malarial zone, is free from malaria and 
the reason of this I Bhowed some years ago was due to 
anopheles mosquitoes being absent. Rome is now in the 
same category and other Pacific islands are said also to be 
free, the danger of the chance introduction of anopheles 
being exemplified by the preseDt-day condition of Mauritius. 
If we extend such a dictum further we may say, "No 
stegomyia fasciata, no yellow fever,” and “No cnlex 
fatigans or other suitable mosquito, no filaria noctuma,” 
What is slightly more difficult to understand is 
why a disease should remain localised to certain 
parts of the world although its intermediate host is 
much more widely distributed. Why, for example, should 
yellow fever have remained so particularly endemic to the 
West Indies and South America when its intermediate host 
stegomyia fasciata is found throughout the tropics 1 It is 
possible that non-introduction of the specific germ is the 
cause, but behind this may there not be something deeper 
that we do not yet thoroughly appreciate 7 Lastly, what is 
even more difficult to understand is why, given the inter¬ 
mediate host of a disease, suitable climatic conditions, and 
the presence of abundant chance of the further introduction 
of the specific parasite, the disease should vary considerably 
in its distribution, abounding in one place, being scanty in 
another, or practically absent in a third, Filaria Bancrofti 
and the diseases it causes follow such an irregular course and 
it is on this interesting feature that I intend to base my 
paper to-night. 

In dealing with fflariasis (including under this term 
the parasites filaria noctuma, filaria Demarquayi, and 
filaria perstans) I have probably taken the most 
difficult of all the tropical diseases because of the 
tediousness in determining its exact distribution. I may 
remind yon that it is the exception for people infected 
with filaria Bancrofti to exhibit symptoms, so the only 
way to arrive at a conclusion of bow many individials in 
a given district are infected is to make exhaustive night 
blood examinations of the population generally, the same 
procedure being adopted with the exception that the blood 
may be taken by day for filaria Demarquayi and filaria 
perstans. This, as those latter two parasites produce no 
appreciable clinical signs, you will see is imperative. A group 
of islands is a suitable area to conduct such observations in 
for many reasons ; they are isolated from each other, many 
of tbeir inhabitants have never been out of them, the popula¬ 
tion is not excessive, and as a rule there is one main town 
with several villages. Recently then when in the West 
Indies I worked out the percentages of infection with filaria 
noctuma and filaria Demarquayi in many of the different 
islands and have tabulated some very interesting results 
which on the whole may be taken as approximately accurate. 

My plan of procedure in this work was as follows. On 
arrival at an island I inquired from the local medical men if 
clinical manifestations of filariasis (elephantiasis, lymph 
scrotum, chyluria, lymphangitis, &o.) were common : then 
after looking for them myself generally, but of course 
without specially selecting them for my statistics, I took the 
night blood from as many of the general population as I 
could get, obtaining these from the streets, hospitals, prisons, 
aDd almshouses, and trying so far as possible to take 
indigenous natives. In some of the places visited I separated 
the different races, as this is important, but in others the 
admixture was so great that this was impossible. Out of the 
numbers examined I noted bow many showed signs of filarial 
disease or were infected—namely, those with symptoms with 
or without embryos and those without symptoms but with 
embryos in the blood. For filaria Demarquayi I examined 
the different villages in detail as well, sometimes taking the 
blood by day, sometimes by night, and as those embryos are 
present at both times, night examinations did both for them 
and noctuma. The results came out in the following 
manner: where there was much clinical filarial disease, 
elephantiasis, &c., then the percentage of ordinary healthy 




280 The Lancet,] DR. G. C. LOW : UNEQUAL DISTRIBUTION OF FILARIASIS IN THE TROPICS. [Feb. 1,1908. 


people with embryos in their blood was high; where there 
was little disease, then the percentage was low. Applying 
such tests to the different islands and British Guiana, all, 
with the exception of the latter and Barbados, much the 
same physically, and all, Barbados and British Guiana 
included, teeming with the proper intermediate host (culex 
fatigans) for filaria nocturna, the inequality of the distribu¬ 
tion was very marked, reaching a very high percentage in 
St. Kitts and falling to practically zero in Grenada. The 
following are the detailed results in order of frequency :— 

St. Kitts.— 143 cases examined by night; 47 suffering from filaria 
nocturna disease = 32 - 8 per cent.; with symptoms 9, without 38. 
White people of the best class: 23 examined, 7 infected = 30 4 per 
cent.; with symptoms 3, without 4. Elephantiasis cases: 14 examined, 
embryos present in 3. 

British Guiana.— 150 examined by night; 25 suffering from filaria 
nocturna = 16‘6 per cent.; with symptoms 5, without 20. liace 
charac*eristics: general population of hospital, negroes, coloured, 
Portuguese, and whiles; 100 examined, 22 infected = 22 per cent.; 
with symptoms 5, without 17. Coolies (East Indians), 50 examined; 
3 Infected = 6 per.cent.; with symptoms nil, without 3. Elephantiasis 
cases : 15 examined, embryos present in 1. 

Barbados.— 600 cases examined by night; 76 suffering from filaria 
nocturna = 12 66 per cent. ; w ith symptoms 27, without 49. Elephan¬ 
tiasis cases : 10 examined, embryos present in none. 


Race Characteristics. 


Knee. 

Number 

examined. 

Non- 

i infected. 

Infected. 

Per 

centage. 

Negroes . 

401 

357 

44 

10*9 

Mulattos .1 

160 

142 

00 

r—i 

11*2 

Whites. 

39 

25 

14 I 

1 

35 3 

Total. 

600 

524 

76 

12-66 


Trinidad.— 4f» cases examined by night; 43 Buffering from filaria 
nocturna = 10 75 per cent.; with symptoms 19, without 24. Elephanti¬ 
asis cases : S3 examined, embryos present in none. 

Dominica.— 144 cases examined by night; 11 suffering from filaria 
nocturna = 7 63 per cent.; with symptoms 2, without 9. Elephantiasis 
cases : 2 examined embryos present in neither. 

St. Lucia —356,cases examined by night; 27 suffering from filaria 
nocturna = 7 58 per cent. Elephantiasis cases : 5 examined, embryos 
present in none. 

St. Y r incent.—\Q0 cases examined by night; 6 suffering from filaria 
nocturna = 6 per cent.; with symptoms 2, without 4. Elephantiasis 
cases : 2 examined, embryos present in neither. 

Grenada.— 174 cases examined by night; none infected = 0 per cent. 

Carriacon (a Grenadine’.—23 cases examined by night; 1 suffering 
from filaria nocturna, but this individual was born and bad lived in St. 
Kitts, only having been in Carriacon one year; so deleting him we 
get a percentage of 0. 

Looking into those figures in detail one notices a very great 
variability in the amount of filarial disease in the different 
islands, St. Kitts, one of the smaller islands, beading the 
list; British Guiana, which, of course, is notan island but on 
the mainland of South America, coming next; Barbados and 
Trinidad, both densely populated, next; with the smaller 
islands Dominica, St. Lucia, St. Vincent, and Grenada 
last. Why this should be is not very clear, and the 
case of Grenada is so pecnliar that I quote the note 
I made on it on leaving the island. “Filaria nocturnal 
disease is very rare in Grenada, this answering to 
the clinical experience of the medical men in the island 
who state that they very rarely see cases. It does, 
however, exist and can, as 0. fatigans is present. This is 
exemplified by one case I saw, a man who, thoogh never 
ont of the island, has varicose groin glands and elephantiasis. 
(Not being able to get his night blood I did not include him 
in my general list.) Similar other rare cases are to be found, 
two such having been heard of. In addition to those 
examined I also saw one Barbadian with elephantiasis and 
another with filarial embryos in his blood. The marked 
exemption of the island may be dne to the chief town being 
mainly on a hillside and to there being few mosquitoes of 
the species C. fatigans present.” The medical man at the 
small village at Carriacon (an island to the north of Grenada) 
also informed me that he never saw filarial cases there and 
my figures obtained bear out bis statement. During the day 
and night I spent there X saw one typical case of 
elephantiasis, however, but he had lived in Trinidad, where 
he probably got his infection and the individual in whose 
blood I found embryos as already mentioned had without 
doubt acquired those in St. Kitts. In my note on Grenada 
I mentioned there being few mosquitoes (culex fatigans) 
present, but still 1 found examples without much difficulty 


and they were certainly very abundant in St. Lucia, which 
is also only slightly infected. It is probable that the number 
of mosquitoes present may have something to do with the 
prevalence of the disease, St. Kitts, for example, owing to 
the dirty privy system in vogue there, simply teeming with 
culex fatigans, and they are also very numerous in Barbados; 
but considering all things I have come to the conclusion that 
there is something more subtle at work thaD this in deter¬ 
mining the distribution of this disease. Climate, by that 
meaning temperature, rainfall, &c., cannot play much 
part, as it is practically the same in all the islands, 
and the same might be said of physical characters, 
though at the same time I think the flat, low- 
lying, and thickly populated places are specially prone 
to the disease. Barbados is of coral formation, the 
other islands volcanic in origin. Looking at other parts 
of the world, I have found in the Swahilis (coast natives) of 
Mombasa 13 out of 50 infected with filaria nocturna, none of 
these showiDg any symptoms, and this giving a percentage 
of 26. In Zanzibar it is probably quite as prevalent, because 
though not making blood examinations there I nevertheless 
saw plenty of cases with definite symptoms. In Uganda in 
the interior it is practically non existent in the indigenous 
races, as I only found it in one pure Waganda, though in 
Nubians from the Nile it occurred in 2 per cent , and I also 
had a well-marked case of elephantiasis in a Nubian woman. 
Its absence from the interior might probably be due to the 
absence or scarcity of culex fatigans, but then, again, 
Mansonia Africana, which Dr. C. W. Daniels easily infected 
with filaria nocturna experimentally in British Central 
Africa, abounds in Uganda also. Quoting from the book of 
our president, Sir Patrick M&nson, on the Prevalence of 
Filaria Nocturna, 1 note South China given as 10 per cent.; 
Friendly Islands, 32 per cent. (Thorpe); Samoa, very high ; 
Madras and West Africa, abundant. In Egypt it is present 
(Sonsino and others) but 1 do not know if its percentage has 
ever been accurately determined. Perhaps Dr. F. M. 
Sandwith may help us in this. In Brisbane in Australia 
(Bancroft), originally introduced by the Chinese, it seems 
to have flourished and spread, and it also occurs in Charles¬ 
town in North America, 

In dealing with the distribution of filaria Demarquayi 
and filaria perstans we are not on so certain ground 
as we do not know the proper intermediate hosts of those 
parasites yet, unless the tick, the ornithodoros moubata, 
as Wellman believes, acts for the latter. This being 
so, their irregular distribution may depend on the 
presence or absence of the proper intermediary, but 
whether this is the reason or not 1 can certainly bring 
forward some remarkable points as regards their prevalence 
in certain places. Filaria Demarquayi was discovered by 
Sir Patrick Manson in blood slides sent to him from the 
West Indies, from St. Lucia and St. Vincent by the late Dr. 
Otho Galgey and Dr. C. Newsome respectively, and he gave it 
the above name in honour of Demarquay who first discovered 
the embryos of filaria nocturna. On arriving at St. Lucia 
Dr. Galgey informed me that the slides he had sent Sir 
Patrick Manson were taken from one of the villages of 
St. Lucia, Gros Islet by name, and that he believed most of 
the cases of this parasite were to be found there. Accord 
ingly I investigated the subject and found that the belief, 
with one possible exception, was perfectly correct, the para¬ 
site was limited to this one village of the island. St. Lucia 
has one main town Castries and five subsidiary townships 
or villages—namely, Soufriere, Vieux-Fort, Dennery, 
Gros Islet, and Anse-la-Eaye. On examining the blood of 
people from these different villages I got the following 
results. Gros Islet: 62 people examined ; 16, or 25*8 per 
cent., infected with filaria Demarquayi. Soufriere: 78 
people examined ; 2 infected, those 2, however, being police¬ 
men who had lived for periods in Gros Islet. Anse-la-Kaye, 
none. Vieux Fort, none. Dennery: not examined. Castries: 
3 infected, 2 of those Barbadians who had lived in different 
parts of the island, Gros Islet included ; the third, a negro, 
aged 19 years, with the following record. He was born and 
had lived in Charlestown Nevis till 17 years of age, then 
went to Castries, then working in the field at a sugar estate, 
called Iioseau, for four months, then back to Castries with 
fever ; has remained in the town since, never in Gros Islet or 
north of island. It is possible he may have been infected 
at Nevis before going to St. Lucia, I also saw the infection 
in a man from a place called Monehy, near Gros Islet, and in 
another man who had lived all over the island. The one 
possible exception was Dennery, a small village on the north 




The Lancet,] DR. G. C. LOW: UNKQUAL DISTRIBUTION OF FILARIASIS IN THE TROPICS. [Fan. 1,1908. 281 


coast which I did cot examine and it is just possible that 
filaria Demarquayi might exist there, though Dr. Galgey had 
never found it in a few examinations he made from there. 

In St. Vincent the same striking peculiarity of the parasite 
being practically localised to one spot occurred. St. Vincent, 
like St. Lucia, has one main town, Kingstown, and several 
villages—viz., Calliqua Layou, Earrouallie, Georgetown, and 
Chateaubelair. I examined blood from all those places with 
the following resalts. Calliaqua : 50 examined ; 16 infected 
= 32 per cent. The others were all uniformly negative 
with the exception of one case from Barrouallie who had 
lived in different parts of the island, Calliaqua included, and 
another discovered in Kingstown who bad also lived at one 
period in the infected village. HaviDg had the experience of 
St. Lucia before me and suspecting that the same might hold 
good in St. Vincent, my procedure on arrival at the latter 
place was as follows. I asked Dr. Newsome where he got 
the blood he sent to London from and he gave me the name 
of a woman living in Calliaqua. I thereupon visited her 
(Sept. 21st, 1901) and found her suffering from malarial 
fever, counting at the same time, however, 40 embryos of 
filaria Demarquayi in her blood, and making the following 
note in my record book: “Embryos of F. Demarquayi 
found in London in 1894 by Dr. Manson.” Other inhabitants 
of the same village examined at the same time showed 
similar embryos and the infected place being found all 
that remained was to see if any other parts of the island were 
infected. In addition to St. Lucia and St. Vincent I also 
determined the presence of filaria Demarquayi in Dominica, 
Trinidad, and probably in St. Kitts, but was unable owing 
to difficulties of transport and time to find the exact focus in 
each place. In Dominica two cases were found, one in an old 
soldier who had served on the West Coast of Africa and had 
been in the other islands, so he might have got the infection 
elsewhere ; but the other, a mulatto born and living in a 
place called Batalie, had never been out of the island. He 
suffered from elephantiasis as well—e.g., a double infection 
—but had no nocturna embryos in his blood. In Trinidad 
two cases were also found, one in a negro born in Dominica 
who had also lived in St. Vincent and St. Lucia, he there¬ 
fore being useless; but the other, a case of Dr. Vincents, 
a girl in the lunatic asylum, born at Matalot, a 
village in the north of the island, bad never been out 
of the island. No further bloods were obtainable from 
that place, but the one case is sufficient to prove that 
the parasite is found in Trinidad in the north, though 
I never found it in the west and south. In St Kitts, 
again, two cases were found, one in a man with elephantiasis 
of the scrotum, a sailor, who had been in Dominica and the 
other islands ; the other in a Portuguese born in Madeira who 
came to St. Kitts when a youth and had only once been out 
of the island, when he lived in Port of Spain for a short 
time. The rest of his life had been spent in Cayon, a village 
on the windward coast of St. Kitts, so this probably means a 
focus of infection there. 

Looking at the infected villages in St. Lucia and 
St. Vincent from a physical point of view there was 
nothing special to be noted in them as different from 
the other non-infected places. They were both situated on 
the sea-coast on level ground, with swamps and scrubby bush 
behind them, and were very malarious. Assuming that a 
mosquito or other blood insect might be the intermediary 
many experimental feedings were made with negative results; 
the only out-of-the-way mosquito noted was at Calliaqua, 
where the inhabitants told me that a big bright-blue one 
sometimes was seen. This was the Haemogogus cyaneus of 
Williston, but I could only obtain one and it died before I 
could feed it on a suitable case. Since Wellman’s work on 
the tick as the spreader of filaria perstans appeared I have 
wondered if such an insect could act as an intermediary for 
filaria Demarquayi, and this is possible, though even were 
this so it is strange how it should be so closely limited to one 
part of the island and not spread universally. Still, ticks of 
different sorts are very common in the West Indies and the 
forests of British Guiana and the hypothesis is worth 
following. It might even be a bug-like tick like the 
omithodoros of Africa. Filaria Demarquayi is not found 
in Barbados and I never met with it in Grenada. In 
British Guiana two embryos are often found in the blood 
of aboriginal Indians and others living in the backwoods of 
thrt colory. On ! is blunttailed and is filaria perstans ora 
closely allied species, the other is sharp-tailed and may be 
filaria Demarquaii, though Daniels in comparing the adults 
believes there are differences, so it may be another species. 


Those embryos are not found in the blood of people in¬ 
habiting the towns or cleared coast lines, only in the 
forests. The following are statistics on their prevalence. 
Aboriginal Indians (Arawaks, Caribs, Wainis, Waraus, 
Akawoios, &c.) : 163 examined ; 105 infected with sharp- or 
blunt-tailed embryos = 64 4 per cent. Double infections, 
38; blunt-tailed alone 56. sharp-tailed alone 11. Half Indians 
(e.g., mixtures of Spanish, Portuguese, &c.) : 20 examined ; 
5 infected = 25 per cent. Creoles (e.g., negroes, mulattos, 
and whites who had lived in the interior) : 28 examined ; 
3, all negroes from the Pomeroon river, only infected. 
Districts : Pomeroon River, 71 per cent, infected ; Cara Cara 
Creek, Demerara River, 60 per cent, infected ; Barima River 
(Morawhana district), 36 6 per cent, infected ; Waini River, 
60 per cent infected. Those figures show that the infection 
is widespread and pretty equally distributed in the districts 
examined. 

In Africa blunt-tailed embryos (filaria perstans) abound in 
some districts while they are entirely absent from others, 
and no one has yet described sharp-tailed embryos on that 
continent corresponding to the New World forms. What 
circumscribes their distribution is again difficult to decide ; 
the absence of the suitable intermediate host, if they have 
to pass through one, would of course preclude them, but 
probably again other factors play a part. Wellman has 
lately brought forward some strong evidence that they 
can undergo a metamorphosis in ticks (ornithodoros 
moubata) and their distribution seems to coincide except 
apparently in British Central Africa, where, though the 
tick is very common, Daniels in some examinations on 
natives there found no filaria perstans. In the vicinity 
of the equator, Uganda, and the Congo the parasites 
are very frequent in the blood of the natives there, in some 
districts almost everyone having them. The following 
figures represent such infections in some of the parts I have 
studied them. Zanzibar and Mombasa, negative ; Kavirondo 
at the east of the Victoria Nyanza, 0 per cent. ; Wagandus 
in Entebbe, 50 per cent, infected ; natives of the Sese Islands 
in the north-west corner of the lake, 86 per cent, infected; 
natives of Ankole, to the west of the lake, 7 • 8 per cent, 
infected ; Alurs from Wadelai (Dr. A. W. G. B igahawe), 
8 4 per cent, infected ; Nubians from Upper Nile, 6 per 
cent, infected. From this it will be seen that the Sese 
Islands in Uganda are a strong focus of infection, the 
prevalence decreasing to the west, the north, and entirely 
disappearing by the time the north-eastern shores of the lake 
are reached. On the western side of the continent it also 
prevails in many different parts. Mr. T. E. Rice at Ibadon 
in Lagos found 30 per cent, of the natives infected there, 
Dr. St. George Gray has informed me that it is fairly common 
in the hinterlands of Sierra Leone, Dr. Wellman reports it at 
Benguella, and I have seen It in slides from the Congo and 
the Nigerias. 

A good deal more mapping out and general search for those 
latter two filarise in different parts of the world is still 
required. There may quite conceivably be other species yet 
undiscovered—for example is the sharp-tailed one from New 
Guinea described by Sir Patrick Manson the same as filaria 
Demarquaii ? The Malay States. Borneo, and Sumatra have 
not yet been tapped to quote only a few places. It is the 
tediousness of searching blood slide after blood slide for 
filariae that keeps men from working at this subject, and then 
the further trouble of isolating villages and working them out 
in detail often addB insurmountable difficulties. Still I think 
you will agree with me that, after the figures I have collected 
and given you to-night, the subject of the distribution of all 
the three filarire is extremely interesting, and if we merely 
limit ourselves to filaria nocturna alone, which after all is 
the only one that produces disease, we will still have 
abundant food for thought and abundant stimulus for re¬ 
search upon the unknown influences which allow it to spread 
in one place while limiting it in another. By focu-sing our 
attention on such a subject we may also indirectly lay bare 
some of the secrets that surround malaria, yellow fever, beri¬ 
beri, and many of the other tropical diseases, and by so 
doing may open up new fields for the prevention and better 
control of those scourges of mankind. 

Bentinck-atreet, W. 


Longevity.— The death occurred at Brighton 
last week of the oldest inhabitant of the borough, Mrs. Ann 
Colwell, who had attained the great age of 101 years and 
seven months. 




282 The Lancet,] DB. A. EDDOWES & DR. J. G. HABE: A CASE OF SEVERE ECTHYMA, ETC,. [Feb. 1, 1908. 


A CASE OF SEVERE ECTHYMA FROM 
WHICH THE DIPHTHERIA BACILLUS 
HAS BEEN ISOLATED. 

By A. EDDOWES, M.D. Edin., M.R.C.P. Loyd., 

PHYSICIAN TO ST. JOHN'S HOSPITAL FOR DISEASES OF THE SKIN, 
LEICESTER'SQUARE, LONDON, W.C.; 

AND 

J. G. HARE, 

PATHOLOGIST AND BACTERIOLOGIST TO ST. JOHN'S HOSPITAL FOR 
DISEASES OF THE SKIN. 


The patient, a girl, aged 11 years, was first seen 
on Jan. 2nd, 1907. The case was recognised as one 
of severe type. The contents of a bnlla were examined 
bacteriologically bnt no streptococcus was found on 
this occasion. Carbolic lotion and mercurial ointment 
were prescribed and the patient was told to come again 
in a week’s time. On the 9th the patient showed numerous 
bailee on both arms, hands, and lips. Upon the left anterior 
pillar of the fauces could be Been traces of a ruptured and 
healing vesicle. There was no false membrane; there was 
no complaint of sore-throat, though there had been some 
soreness felt in the throat three days previously. As the 
child appeared ill and the case was probably being mis¬ 
managed at home she was admitted to St. John’s Hospital 
for Diseases of the Skin as an in-patient, but before admis¬ 
sion the case was again sent for a careful bacteriological 
examination. Some uneasiness was felt on account of the 
patient’s general symptoms, but improvement took place at 
once after she had passed into the hands of the nnrses and 
had all the sores thoroughly dressed with antiseptics ; in fact, 
in 24 hoars the patient was quite ont of danger and made an 
uninterrupted recovery. Careful inquiry failed to elicit any 
plausible origin of the infection. Incidentally it may be 
mentioned that the child’s father is the subject of myxcedema. 
The child’s skin, however, is naturally normal. In May 
the child was seen and again later and there had not been 
any relapse. 

Bacteriological Report. 

1. A small bulla on the right hand w as carefully sterilised first with 
1 in 20 carbolic acid solution and afterwards with ether and then a 
sterile platinum needle was inserted and an agar slope inoculation 
was made with the fluid. From this a growth of staphylococcus 
aureus with the staphylococcus epidermidis albus was obtained 18 
hours later. On plating these two organisms were found to be in pure 
cultuer. 

2. The surface of the bulla was excised and a gentle impression was 
made on a microscopic slide from the “ceiling ” or under surface of 

FIG. 1. 



Streptococci. Impression from bulla. 

the roof of the bulla. This was also scraped with a sterile platinum 
loop and an sgar tube inoculated. Tbe slide was stained with Loeffler’s 
methylene blue and on examination it showed long-chained strepto¬ 
cocci, apparently in pure culture (Fig. 1). From the inoculated tube 


a growth of streptococcus was obtained in pure cultivation. This was 
again subcultured in broth and a characteristic growth was obtained. 

3. A small unbroken pustule on the left hand was then examined. 
A platinum needle was inserted and two agar-agar tubes inoculated. 
The growth obtained 18 hours later was typical staphylococcus aureua 
and albus but together with these, and in separate colonies, there was 
a thin translucent growth which on smears being made and stained 
with methylene blue showed a bipolar staining bacillus. The bacilli in 
parts were only faintly stained; the grouping arrangement was 
pnrallel; there were many club-shaped forms, also V-shaped 
splitting (Fig. 2). The organism react ed to NeiBser’s stain and it also 
stained by Gram’s method. From this colony two blood-serum tubes 
were inoculated and the bacilluB was obtained in {Jure culture. 

On Jan. 17th, 1907, a 300 gramme guinea-pig was inoculated per 
peritoneum with two cubic centimetres of serum suspension of this 
culture. 27 hours later the guinea-pig was dead. On the 19th a post¬ 
mortem examination was made, revealing extensive oedema of the 
peritoneum and hemorrhages and enlargement of the spleen. Cultures 
were made from the scat of inoculation and from the heart on blood 
serum and a growth of this organism was obtained 18 hours 
later. At the same time a guinea-pig was inoculated with 
the streptococcus. The organism appears to be non-pathogenic, as 

Fig. 2. 



■u 

Klebs-Loffler bacillus from pustule on the hand. 

up'to the time of writing the guinea-pig is still alive. A third guinea- 
pig, however, being inoculated with the bipolar staining bacillus plus 
the Btaphylococcus died 72 hours later, and both organisms have been 
recovered in pure cult ire. Further inoculations were then made. A 
guinea-pig was inoculited with 0 75 cubic centimetre of the organisms 
obtained in pure culture from the guinea-pig. Death occurred 48 hours 
later, while one inoculated with 1 2 cubic centimetres of culture plus 
1 cubic centimetre of diphtheritic antitoxin is still alive. 

All the lesions cleared up rapidly under local antiaepti I treatment' 
so it^was not.deemed necessary to employ antitoxin. 

In a second case 1 am indebted to Dr. Alan B. Slater for 
carrying out the treatment at the patient’s own home. 

*,* The second case referred to by Dr. Eddowes appeared 
in The Lancet of Jan. 4th. No mention was then made 
by Dr. Slater that he was associated with Dr. Eddowes in 
the case, while we were unaware that the patient came 
under treatment at the St, John’s Hospital for Diseases of 
the Skin and not at the Farringdon General Dispensary, 
where Dr. Slater is physician to the Skin Department. 
Dr. Slater, whose attention we have drawn to the matter, 
says that the case was handed over to him by Dr. Hargreaves, 
physician to the St. John’s Hospital, whose assistant he was, 
with full permission for publication. —Ed. L. 


The Royal Sanitary Institute.— The List 
of Honorary Fellows, Members, and Associates elected in 
January, 1908, includes the following names : Professor Dott. 
Cavaliere Giuseppe Badaloni, of Rome; Professor Leo 
Burger6tein, of Vienna; Professor G. W. Cblopine, of St. 
Petersburg ; Professor H. Griesbach, of Mulhausen ; Professor 
Kirohner, of Berlin ; Dr. Albert Mathieu, of Paris ; Professor 
M. Mishima, M D., Principal Medical Officer, Ministry of 
Education, Tokio ; Dr. Luigi Pagliani, Professor of Hygiene, 
University of Turin ; Professor Alb. Palmberg, of Helsingfors; 
Sir H. H. Pinching, K C.M.G., late Director-General, Public 
Health Department, Cairo, Egypt; and Dr. Marc Armand 
Buffer, O.M.G. 





The Lancet,] DR. SAWYER: THE VALUE OF CYTODIAGNOSIS IN PRACTICAL MEDICINE. [Feb. 1,1908. 283 


THE VALUE OF CYTODIAGNOSIS IN 
PRACTICAL MEDICINE . 1 

By JAMES E. H. SAWYER, M.A., M.D.Oxox., 
M.R.C.P. Lond., 

•CASUALTY ASSIST ANT PHYSICIAN AND MEDICAL REGISTRAR, THE 
GENERAL HOSPITAL, BIRMINGHAM; PHYSICIAN FOR OUT¬ 
PATIENTS, THE CHILDREN’S HOSPITAL, IIIRMINGHAM. 

f I PURPOSE in this paper to describe a help to diagnosis 
■which is of considerable value and clinical importance and 
which might be more extensively made use of than it is at 
present, as the examination required is one that can be 
performed by many medical men for themselves. By cyto- 
diagnosis is meant the diagnosis which can often be ascer¬ 
tained by determining the nature of the cells occurring in 
serous effusion or cerebro-spinal Quid. I do not wish to take 
credit for having done any original work upon this subject, 
but while I was pathologist at the General Hospital, 
Birmingham, and since that time, I hare had abundant 
opportunities of examining the different forms of cells which 
are found in certain serous effusions and by my observations 
I have been able to confirm most of the excellent work that 
has been done on this subject. I should like to take this 
opportunity to thank the honorary physicians and surgeons 
of the General Hospital for kindly giving me permission to 
make use of their cases for this paper. My thanks are also 
due to the house officers of the hospital for their help in 
collecting for me the materials from the wards. 

It is only during the last eight years that the subject of 
cytodiagnosis has attracted any notice at all, and during 
this time only a very few people have taken advantage of it. 
No advance in the subject was made until 1900, when Widal 
and Ravaut published a very complete account and showed 
the relationship between the cytological appearances of the 
effusions and the clinical diagnosis. A most exhaustive 
investigation of the value of cytodiagnosis has recently been 
made by Dr. E. A. Ross at the Louis Jenner Clinical Labora¬ 
tory, St. Thomas’s Hospital, and his work is published in 
the Transactions of the Pathological Society of London for 
1906. All pathological fluids of the body may be examined 
for the cellular elements they contain, but the fluids with 
which I purpose to deal are pleural serous effusions, cerebro¬ 
spinal fluids, and ascitic fluids. Speaking generally, the cells 
found in all effusions and the percentage of each kind of cell 
to the total number vary in the same way in all these patho¬ 
logical fluids, according to the disease which produces the 
effusion. 

In making a cytological examination it is necessary to 
obtain the fluid as soon as possible after it has been removed 
from the body. After a few hours the cells begin to 
degenerate and become in consequence very much more 
difficult to recognise. Some of the fluid should be centri- 
fugalised gently and then the fluid poured off and a film 
made of the sediment. Care should be taken not to centii- 
fugalise too long or too forcibly or otherwise many of the 
cells will be destroyed. It is much better to centrifugalise 
the fluid than to let it stand in a conical jar and then 
examine the sediment, for the cells degenerate very rapidly. 
After a film has been made it can be stained at leisure. The 
two stains I find most nseful are Leishman's and Jenner's. 
The differential count should be made under the one-twelfth 
oil immersion lens and to get an accurate percentage of the 
cells 500 should be counted. In many instances, however, 
and especially in cerebro-spinal fluid of which only a small 
quantity can often be obtained, it is impossible to connt so 
many on account of the scarcity of the cells. The differences 
in the percentages of the cells to each other in the various 
pathological conditions are often so great that usually such a 
Urge number of cells need not be counted. 

The cells found in serous effusions and cerebro-spinal 
fluids may beany of those which occur in the blood, as often 
some blood becomes mixed np with the fluid in its removal 
from the body, while sometimes the exudation itself con¬ 
tains blood. The cells, however, which we have to consider 
from the cytological point of view are (1) the small lympho¬ 
cytes ; (2) the polymorphonuclear cells ; and (3) the endo¬ 
thelial cells. The small lymphocytes are a little larger thao 
the red blood corpuscles, but they vary considerably in size 
and are characterised by a comparatively very large, deep- 
staining, and »n l -erionl nucleus The rim of protoplasm 


1 A paper read beluro Ihe Mluiiilld Medical Society on Oct.Hlh, 1907. 


around the nuolens is usually very narrow. The polymorpho¬ 
nuclear cells are considerably larger than red blood 
corpuscles, usually circular in outline, and with a nucleus 
variously lobed, so that it may be horse-shoe shaped or 
resembling the letters E, Z, W, or S. There is a large 
amount of protoplasm containing minute granules, which 
give the name of “ finely granular oxyphile ” to the cell. In 
effusions these cells are often seen to have burst and their 
granules lying around. Sometimes they become very de¬ 
generated and their nuclei so swollen up that the cells are 
very difficult to recognise. 

Endothelial cells differ greatly from either of the former, 
but even these in certain circumstances may be confused 
with small or large lymphocytes. The cells are very much 
larger than the previous two. The nucleus is large, oval, 
and slightly irregular in shape, staining as a rule not so 
deeply as the nucleus of the small lymphocytes. The proto¬ 
plasm is abundant and the outline of the cell is irregular in 
shape. These cells may be difficult to distinguish from 
lymphocytes and also from cells derived from a malignant 
growth. Mitotic changes can often be seen in the endo¬ 
thelial cells. 

When serous exudations or cerebro-spinal fluids are 
examined very few cells may be present in Borne cases, and 
often is this seen in the latter fluids. In health it is usually 
difficult to find cells in the cerebro-spinal fluid and the 
presence of many cells, whatever be their nature, is a clear 
indication of disease. In cerebro-spinal fluids not only the 
percentage of cells to each other should be ascertained but 
also any increase in their number must be noticed. Often 
there are degenerated cells, and other cells which cannot be 
classified under any of the three heads mentioned above, and 
so, for the sake of clearness, chiefly those cases are given in 
this paper in which the cytological count was not com¬ 
plicated by other forms of cells, which when present only 
occur in very small numbers, and have no practical 
significance. 

Predominancy of small lymphocytes — A large number 
of small lymphocytes in a eerebro-spinal, pleuritic, or 
ascitic fluid means that the exudation is due to an irrita¬ 
tive process, and that it is not due to any acute inflammatory 
condition. Thus, in a pleuritic effusion a high percentage 
of small lymphocytes would point to the condition being due 
to tuberculosis. This is a very important point, because often 
it may be very difficult to be certain whether a pleurisy is 
tuberculous in origin or not. In a well-developed pleurisy 
of tuberculous origin the differential leucocyte count of the 
effusion is very characteristic, as may be seen in the follow¬ 
ing four examples of the condition :— 


Small lymphocytes. 

.. 94 4 . 

. 90-5 . 

. 73 4 . 

. 790 

Polymorphonuclear cells . 

. 51 . 

. 79 . 

. 22 2 . 

. 18-0 

Endothelial cells .. 

.. 0*5 . 

. 1-6 . 

. 44 . 

. 3-0 


In the very early stages of the tuberculous pleurisy this 
definite cytological picture may not be quite so clear, as the 
percentage of the lymphocytes is usually not 60 high; but 
still they predominate. It is very rare, indeed, for the 
polymorphonuclear cells to be in excess of the small lympho¬ 
cytes in plenral effusions, however acute the condition. It is in 
the tuberculous pleurisies that a cytological examination of 
the flnid is of such great value. A bacteriological examina¬ 
tion might also be made, but the tubercle bacillus is very 
difficult to detect in a pleuritic effusion and often entails a 
considerable amount of labour. The absence of the tubercle 
bacillus in the film would not exclude the tuberculous origin 
of the disease, but the absence of lymphocytosis would. I 
have not yet found a lymphocytosis in a pleuritic effusion 
which was found to be other than tubercnlous. 

A difficulty arises in cytodiagnosis when the count shows 
about an equal number of small lymphocytes aDd polymorpho¬ 
nuclear cells in a pleuritic fluid, but in such a case the 
important cells to notice are the lymphocytes; aDd if there 
a e a large number of them the condition is probably due to 
tuberculosis. The presence of such a large number of poly¬ 
morphonuclear cells in these cases may be due to an 
extremely acute onset of the tuberculous pleurisy or 
to a secondary infection by another organism. In the 
cerebro spinal fluid of a child a high percentage of 
small lymphocytes usually means tuberculous meningitis. 
A lymphocytosis is also found in locomotor ataxia and any 
syphilitic disease of the meninges. In five cates of tubercu¬ 
lous meningitis which I examined lymphocytes were practi¬ 
cally the only cells present, while in two others thiy were 
75 and 60 per cent, respectively. 1 should like to suggest 





284 Thb Lancet,] DR. CUNNINGHAM : ACID INTOXICATION & ETHYL CHLORIDE ANAESTHESIA. [Feb. 1,1908. 


that in cases of cerebral tumour it may be possible by cyto- 
logical examinations of the cerebro-spinal fluid to distinguish 
between tumours of tuberculous or syphilitic origin on the 
one hand and those of different formation on the other. In 
a tuberculous or syphilitic tumour I should expect to find a 
lymphocytosis and no such change in a tumour of another 
source. I have not had an opportunity to verify this. Again, 
in an ascitic fluid alymphocytosis points to the effusion being 
due to tuberculosis. 

Predominancy of polymorphonuclear cello. —An excess of 
polymorphonuclear cells in any serous fluid points to it being 
of an acute inflammatory origin. These cells can only have 
been derived from the blood by diapedesis through the vessel 
walls. Dr. Ross has tabulated 12 cases of acute infec¬ 
tive conditions in which he examined the effusions and in 
all of these he found a very high percentage of polymorpho¬ 
nuclear cells. In two cases of post-basic meningitis these 
were the principal cells present. It has been proved by many 
observers that a large number of polymorphonuclear cells in 
a serous effusion or cerebro-spinal fluid occurs in acute in¬ 
fective conditions. When examining such exudations con¬ 
taining numerous polymorphonuclear cells cytological counts 
are in many cases not necessary, for the micro-organisms 
producing the condition are very frequently found in the 
films. The following are typical counts of the cells in two 
cases of pleuritic effusion caused by the pneumococcus of 
Fraenkel : — 


Small lymphocytes . 

... 22 4 ... . 

. ... 150 

Polymorphonuclear cells ... 

... 64-4 ... . 

. ... 81-2 

Endothelial cells . 

... 13*2 ... . 

. ... 3-8 


Only once have I examined cytologically a pericardial 
effusion and this was one due to the rheumatic diplococcus. 
The count was as follows : polymorphonuclear cells, 93 2; 
and small lymphocytes, 6 8 per cent. 

The following are examples of cytological counts in four 
cases of cerebro-spinal meningitis, showing the great pre¬ 
dominance of polymorphonuclear cells. 


Polymorphonuclear cells . 

84 0 . 

. 791 . 

. 85-7 . 

. 74-6 

Small lymphocytes. 

156 . 

. 186 . 

. 11-9 . 

. 24 0 

Endothelial cells . 

0-0 . 

. 0-6 . 

. 00 . 

. 0-7 

Degenerated or cells not classiiicd 

04 . 

1*7 . 

. 24 . 

. 07 


In two cases of cerebral abscess in which I examined the 
cerebro-spinal fluid cytologically the differential counts 
were:— 


Polymorphonuclear cells . 

... 66-4 .. 

,. 970 

Small lymphocytes . 

... 30-5 .. 

.. 2'4 

Degenerated or cells not classified... 

... 31 .. 

04 

Endothelial cells . 

... 0 0 . 

.. 02 


The cytodiagnosis in these two cases was of acute meningitis 
of non-tuberculons origin. With the help of the clinical 
history of the cases a diagnosis of cerebral abscess was made. 
In the first case the patient was operated upon by Mr. George 
Heaton and a large abscess was found in the right temporo- 
sphenoidal lobe, secondary to ear disease. In the second 
case the presence of a cerebral abscess was not proved until 
a post-mortem examination was performed. 

Predominancy of endothelial cells. —When there is a large 
percentage of endothelial cells in a cytological count it indi¬ 
cates that the effusion is mechanical in origin. By mechanical 
effusion is meant such a one as occurs in-serous cavities as a 
part of a general oedema or in the peritoneal cavity as a 
result of portal obstruction. Endothelial cells are nearly 
always present in small quantities in all serous effusions, but 
it is only when they are in large numbers relative to the 
other cells that they are of any diagnostic value. In a 
mechanical effusion the cells present are usually not nearly 
so numerous as are found in an exudation of acute inflamma¬ 
tory origin and are even much fewer than those found in an 
exudation due to tuberculosis or syphilis. In two cases, 
however, I have found them in very large numbers. Some¬ 
times there are seen collections of endothelial cells as though 
they had been shredded off the serous membranes. These 
collections of cells or plaques have before now been mistaken 
for portions of malignant growth. 

It has been definitely proved by the observations of Dr. 
Ross that numerous endothelial cells indicate a mechanical 
origin for the effusions, notwithstanding the presence of 
polymorphonuclear cells and small lymphocytes. In ascites 
due to cirrhosis of the liver numerous endothelial cells are 
found and the following are typical counts from two cases :— 


Endothelial cells . 

... 96-4 


.. 988 

Small lymphocytes . 

... 3*4 .. 


0-2 

Polymorphonuclear cells ... 

... 0-2 ... 


.. 0-4 

Unclassified cells. 

... 0-0 ... 


. 0 6 


The difference between an ascites due to cirrhosis of the liver 
and that due to tuberculous peritonitis can usually be 
ascertained by a cytological examination. In the former 
case there would be an excess of endothelial cells and in the 
latter an excess of small lymphocytes. As tuberculosis of 
the peritoneum does sometimes occur as a complication of 
cirrhosis of the liver it may be important that the ascitic 
fluid be examined. 

There is an excess in endothelial cells in all serous effusions 
occurring in general oedema, but whether this is the case in 
the cerebro-spinal fluid under such conditions I do not know. 
I have never examined the cerebro spinal fluid cytologically 
in a case of general oedema during life but in one case 
examined after death I found that the endothelial cells were 
over 93 per cent. I do not, however, attach importance to 
this observation as many of the endothelial cells were 
probably shed into the fluid after death. 

Effusions due to malignant disease. —A few observers have 
stated that it is possible to diagnose the presence of a 
malignant tumour by a cytological examination of the 
effusion. This they do by recognising a few cells in the fluid 
as having been detached from the malignant growth. The 
recognition of isolated cells in this way is, however, 
practically impossible and in those cases where a cyto¬ 
diagnosis of malignant disease has been made it is very 
probable that the cells considered to be of malignant origin 
were really endothelial cells after all. Such cells usually 
predominate in effusions which are caused mechanically by 
the presence of a neoplasm and often appear in plaques. 
Unless there be a large collection of the malignant cells in 
the fluid it must be impossible to diagnose the condition by a 
cytological examination. 

Without doubt a cytological examination of a serous 
effusion or a cerebro-spinal fluid may be of great help in 
diagnosis. A diagnosis should not, however, be made on the 
cytological finding alone, and the examination of the cells in 
the fluid must only be considered as an additional help in 
diagnosis. As a general rule it can be relied upon, and only 
in a very few cases does it mislead. In a very rare case 
of acute tuberculous cerebro-spinal meningitis published 
recently in The Lancet by Dr. T. Stacey Wilson and Dr. 
James Miller, 2 the cytological examination pointed to the 
condition being of acute inflammatory origin and not tuber¬ 
culous, on account of the large percentage of polymorpho¬ 
nuclear cells present. The appearances at the post-mortem 
examination were all those found in the cerebro-spinal 
meningitis due to the diplococcus of Weichselbaum, but on 
microscopical examination numerous tubercle bacilli were 
found to be present. 

Conclusions —1. Effusions of tuberculous origin contain a 
large percentage of small lymphocytes, ranging in my series 
from 59 to 100 per cent. 2. Effusions of acute inflammatory 
origin contain a large percentage of polymorphonuclear 
cells, ranging from 64 to 97 per cent. 3. Mechanical 
effusions contain chieflv endothelial cells, the highest count 
being 98 8 per cent. 4. Effusions due to malignant disease 
can rarely be diagnosed by cytological methods alone, bnt 
when such a condition is suspected to be present the pre¬ 
dominance of endothelial cells would greatly support that 
view. 

Birmingham. _ 


ACID INTOXICATION FOLLOWING ETHYL- 
CHLORIDE ANAESTHESIA. 

By H. H. B. CUNNINGHAM, M.D. Bnux., 
F.R.O.S. Ikel., M.R.C S. Eng , 

OPHTHALMIC A.VD AURAL SURGEON TO THE ULSTER HOSPITAL KOR 
CHILDHEN AND WOMEN, BELFAST; LATE SENIOB CLINICAL 
ASSISTANT TO THE ROYA1. EAR HOSPITAL, LONDON. 


Acid intoxication following on general anesthesia has 
only been described comparatively recently, but so far as I 
am aware it has only been recorded as an after-effect of 
chloroform anesthesia. Thus in 1894 Dr. Leonard G. 
Guthrie first drew attention to this subject by his paper on 
Some Fatal After-effects of Chloroform on Children pub¬ 
lished in The Lancet of Jan. 27th (p. 193) and Feb. 3rd 
(p. Z57) of that year. In the Transactions of the Ulster 
Medical Society for 1906-07 Mr. Robert Campbell, after 
mentioning the papers published on this interesting subject, 


2 Tnr. Lavcft. Sep f . 14th, 1907, p. 763. 




Thb Lancet,] MR. C. W. MANSELL MOULLIN : SECONDARY NODULES IN SUTURE SCARS, ETC. [Feb. 1,1908. 285 


describes in detail three cases with the post-mortem appear¬ 
ances. Bat in this communication every case described 
followed chloroform administration. My case shortly is as 
follows 

A well-developed, bright-looking, and apparently healthy 
girl, aged six years, was admitted to hospital for deafness 
owing to the presence of adenoids. On the morning of 
Nov. 13th, 1907, after having been prepared in the usual 
manner, ethyl chloride was administered and the adenoids 
were removed, the operation, including administration 
of the anaesthetic, taking about a minute ; the child 
recovered completely and was then placed in bed. Towards 
evening she vomited twice but slept well during the 
night and no vomiting occurred. On the next day she 
complained of severe headache and of nausea. She retched 
a good deal during the day and vomited a few minutes after 
taking any food, so she was given some bismuth mixture in 
the evening. Daring the night she slept fairly well but 
vomited once, whereupon the medicine was repeated. On 
the 15th she complained of violent frontal headache and 
vomited immediately after taking anything by the mouth. 
Towards evening the pulse became rapid and small and the 
child felt very cold, so hot bottles were placed in the bed. 
During the night she slept fairly well but vomited twice 
after drinking a little milk. On the 16th the aspect of 
the child had completely altered during the past two 
days. She now lay in bed with her knees drawn up, taking 
no notice of anything, but answering when spoken to and 
complaining of great frontal headache and of pain in the 
abdomen ; her eyes were very sunken and her face was some¬ 
what pale, worn-looking, and drawn ; in fact, her aspect 
resembled that of a patient who had suffered from some 
severe illness, such as typhoid fever, for some weeks. The 
child was very cold, her tongue was coated and dry, her 
pulse was quite feeble, very rapid and irregular ; in fact, she 
was very ill. 8he had been given an enema simplex and was 
receiving bismuth mixture every four hours ; she retained no 
food, vomiting immediately anything that she swallowed. It 
had been thought up to now that probably she was develop¬ 
ing some intercurrent disease. However, her aspect and the 
continual vomiting made me suspect acid intoxication, so a 
sample of urine was obtained, which Dr. T. Houston kindly 
tested and found it to contain diaoetic acid, thus confirm¬ 
ing the diagnosis. She was now given rectal injections 
of 1 drachm of bicarbonate of sodium in 2 ounces of 
warm water every four hours, and during the night, also 
bismuth mixture and a little peptonised milk and water, 
this and the mixture containing 10 grains of bicarbonate of 
sodium to the dose, but both were vomited immediately after 
being drunk and so were stopped. On the 17ih the child was 
distinctly better, the worn aspect had vanished, and the eyes 
did not appear so sunken. She looked brighter and felt 
easier and had no headache or pain in the abdomen ; the 
pulse was still rapid but regular and better in quality. 
During the early part of the night she had vomited twice, 
but not since she was not given any food by the mouth, 
receiving rectal feeds of 4 ounces of peptonised milk con¬ 
taining 20 grains of bicarbonate of sodium every four hours. 
After 6 p.m. she was given peptonised milk in half ounce 
quantities by the mouth which she retained. This was 
therefore gradually increased in quantity as no vomiting 
occurred, the rectal feeds being continued during the night. 
On the 18th there was no vomiting, the child looked brighter 
and better, and did not complain of pain anywhere. The 
pulse was slower, steadier, and improving in quality ; the 
tongue was becoming clean. The rectal feeding was now dis¬ 
continued, the patient being given 5 ounces of peptonised 
milk every two hours by the mouth ; in the evening this was 
replaced by ordinary milk. On the 19th the child was im¬ 
proving rapidly; there was no vomiting and the pulse was 
normal. The urine tested on this day was found to be free 
from diaoetic acid. The subsequent history was uneventful. 
The temperature during the illness never rose above 99 ■ 8° F., 
nor fell below normal. 

This, then, appears to be a case of acid intoxication 
following ethyl-chloride anaesthesia, which when recognised 
and treated appropriately had a fortunate termination, though 
on the third day after the operation the little patient was so 
ill that this, coupled with the fatal terminations in the 
recorded cases following chloroform administration, made 
one give a very gloomy prognosis. In view of the able 
manner in which Mr. Campbell has described the whole 
subject of chloroform poisoning I will refer the reader to his 
paper and content myself by quoting as an explanation why 


acid intoxication should follow ethyl chloride administration 
the suggestion made by Dr. V. G. L. Fielden, the anaesthetist 
to the hospital, that the halogen group occurs both in chloro¬ 
form and in ethyl chloride. In conclusion, I have to thank 
Miss Tate, the matron, for many of the notes on this case. 

Belfast. 


A NOTE ON THE DEVELOPMENT OF 
SECONDARY NODULES IN SUTURE 
SCARS AFTER OPERATIONS 
FOR THE REMOVAL 
OF CANCER. 

By C. W. MANSELL MOULLIN, F.R.C.S. E.vo., 

SENIOR SUBC1EON AN I > LECTURER OS SURGERT AT THE LONDON 
HOSPITAL. 


Ik The Lancet of Nov. 9th, 1907, Mr. Charles Ryall 
called the attention of the profession to the very grave risk 
of cancer infection taking place during the performance of 
operations for the removal of cancerous growths, and 
instanced many cases in which it seemed to be obvious that 
such infection had occurred. One of the examples brought 
forward was the well-known frequent recurrence of the 
disease in the suture cicatrices alter operations upon the 
breast, and several striking instances were mentioned in 
which infection had taken placs around a laparotomy wound 
even when the operation had been merely of an exploratory 
character. A case that has been recently under my care 
illustrates this point well, but at the same time suggests that 
the mode of transference of the cancer infection is not of 
quite such a simple character as is usually believed. The 
sutures must bear a part of the blame, perhaps the greater 
part; but there is something more than the mere conveyance 
of a cancer cell from one spot to another by the needle or 
suture employed. 

The patient, a man 48 years of age, was sent to me with 
the history that he had suffered from chronic gastric ulcer 
for the last 18 years, and that lately, in spite of medical 
treatment, the attacks of pain and vomiting had become 
more frequent. Cancer had supervened upon the old ulcer, 
as it so often does, and at the operation a tight stricture of 
the pylorus was found with some disseminated nodules 
scattered over the serous surface of the stomach. Posterior 
transmesocolic gastro enterostomy was performed and the 
patient made an uneventful recovery. Six months later I 
saw him again. He was much better so far as pain was con¬ 
cerned and was considerably stouter, but there was a double 
row of cancer nodules on either side of the laparotomy 
wound. Two sets of sutures had been inserted : one, of 
stout catgut, interrupted, passing through all the layers of 
the abdominal wall except the skin ; the other, of finer cat¬ 
gut, continuous, through the skin only. Practically all the 
suture points of the former series were infected ; none of the 
latter, lb was evident that cancer cells from the peritoneal 
cavity had invaded the wall wherever the parietal peritoneum 
had been pierced by a suture. The sutures had not carried 
the cancer germs in, for they had never been near the 
growth; but either by perforating the serous layer or by 
acting as irritants they had helped the development of the 
invading germs to such an extent that each point had 
become a cancer nodule. The immediate source of infection 
was in all probability the nodules noted on the serous coat 
of the stomach, which were constantly rubbing against the 
anterior abdominal wall. The line of the laparotomy 
incision itself seemed to be intact between the two rows of 
nodules. 

The same explanation, it seems to me, is the more rational 
one in those cases in which cancer recurs at the suture points 
after operations for mammary carcinoma. It is not that the 
cancer germs are carried in by the needle or suture 
mechanically at the time of the operation and left to grow 
in the puncture made, but that they are more widely dis¬ 
tributed in the surrounding tissue interstices than is apparent 
at the time, and only develop, or perhaps develop first, at 
those points where the resistance of the tissues is lowered by 
the presence of an irritant such as a 6uture. 

That healthy tissues do possess some power of resistance 
to the growth of invading cancer germs is obvious. The dis¬ 
tribution of cancer germs from a primary focus must begin 
at a very early date, but it is a long time before secondary 




286 Thb Lancet,] DR. ARTHUR H. BURGESS: TWO CASES OF URETERO-PYELOPLA8 TY. [Feb. 1, 1908. 


growths make their appearance, and early removal of the 
primary one often prevents their development entirely. 
Moreover, though surgeons not uncommonly become infected 
in the coarse of operations by pyogenic organisms and by the 
organisms of tubercle and syphilis, and though they must 
have run the risk many thousand times in the course of 
operations upon patients suffering from cancer, I am not 
aware of any single instance in which they have become 
infected. All the instances in which transplanted cancer 
germs have succeeded in growing have been cases in which 
the patients were suffering from cancer already, in whom it 
may be presumed the power of resistance had been already 
overcome. 

One of the cancer problems is to discover in what this 
power of resistance may consist. It exists at first appa¬ 
rently in all alike. It must be present and well developed 
for some considerable time in the tissues around a cancerous 
growth, but it fails at last, and it fails much more quickly 
if there is some additional irritant present, such as a suture. 

Wimpole-street, W. 


TWO CASES OF URETERO-PYELOPLASTY 

Bv ARTHUR H. BURGESS, F.R.C.S. Eng., M.B., 
M.Sc. Vict., 

HONORARY ASSISTANT SURGEON TO THE MANCHESTER ROVAT, INFIR¬ 
MARY AND MANCHESTER CANCER HOSPITAL ; LECTURER 
IN SURGERY, UNIVERSITY OF MANCHESTER. 


Thb operation of uretero-pyeloplasty is one which seeks to 
overcome a constriction at the junction of the renal pelvis 
and ureter by a procedure analogous to the better known 
“pyloroplasty”—viz., longitudinal incision through the 
stricture, followed by transverse Buture of the wound. It is 
indicated in oases of distension of the renal pelvis from 
stricture at or about the uretero-pelvic junction, provided 
sufficient healthy renal substance yet remains to justify con¬ 
servatism. Constriction at this situation may arise from 
trauma, from the contraction of an ulcer snch as may result 
from the pressure of an impacted calculus, from the con¬ 
traction subsequent to peri ureteric or peri-nephiitic inflam¬ 
mation, and it is also one of the two less rare sites of 
congenital stricture, the other being at the entrance of the 
ureter into the bladder. I regard, for reasons shortly to be 
stated, the two cases I am now recording to be instances of 
congenital stricture, leading in the one case to hydro¬ 
nephrosis, in the other to pyonephrosis. 

CASE 1.—A female, aged 32 years, was sent to me at the 
Royal Infirmary with a swelling in the right side of the 
abdomen. For some months past she had complained of 
dull aching paiDS in the right loin, coming on at intervals of 
about ten days, and one month ago she accidentally dis¬ 
covered the swellng, which she stated had not appreciably 
altered in size since. She had never noticed anything 
unusual in the quantity or quality of her urine. The swelling 
was of about the size of a cocoanut, distinctly fluctuant, 
freely moveable in any direction, and easily replaceable into 
the right loin. The urine was acid, of specific gravity 
1022, and contained no abnormal constituent. On Feb. 5th, 
1907, under chloroform, I oystoscoped the bladder and 
found it quite healthy, nor were there any differences 
in appearance between the two ureteric orifices. As 
the kidneys had temporarily stopped secreting under 
the influence of the anaesthetic the character of the 
urinary flow from the two orifices could not be com¬ 
pared. A catheter passed easily along the right ureter for a 
distance of 11 inches, and was left in situ , no urine escaping 
from it. The patient was then turned over on to her left 
side and the usual lumbar incision for exposure of the kidney 
was made. The large cyst was readily exposed and incised, 
arid about 30 ounces of a pale-yellow fluid escaped. The cyst 
was then separated and brought well up into the wound, when 
it was found to be the dilated renal pelvis, with the kidney, 
the calyces of which were comparatively but slightly affected, 
situated on its outer and posterior aspects. The ureter 
was readily found by means of the catheter still remaining 
in it, and which was Been to have passed as far as the junc¬ 
tion of the ureter and the distended pelvis, where its further 
passage had been prevented by a very tight constriction. 
The ureter was of normal Bize and there were no signs of 
any previous peri-ureteritis. A small incision was made on 
the anterior surface of the pelvis, half an inch above the 
uretero-pelvic junction, and the constriction was examined 


from above. With some difficulty a fine wire' [probe was 
passed through it from above and the catheter was withdrawn 
from the ureter. The incision was then continued down¬ 
wards through the stricture and along the long axis of 
the ureter for a distance of half an inch. There was no 
ulceration at the site of the stricture, nor did the mucosa 
exhibit any scars. This longitudinal wound was then sutured 
transversely, with two rows of fine catgut, the inner not in¬ 
tentionally including the mucosa. A large rubber drainage- 
tube was then inserted into the pelvis through the original 
incision into it and the kidney was fixed to the loin as high up¬ 
as possible. The external wound was closed around the tube. 
Five days later the tube was removed and on Feb. 20th the 
external wound was completely healed. I last saw her on 
Nov. 12th and could feel the kidney, rather smaller than 
normal, firmly fixed to the loin. There had been no recur¬ 
rence of the swelling and the symptoms had been completely 
cured. 

The absence of any signs of cicatricial contraction or other 
cause to account for the constriction in this case, together 
with its exact limitation to the uretero-pelvic junction, 
incline me to regard it as of congenital nature. The absence 
of hydronephrosis until middle life shows that the constric¬ 
tion was not at first of severe degree. Later the kidney 
became moveable and consequently no doubt suffered from 
frequent attacks of congestion which sufficed to aggravate 
the constriction to an extent sufficient to lead to pelvic 
distension. 

Cask 2.—A female, aged 21 years, was admitted to the 
Royal Infirmary on Dec. 17th, 1906, complaining of “pains 
in the back ” and " muddy ” urine. She had been told that 
her pains commenced at the age of three years, and she 
heiself did not remember ever being free from them for any 
length of time. The chaDge in the urine was noticed about 
three years ago and though slight at first it bad steadily 
become more marked. She bad been in hospital several times 
without material relief. On admission she located her pain to 
the upper lumbar region of the spine and could not say that 
it was ever more marked on one side than on the other. The 
pain always came on in attacks and usually during the night. 
The abdomen appeared to be tender and palpation was 
difficult, but I thought palpation over the left kidney was 
more painful and gave a feeling of greater resistance 
than that over the right. The urine was 1020, alkaline, 
contained albumin, no sugar, with a very thick deposit 
of pus. A radiogram showed an indefinite shadow in 
the left kidney region. On Dec. 28th I cysto- 
scoped under anaesthesia and found the appearances of 
general cystitis. Apart from this the right ureteric orifice 
was unaltered, but that on the left stood prominently 
out like a pyramid and its margins were extremely swollen 
and acutely congested. The discharge from the right ureter 
was apparently clear while that from the left came irregu¬ 
larly and was very turbid. I at once exposed the left kidney 
from the loin, separated it from its adhesions to surrounding 
parts, and drew it well up into the wound. The pelvis and 
calyces were distended with pus. The kidney was incised 
along its convex border through a dilated calyx and the pelvis 
was thoroughly flushed out with saline solution. Three small 
calculi were found inclosed in the lowest calyx and were 
removed. The ureter was now exposed and was found to be of 
normal size, but exactly at the uretero-pelvic junction there 
was a narrow constriction. A small incision was then made 
in the anterior wall of the pelvis half an inch above this con¬ 
striction and its upper aspect was inspected. It was treated 
as in CaBe 1 by uretero-pyeloplasty, but before closing the 
incision in the pelvis and ureter a bougie was passed down¬ 
wards along the latter into the bladder to insure the absence 
of other obstruction. The pelvis was drained by a rubber 
tube passed through the original incision in the kidney sub¬ 
stance and the organ was fixed to the lumbar wound, a 
tube beiDg inserted also into the perirenal space below. 
Shock was rather severe for two days but afterwards 
the patient steadily progressed. The tubes were retained 
until Jan. 12th and she left for the convalescent home 
on the 30th with a small sinus, which finally healed 
on March 15th. She is now free from the old pains, is in 
good general health, and the kidney can be felt firmly fixed 
to the loin and of small size. There is still a small deposit 
of pus in the urine, which has been acid ever since the 
operation, but this is gradually diminishing. She can hold 
her urine for four hours, whereas formerly she passed it as 
often as every ten minutes. 

I think it is probable that in this case also the stricture 




The Lancet,] DR. J. ADAMS: SEVERE SPASMODIC CONTRACTION OF A FINGER, ETC. [Feb. 1, 1908. 287 


'was of congenital origin, the symptoms dating back as they 
do to the early age of three years. An alternative supposition 
is that the primary condition was renal calculus with im¬ 
paction of the calculus in the upper end of the ureter and 
hydronephrosis ; subsequent infection would lead to pyo¬ 
nephrosis, ulceration around the calculus would cause it to 
be loosened and drop back into the dilated pelvis (no stone 
■was ever known to be passed), and the healing of the ulcer 
would bring about cicatricial contraction of the uretero- 
pelvic junction. 

Manchester. _ 


SEVERE SPASMODIC CONTRACTION OF 
A FINGER CURED BY STRETCHING 
THE MEDIAN NERVE. 

By JAMES ADAMS, M.D.Auerd., F.R.O.S. Eng. 


A woman, aged 45 years, a widow who earned her living 
by needlework, came under my observation in November, 
1905, for extreme contraction of the middle finger of the 
right band. She gave the following history. In December, 
1902, she pricked the thumb of her left hand and it became 
swollen, tender, and inflamed, and it suppurated. As it did 
not improve but on the contrary got much worse she went to 
University College Hospital, London, in January, 1903. and 
remained there for two months, all the fingers and hand 
becoming involved in what was evidently a septic infection. 
The fingers and hand were freely incised and drained and the 
patient was discharged in March with drainage-tubes still in. 
She returned to the hospital in the following May with the 
wounds unhealed and the mischief spreading farther and 
amputation was performed at the middle of the forearm. 
The surgical registrar of the hospital, Mr. O. L. Addison, has 
sent me the report of her case. He says : “The patient was 
admitted to University College Hospital with a septic 
infection of the palmar sheaths and cellulitis of forearm 
following a poisoned wound of the thumb. The arm had to 
be amputated to prevent further extension of the suppura¬ 
tion.” 

In February, 1905, the middle finger of the right hand 
began to contract, and in November the patient was admitted 
under me to the union infirmary with the finger badly con¬ 
tracted. There were no signs of disease in the finger. With 
much force and some difficulty I could extend the finger 
fully but it gave her great pain to allow me to do it and 
when freed the finger at once returned to its state 
of rigid contraction with the tip firmly fixed in the palm. 
Before admission the finger had been treated in various ways 
without success and after admission I tried internally anti- 
rheumatic and anti-gouty medicines and iodide of potassium 
in large doses ; also locally I ordered hot brine baths, 
liniments, ointments, massage, icc., as well as applying 
splints to the palmar surface by which I could keep the 
finger extended, but all without the least benefit. It was 
■very painful to the patient to have it kept in a position of 
complete extension and it also proved useless, for when the 
splint was removed the finger at once re-contracted. After 
six weeks’ treatment with no result the patient begged me 
to amputate the finger as it was so inconvenient to her, 
besides preventing her from earning her living. Accordingly, 
in January, 1906, 1 removed the finger at the metatarso¬ 
phalangeal joint with the head of the metatarsal bone. The 
wound healed normally and quickly and in February she 
returned home to her work with a useful hand and with the 
rest of the fingers in a normal condition. 

For six months this continued, but in August the ring 
-finger began to contract and in spite of treatment became as 
bad as the middle finger had been, and in November she was 
readmitted in order to have this finger alsu amputated. The 
condition, appearance, and symptoms were identical with 
those of the other finger. It was in a state of marked tonic 
contraction with its tip fixed and kept firmly in the palm. 
By no effort on her part could she move it, and I could only 
extend it by using much force and giving her great pain ; on 
my releasing it the finger returned at once to its vicious 
position like a strong spring set free. The finger was not 
swollen, red, or painful, and its sensation was normal, and 
the other fingers were normal in every way, as were the hand, 
the forearm, and the upper arm. The patient’s general health 
was excellent, her appetite was good, and she slept well. 


She is a placid, non-neurotic type of woman, dark com- 
plexioned, well nourished, and is active and industrious. 

To remove a second finger from the hand of a woman of 
this class, already deprived of her other hand, would be 
indeed a serious misfortune for her. Instead of again 
putting her through a course of treatment I showed her at a 
meeting of the Eastbourne Medical Society, where she was 
examined thoroughly and with much interest by about 20 
members who were present. A suggestion was made that 
stretching the median nerve might be beneficial and 1 readily 
acquiesced in this, for I was very reluctant to amputate. In 
December, 1906, loperated. I cut down at the junction of 
the middle and lower third of the upper arm, making a three- 
inch incision in the course of the nerve, and at once came on 
it lying in its normal situation. I separated it from its bed, 
took it up with my forefinger and thumb, and stretched 
the distal portion forcibly for four or five minutes, and 
then the proximal end for the same time. The wound 
healed kindly and the operation was simple and easy, 
taking only a short time to do. While under the anaesthetic 
the finger could be readily extended as was the case in a 
patient of Professor Nussbaum to whom I shall again refer. 
Before my patient had recovered from her anaesthesia I put 
the finger on a palmar splint and kept this up for three 
weeks, removing it twice a day for passive exercise. At the 
end of this time I ordered the splint to be kept on by night 
only for another fortnight and then left it oil altogether. For 
nearly a month the patient had numbness in some of the 
fingers and disordered sensation in parts of the hand, and, 
curious to relate, the numbness was in the two fingers 
supplied by the ulnar nerve—viz., the little and ring fingers— 
there being no numbness in the thumb and forefinger. 
Brown-8<jquard refers to a similar occurrence as regards 
sensation when on stretching the sciatic nerve in guinea-pigs 
the part of the foot innervated by the anterior crural 
nerve became anaesthetic and sometimes even the leg 
on the opposite side to that of the operation became also 
anaesthetic. In one case there were an incomplete paralysis 
and anaesthesia in the right leg after considerable stretching 
of the sciatic nerve on the left side. And he adds : “ It is clear 
that the spinal cord is modified by the stretching of a 
nerve” (Holmes’s “System of Surgery,” Vol. II.). After 
leaving off the splint there was no contraction of the finger 
or tendency to contraction, and three months after the 
operation I had the satisfaction of showing the case again to 
the local medical society with the finger cured and the 
patient possessing a useful hand. 

In December, 1907, the patient came to see me and she 
could bend and extend the finger normally and there was no 
tendency to contraction ; and as a year has elapsed Bince I 
stretched the nerve the cure may be regarded as permanent. 

The etiology of the case is obscure and I oan only state 
its negative side. It was not a Dupuytren's contraction nor 
an osteo-arthritic finger, neither was it inflammatory nor a 
seqnel of inflammation, nor gont, nor rheumatism, nor an 
example of neuromimesis. The tissues and joints of the 
finger 1 amputated were all healthy. The contraction was 
certainly not organic but was a true spasm and became more 
violent the more that one attempted to oppose it. 

I can find no instance of stretching the median nerve 
having been done in England for contraction of a finger. 
Callender relates a case of stretching it for neuralgia, and 
Morton for athetosis, in which both median and ulnar nerves 
were stretched with success. The nearest case to mine 
whioh I have been able to find is that by Professor 
Nussbaum. He describes operating on a tuberculous girl, 
six years of age, in which in the course of a resection 
of the elbow for ankylosis at an inconvenient angle some 
traction was exercised upon the ulnar nerve and a 
spasmodic contraction of the fourth and fifth fingers which 
had hitherto existed was in consequence completely cured. 
Professor Nussbaum relates at length in the same article a 
successful result of stretching the ulnar nerve, and the 
various branches of the brachial plexus in the axilla for 
extreme spasmodic contraction of the hand, forearm, and 
upper arm accompanied by anaesthesia of dorsal aspect of the 
forearm in a soldier, aged 23 years, the condition being the 
result of traumatism. In this patient, as in mine, under an 
anaesthetic all spasmodic action ceased. 

Had I stretched the nerve when the patient first came 
under my treatment I have no doubt that I should have saved 
the middle finger from amputation, as I have now done the 
ring finger. No doubt the rarity of such a form of spasmodic 
contraction in a finger partly accounts for the rarity of the 




288 The Lancet,] 


CLINICAL NOTES. 


[Feb. 1, 1908 


operation, but it forcibly illustrates the utility of such a safe 
and simple surgical procedure where any one muscle or group 
of muscles is similarly affected by this form of intractable 
spasm. 

Bibliography —Artaud et Gilson : Revue de Chirurgie, 1882, vol. ii. 
Blum: Archives Gcnerales de Mcdecine, 1878. vol. i. Callender: 
The Lanot, June 26th. 1875, p. 883; Transactions of the Clinical 
Society, 1874, v5l. vii. Ciceri: Gazzetta Medica Itnliana Lombardia, 
1887. vol. vii. Cod man : Boston Medical and Surgical Journal, 1906, 
vol. civ. Galignani: Gazzetta degli Ospedali, 1887 vol viii. liolmes 
and Hulke: System of Surgery, vol. ii. Morton: Journal of Nervous 
and Mental Diseases, 1882, vol. ix. Nussbaum*. The Lancet, 1872. 
vol. 11., p. 783. 

Eastbourne. 


CInutal States: 

MEDICAL, SURGICAL, OBSTETRICAL, AND 
THERAPEUTICAL. 


NOTE ON THE REMOVAL OF AN OPEN SAFETY-PIN 
FROM THE (ESOPHAGUS OF A CHILD AGED 
FIVE MONTHS. 

By Donald R. Paterson, M.D. Edin., 

SUBGEOK TO THE EAlt AMD THBOAT DKPAHTMEST, CABDIFF INITKMAKY. 


This interesting case with its happy issue 1 raises the ques¬ 
tion of the proper treatment of foreign bodies in the food and 
air passages and affords me an opportunity of again putting 
in a plea for more precise and modern methods of treatment 
in this important branch of surgery. I agree with Dr. J. S. 
Manson that in the case he reports it was impossible to get 
the pin up by means of a probang. But there is a method, 
unhappily almost entirely ignored in this country, which 
is scientific, accurate, and safe, by which the extraction 
of the body might be carried out. I allude to the direct 
method or oesophagoscopy. I have already 3 discussed its 
general technique, and in the case in question 1 need only 
say that the passage of an cesophagoscopic tube would at 
once disclose the relations of the foreign body in the gullet. 
Having ascertained the situation of the point of the pin—in 
this instance directed upwards—a long fine tube, such as 
that used in the Killian broncboscopic forceps, could be 
passed over it and left in situ. Having thus protected the 
point, the straight forceps which I described in The Lancet 
of July 21st, 1906 (p. 155), could be passed alongside 
of it and the other limb of the pin seized and drawn 
into the icsophagoscopic tube. If Dr. Manson will try the 
experiment through a Killian tube he will probably be 
surprised at the ease and safety with which it can be 
accomplished. The attempt “ to push it down into 
the stomach and hope for the best” is not with¬ 
out risk, though one recognises that it is difficult to 
do otherwise when the armamentarium of most of our 
hospitals, not excepting the large teaching hospitals, is 
generally limited to a probang and a more dangerous coin¬ 
catcher. 1 have known serious damage done to the gullet 
by a probang and I have extracted sharp-pointed bodies 
which were so situated at the cardiac end of the oesophagus 
that an effort to push them down would inevitably nave 
caused grave injury. On the other band, an attempt to pull 
them up by a coin-catcher is often more dangerous. With 
small rounded bodies such as coins which can be localised 
by a skiagram its use may be justifiable, but where sharp 
substances such as pieces of bone lie in the gullet serious 
damage may be inflicted and cases have occurred when fatal 
results have followed a rent made in the oesophageal wall. But 
whether these efforts are successful or not is a matter of pure 
chance ; they are done in the dark, and therefore to be dis¬ 
countenanced, for it is surely preferable to work under 
control of the eye. 

These remarks apply with even more force to foreign bodies 
in the air passages. Their rational treatment makes but 
slow progress. A collection of 200 cases of bronchoscopy for 
foreign body made from medical literature from its inception 
nine years »go to the present time shows few, very few, from 
English sources. For this our teaching authorities have to 
bear some responsibility. The Dewer methods are not put 
into practice, and so long as surgeons in our teaching centres 


1 The Lamcet, Jan. 4th, 1908, p. 20. 
s Brit. Med. Jour., August 18th, 1906. 


think the only treatment is to lay open the trachea “and 
hope for the best,” so long will this important branch remain 
a reproach to English surgery. 

Cardiff. _ 

A CASE OF ACUTE PULMONARY (EDEMA. 

By W. B. Silas, M.R.O.S.Enc., L.R.C.P. Lond. 

In view of the correspondence in the columns of 
The Lancet it may be of interest to record another case 
of acute pulmonary oedema. The patient, a girl, aged 14 
years, was brought to my notice on Jan. 4th with a slight 
tonsillitis. This was the fourth patient in that house who 
was affected with tonsillitis, but the affection, so far as the 
first two were concerned, was of a severe type and almost 
entirely unilateral in character. The patient to whom this 
note refers bad nothing more than a slight congestion of the 
throat with a temperature of 99° F. Incidentally it was 
mentioned that during the last four weeks she was at 
times short of breath on exertion and occasionally puffy 
about the face and legs. The heart and lungs were examined 
and were then found to be normal; there was no oedema 
anywhere to be seen. A specimen of the urine was 
not sent on that day as requested but on the evening 
of the 5th ; it was then found to be loaded with 
urates and about one-eighth albumin. As soon as the 
albuminous nature of the urine was discovered the patient, 
who had previously kept in her room, was ordered to bed and 
the case was treated as one of Bright’s disease. On the 7th 
(the fourth day of my attendance on her) there was distinct 
pufliness of the face and both legs ; fine crepitations were 
discernible in the lungs but only at the bases. That examina¬ 
tion was made at 1.30 P M. The quantity of urine collected 
in the previous 24 hours was about 12 ounces, but as there 
was diarrhoea that quantity was below the real amount 
passed. About four hours after that visit an urgent 
message came for me to go to the patient as she 
was much worse. She was then found sitting up in 
bed gasping for breath and extremely cyanosed, whilst 
from her month and nostrils a profuse frothy blood-stained 
fluid was pouring. A T J„th of a grain of nitro-glycerine 
was administered subcutaneously and as the case was 
regarded as one in which venesection was called for the 
patient was left for 20 minutes while I fetched suitable 
instruments. On my return she seemed better, but relapsed 
again, so from eight to ten ounces of blood were drawn off 
from the right median basilic vein. No real improvement 
followed tiie venesection, so two more hypodermic injections 
of nitroglycerine ( 5 J 5 th of a grain each) were administered 
at intervals of half an hour. The patient died at 9 45 P M., 
about four and a quarter hours after the onset of the attack. 

The only thing which seemed to benefit the condition was 
the first hypodermic injection of nitroglycerine. The pre¬ 
vious history of the patient was diphtheria three years ago 
and chorea about 15 months ago. 

Southgato-road, N. 


SUbioiI Societies. 


ROYAL SOCIETY OF MEDICINE. 


PATHOLOGICAL SECTION. 

Diffuse Cancellous Osteoma of the Femur .— Tuberovlous Endo¬ 
carditis.—Effects of Calculi upon Photographic Plates 
in the Dark —Malignant Disease of the Rectum .— Chimney¬ 
sweep Carcinoma. 

A meeting of this section was held on Jan. 21st, Mr. S. G. 
SHATTOCK, the President, being in the chair. 

Mr. W. H. Battle and the President gave an account 
of a remarkable case of Diffuse Cancellous Osteoma of 
the Femur following a Fracture in which similar growths 
afterwards developed in connexion with other bones. A 
section of the original tumour was shown with microscopical 
sections of the growth and several skiagrams showing the 
structure and position of the growths were also exhibited. 
The patient, a boy aged four yearB, was in St. Thomas’s 
Hospital in 1901 for a tumour of the left femur. The 





The Lancet,] 


MEDICAL SOCIETY OF LONDON. 


[Feb. 1,1308. 289 


femnr bad been broken by a simple fall in April; 
splints were removed three weeks later on account of 
extensive swelling of the thigh which was said to have 
reached three times the size of the opposite one ; there 
had been some diminution in size, but at the time of opera¬ 
tion, in November, 1901, it still measured 15 inches in 
circumference, twice the size of the opposite limb at a corre¬ 
sponding point. Examination with the x rays appeared to 
confirm the diagnosis of osteo-sarcoma. It was the only 
growth to be found on the skeleton and his general health 
was satisfactory. Amputation at the hip was followed by a 
good and rapid recovery. The family history was good at 
that time, but a few months later his mother underwent 
amputation of the thigh for osteo chondroma of the femur, 
while another child, a boy, aged three years, is now 
(January, 1908) in a hospital with a growth of his femur 
following a fracture: from the account given the case is a 
similar one. On June 9th, 1903, the subject of the 
communication was again taken to the hospital for a 
growth of smaller Bize affecting the lower end of the right 
femur; this presented characters similar to those of the 
original growth but did not prevent his getting about. When 
again admitted to hospital in March, 1907, the growth of 
the right femur had disappeared, leaving no trace. There 
was, however, a tumour of the tibia present which dated 
from an injury 12 months before, due to a fall on the pave¬ 
ment. An incision had been made into this (the scar of 
which remained) and a diagnosis of sarcoma given. The 
tumour had diminished in size and there had been less pain 
afterwards. There had been a change also in the appearance 
of the head, which was enlarged and bossy, due to a thicken¬ 
ing of the outer table. There were also small bony growths 
of the ulnar bones in no way resembling the characters of 
inflammation or of sarcoma. By means of the X rays the 
tumour of the tibia could be clearly defined, and although 
the outline of the tibia could be distinctly traced through 
it, it was not invaded by the growth, which was distinctly 
circumscribed and of bony structure, resembling an osteoma. 
After giving the account of the case Mr. Battle and 
the President made reference to the various conditions 
which might cause a difficulty in the diagnosis of tumours 
of the long bones following injury, the chief difficulty 
being met with when there was a resemblance to periosteal 
sarcoma. A case of traumatic subperiosteal hiematoma 
in which there had been a development of bone which gave 
egg-shell crackling on manipulation was related, the specimen 
being in the museum of St. Thomas’s Hospital. The femur 
was the bone affected and amputation had been done at 
another hospital on the supposition that the case was one of 
hmmorrhagio sarcoma. There was a history of improper 
feeding. Reference was made to cases published in a 
lecture by one of the readers of the paper (Mr. Battle) 
which appeared, with illustrations, in The Lancet of 
August 27th, 1904, p. 580. In that lecture examples were 
given of excessive formation of callus after fracture 
when too much movement of the fractured ends had been 
permitted or when the patient was the subject of locomotor 
ataxy. A case now under observation of a similar condition 
following fracture in a man the subject of general paralysis 
of the insane was also adduced. The characters of the 
tumour produced in a long bone which was affected by osteitis 
deformans confined to that bone were pointed out. The 
great difficulty sometimes experienced in making a diagnosis 
in necrosis, if the sequestrum was small and the x rays 
failed to show it, was drawn attention to, whilst, finally, 
allusion was made to the well-known case of leontia6is 
ossea in which the • fibula was occupied in part by a 
large bony mass similar to that which affected the head and 
face bones. A case of localised enlargement of bone reported 
by Mr. Bilton Pollard was also mentioned. Finally, the 
gTeat difference between the tumours which appeared in this 
case and the varieties of cancellous osteomata was pointed 
out, it being considered that from a clinical point of view 
the growths which formed the subject of this communication 
constituted a distinct and separate type. To the naked 
eye the tumour consisted of a finely cancellous osseous 
tissue, the interstices of which were filled with adipose 
medulla. In the latter there were strands of proper medul¬ 
lary tissue comprising finely and coarsely granular 
myelocytes, lymphocytes, and erythrocytes. No histo¬ 
logical marks of inflammation were present and the growth 
must be classed as a cancellous osteoma. Mr. Bilton 
Pollard had described under the title of “hypertrophied 
callus of the tibia and fibula” a fusiform formation which 


followed an injury. The limb was amputated on the sup¬ 
position that the disease was sarcomatous. In this case, 
however, the original bone was replaced by the new forma¬ 
tion, and the interstices of the cancelli were occupied 
with cellular connective tissue, without a trace of fat or 
proper marrow ; the lesion for this reason did not bear 
classifying as a cancellons osteoma but was rather an 
inflammatory or irritative hyperostosis. The tumour on the 
femur of the child’s mother fell histologically into Virchow’s 
group of osteoid chondroma. The growth of osteomata in 
her two children became thus an example of the heredity 
of benign tumours, which in the case of chondromata 
and osteomata was so striking and well established. A 
further matter of interest in the history of the boy was that 
bony tumours afterwards grew around other bones and that 
one of these disappeared spontaneously. That around the 
tibia appeared after an injury. The only comparable case 
in this regard of which Mr. Battle and the President knew 
was one recorded by Abernethy in which osseous formations 
ensued after local injuries, some of which formations spon¬ 
taneously disappeared. 

Dr. W. O. Meek read a paper on “Tuberculous Endo¬ 
carditis ” based on a pathological examination of two cases 
of miliary tuberculosis. 

Dr. H. A. Colweli. showed some photographic plates 
which had been placed in contact with sections of vesical 
calculi in the dark. After development a more or less 
faithful picture of the calculus was in the majority of cases 
obtained, which, however, showed that the action upon the 
silver salt was confined to certain strata of the calculi. 
Thus the nucleus, which consisted in each case of com¬ 
paratively pure uric acid and was compact in character, 
produced no photographic effect. On the other hand, layers 
of calculi, which were of more porous consistency and which 
also consisted of uric acid in combination as well as uric 
acid itself, gave positive results. Phosphatic portions of the 
calculi were without effect except when mixed with urates. 
The external layers of a predynastic Egyptian calculus lent 
by the President from the collection of the Royal College of 
Surgeons of England also gave a positive result, the nucleus 
being without any apparent t fleet. 

Mr. Cecil W. Rowntree read a paper on a case of 
Malignant Disease of the Rectum in a boy, aged ten years. 

Mr. Walter G. Spencer Bhowed a case of Chimney-sweep 
Carcinoma. 


MEDICAL SOCIETY OF LONDON. 


The Use of Chemicals in Aseptic Surgery. — NervousPhenomena 
in Pneumonia. 

A meeting of this society was held on Jan. 27th, Dr. 
J. Kingston Fowler, the President, being in the chair. 

Mr. 0 B. Lockwood read a paper on the Use of Chemicals 
in Aseptic Surgery. He said that at the present time 
attempts were being made to conduct surgery without the 
use of chemicals, but there were many surgeons, himself 
among the number, who still used chemicals. Whatever 
means surgeons adopted the aim was the same—namely, to 
banish bacteria from the field of operation, from everything 
brought in contact with the wound, and from the wound itself. 
Nothing short of that would ever content him. As far as 
possible heat was used by everyone to kill bacteria and when 
heat could be properly applied its effects were asepsis. A long 
series of tests performed regularly for 15 years led to the 
conclusion that bacteria seldom reached wounds from any¬ 
thing to which heat could be properly applied. Wound in¬ 
fection came from the hands and person of the surgeon and 
his assistants, from the skin of the patient, and from the 
atmosphere. Mr. Lockwood said he used what was 
commonly known as spirit and biniodide of mercury lotion 
which was more correctly described as a solution of 
mercuric iodide in iodide of potassium. Alcohol was 
a powerful germicide and had the additional advantage of 
penetrating and removing the cutaneous grease. His method 
was to cleanse the hands in the usual way, soak them for 
not less than two minutes in spirit and biniodide lotion, and 
transfer them repeatedly from that lotion into a watery 
solution of biniodide of mercury 1 in 2000. The effect was 
to cause the biniodide to enter into a close alliance with the 
skin but not into chemical combination with it. It could 
be demonstrated that the skin contained an appreciable 
quantity of mercuric iodide after this method had been 
used. The plan, however, required care, accuracy, and 





290 Thh Lancet,] LEEDS AND WEST RIDING MEDICO-CHIRURGICAL SOCIETY. 


[Feb. 1, 1908. 


technical knowledge, therefore inexperienced assistants 
should wear gloves. The skin of the patient was 
cleansed by treating it alternately with the spirit and 
blniodide lotion and the watery eolation of biniodide of 
mercnry for not less than three minntes, acting on the 
assumption that asepsis depended upon saturating the skin 
itself. Infection from the atmosphere might be better 
described as environment infection, for throat bacteria were 
coughed long distances and boots introduced into the 
operating-theatre much filth crowded with equine Intestinal 
bacteria. Coughing audiences might be screened off 
and the air of the theatre might be improved by 
ventilation, but it was a costly process. In con¬ 
clusion, Mr. Lockwood said that judging from the clinical 
results of his own operations he could not allow that ill 
results followed the use of dilute chemical antiseptic solu¬ 
tions.—Mr. T. H. Kkllook said that they had heard a great 
deal about surgeons giving up the old methods of antiseptics, 
bat he trusted in the use of mild antiseptics which up to the 
present time had not failed him.—Mr. Lockwood then 
replied. 

Dr. Samuel West read a paper on Nervous Phenomena in 
Pneumonia. He said that few cases of pneumonia ran their 
course without nervous phenomena of some kind. They 
generally occurred during the acute Btage, were transient, 
and of toxic origin. Rigor was due to the sudden upset of 
physiological equilibrium owing to the acute onset of the 
disease and was single and severe. If the onset were less 
abrupt shivering might be repeated. In children, when 
replaced by fits and followed by unconsciousness it might 
suggest meningitis. Insomnia might be extreme and was likely 
to be followed by prostration, and opiates might be necessary. 
Hiccough was a rare but grave symptom. Delirium if active, 
as In delirium tremens, might end in great exhaustion and 
death. It was most marked in children and in drinkers and 
in apex pneumonia. If long continued it was of bad prognosis. 
Wandering at night might set in after the crisis and was then 
an indication for stimulants. The knee-jerk, normal for the 
first day or two, disappeared on the third or fourth day, 
remained absent till the ninth, and returned to the normal at 
the end of the second week. It stood in no relation to the 
crisis and disappeared early in bad cases and late in mild ones. 
Hughlings Jackson first described the absence of knee jerk in 
pneumonia in 1894. Subsultus tendinum and muscular tremors 
occurred only in grave asthenic cases. Acute tympanites 
was a neuromuscular paralysis and of fatal omen. General 
cutaneous hyperesthesia was rare but not so rare locally. 
Spinal irritation sometimes appeared as tremors or spasms 
produced by movement. Stillness of the back and neok, 
retraction of the head, and arching of the back might suggest 
cerebro-spinal meningitis. The symptoms were only present 
in the early hours of the attack and disappeared on the second 
day or so. Transient paralyses of the limbs and face, 
aphasia, and eye disturbances might occur but were very 
rare. Meningitis which might start during the acute 
stage might last after it. It was often found post mortem 
when not suspected during life. Epidemic cerebro-spinal 
meningitis was frequently complicated with pneumonia 
and the spinal symptoms of pneumonia might simulate 
it, but the two diseases were distinct. Hemiplegia, except 
in the transient cases referred to, was due to throm¬ 
bosis or embolism. Infective endocarditis might develop 
as in other specific fevers. Mental defects, mania, melan¬ 
cholia, &c., might follow pneumonia. As a rule they were 
recovered from in time. Peripheral neuritis might follow 
as in cases of diphtheria but, like them, ended in 
recovery. Nervous phenomena played a more important 
part in pneumonia than was usually assigned to them.— 
The Presi dent said that they had yet to learn the clinical 
aspects of the different forms of pneumonia. He agreed 
with Dr. West in regard to the importance of obtaining sleep 
in the circumstances indicated but pointed out the necessity 
of avoiding narcotics as far as possible. He related a case 
in which hiccough was relieved by a hypodermic injection of 
morphine. Concerning the use of alcohol in pneumonia he 
said that the longer experience he had the less be ordered 
stimulants.—Dr. F. de Havilland Hall remarked on the 
fact that head symptoms were particularly pronounced in 
cases of apical pneumonia.—Dr. E. Cautley said that it 
was uncommon to find true pneumonia in children com¬ 
mencing with fits. In his opinion, by far the most usual 
symptom was vomiting in place of the rigor seen in adults. 
Nervous phenomena were rare and before accepting them 
as due to simple pneumococcal pneumonia it must be 


made clear that they were not due to influenzal pneu¬ 
monia. He did not advise the administration of alcohol in 
pneumonia except to aged patients at the time of the crisis. 
—Dr. F. J. Poynton said that he had noticed occasionally 
after pneumonia that there was an extraordinary slowing of 
the pulse which might drop to 40 or 50 beats per minute and 
that condition might last for a few days. He described two 
cases of pneumonia in which permanent hemiplegia had 
resulted.—Dr. West, in reply, said that alcohol was un¬ 
necessary in the treatment of pneumonia but in cases of 
dangerous collapse its timely administration was useful. 
The occurrence of hemiplegia after pneumonia was due, he 
thought, to an infective arteritis which was not limited to the 
brain. He knew of a case in which such infective arteritis 
had caused the loss of two fingers. 


SOCIETY OF TROPICAL MEDICINE AND 
HYGIENE. 


The Unequal Distribution of Filariasis in the Tropics. 

A MEETING of this society was held on Jan. 17th, Sir 
Patrick Manson, the President, being in the chair. 

Dr. G. C. Low read a paper on the Unequal Distribution 
of Filariasis in the Tropics, which is printed on p. 279 of 
this issue of The Lancet. 

Dr. L. W. Sambon suggested that unequal distribution of 
filariasis was due to hyperparasitism. 

Dr. R. T. Lkipkr said that from observations which he had 
made on a recent expedition he was able to confirm Dr. Low’s 
work in regard to the presence of filaria perstans in the blood 
of natives round Entebbe. When the adult form came to be 
examined it might be found that there were two or three 
species in filaria Demarquayi. 

Dr. F. M. Sandwith described his experiences in regard 
to filariasis in Egypt. 

The President said that the paper showed how the more 
that was learned about filariasis the wider the field for in¬ 
vestigation became. He did not consider that the propaga¬ 
tion of the filaria was restricted by hyperparasitism. Until 
they studied the mature worm it was impossible to settle 
from the embryo the whole truth of the matter. 

Dr. Low, in reply, admitted the difliculty of identifying the 
species from the embryo and urged that there must be some¬ 
thing more in the question that they did not understand to 
explain the distribution of filariasis. 


LEEDS AND WEST RIDING MEDICO- 
CHIRURGICAL SOCIETY. 


The Chemistry , Pharmacology, and Therapeutics of Ergot, 
Strop hanth us, Squill, and Digitalis.—Medical Student 
Life at Montpellier in the Middle Ages.—Exhibition of 
Cases and Specimens. 

A meeting of this society was held on Jan. 17th, Dr. 
J. Allan being in the chair. 

Dr. J. Gordon Sharp read a paper on the Chemistry, 
Pharmacology, and Therapeutics of Ergot, Strophanthus, 
Squill, and Digitalis, with special reference to recent 
research. Speaking first of ergot, he said that it was one of 
those drugs which was both praised and abused, but the best 
proof of its usefulness was to be found in the fact that it had 
found a place in all pharmacopoeias. Although much work 
had been done on its chemistry not any advance had been 
made since Tanret described pure inert crystalline ergotonine 
till 1906 when Barger and Carr confirmed Tanret's work on 
ergotonine, and in addition they obtained Tanret's amorphous 
toxic ergotonine in a pure state and had succeeded in 
forming crystalline salts of the same. On account of its 
toxic action, which had been investigated by Dale, a 
Cambridge graduate working in the Wellcome Research 
laboratories, it was renamed ergotoxine. This toxic 
ergotoxine could be readily converted into the inert ergo¬ 
tonine, and conversely inert ergotonine could be converted 
into poisonous ergotoxine. Ergotoxine was a hydrated 
ergotonine, and Kraft, a German investigator, who, 
independently of Barger and Carr, isolated the pure toxic 
alkaloid, called it hydro-ergotonine instead of ergotoxine. 
Ergotonine in the pure state was inert, but it was just possible 
that in certain states of the tissues a small portion of it 
might be converted into potent ergotoxine. However, it was 




The Lancet,] 


ROYAL ACADEMY OF MEDICINE IN IRELAND. 


[Feb. 1, 1908. 291 


not a point of great practical import. Dr. Sharp said he 
believed that ergotoxine was the one active alkaloid con¬ 
tained in ergot, although Dale believed that it had not the 
action on the heart that was attributed to crude ergot nor did 
it produce convulsions as did ergot. It produced all the other 
actions at least of ergot, including gangrene. The adult 
dose was , J 0 th or 5 ' 0 th grain (0 • 0006 or 0 • 0012 gramme) for 
a single injection, or ,',th to ,lth grain (5 to 10 milligrammes) 
in the 24 hours, In small doses there is a rise of blood pres¬ 
sure, while after very large doses there is a fall with dilatation 
of the peripheral vessels just as with the rise in pressure there 
is constriction of the same vessels. This paralysis affects the 
junctions of the motor fibres of the sympathetic with the 
muscles—the so-called myoneural junctions. In fact, with 
large doses ergot and ergotoxine paralysed the very parts 
which adrenal stimulates. This fact had been seized upon 
and it had been practically employed by Dale in the 
standardisation of ergot preparations. The action of ergot 
and ergotoxine being on non-striped involuntary or plain 
muscle its effect could be well observed on the uterus. The 
action was both direct on the muscle and indirect through the 
sympathetic. In small doses it stimulated and contracted ; 
in large doses it paralysed and inhibited or relaxed. This 
paralytic action was alone through the sympathetic. The 
muscle fibres suffered no paralysis, neither did the cerebro¬ 
spinal nerves supplying the uterus. It was now known that 
both effects depended on one alkaloid—namely, ergotoxine, 
and it was only a question of dosage. It was important from 
a practical standpoint to remember that after paralysis 
through the sympathetic the uterus still readily responded to 
mechanical or electrical stimulation. Dr. Sharp said that 
the alkaloid was the best preparation to employ when it was 
necessary to raise the blood pressure rapidly. In all other 
cases the liquid extract was preferable. He said that he had 
found it to be quite active at the end of 12 months. The 
dose generally given was too large. The limit of single 
doses to cause uterine contraction in connexion with labour 
was half a fluid drachm. The benefits of ergot were indirect 
rather than direct, for when the drug was given to expel 
foreign bodies from the uterus the tonic contractions which 
it set up might by expelling these put the uterus in the best 
condition in which nature could repair the damage done. In 
Addison's disease, in neurasthenia, in chilblains, in nervous 
disease, or wherever the vascular tone was wanting, ergot in 
small doses might do good indirectly by improving the 
tone. In regard to strophanthus, squill, and digitalis Dr. 
Sharp said that his own experience confirmed that of Dixon 
and Haynes that many preparations of strophanthus were 
below the standard but he disagreed with them as to the 
relative toxicity of the three drugs. Strophanthus when 
given under the Bkin was much more toxic than when 
administered by the mouth, but squill and digitalis were not 
so suitable for hypodermic injection, hence they could not 
draw parallel conclusions. Strophanthus was not an indirect 
diuretic like digitalis. Its diuretic action was direct but 
uncertain. It might relieve dyspnoea of cardiac origin. 
Squill was a good adjunct to digitalis but it was not of 
itself a heart remedy of great value. Digitalis he regarded 
as the only real heart tonic. He had shown that the tincture 
remained active for at least 13 months. When the pressure 
was very low, as in cases of extensive dropsy, it acted more 
rapidly than was generally believed. In one case he had 
known it to act in nine hours and in other cases from 12 to 
16 hours, setting up active diuresis. 

Dr. O. C. Gruner read a paper on Medical Student Life at 
Montpellier in the Middle Ages. The paper was illustrated 
by a number of lantern slides prepared from old drawings. 
The aspect of the city was first di scribed with some 
minuteness and emphasis was laid on the clerical character 
of the university. Illustrations of the teaching of students, 
including one of a necropsy and some of out-patient 
diseases, were shown and a short account of this class 
of teaching was given. The clinical teaching of this 
University was that which made it famous. After reviewing 
Borne of the social conditions and illustrating the domestic 
side of medical student life an account was given of the 
ceremony of conferring of degrees. Quotations from an actual 
speech were given to illustrate the religious character of the 
degree ceremony in those days. 

Mr. R. Lawfobh Knaggs read a paper on Angulation of 
the Sigmoid Flexure. 

Mr. H. de C. Woodcock showed three cases with 
Calmette’s Ophthalmo-reaction. He said that in 100 cases 
he bad found that a positive reaction is not necessarily found 


in severe tuberculous infection. Also the reaction was 
present in some people not considered tuberculous, in people 
in full work and without illness. He had tried the inocula¬ 
tion of a blistered surface ; it had answered very well and he 
was satisfied with it. He had not heard of its use anywhere 
but at Armley Hospital. He Ehowed a chart demonstrating 
the great value of cryogenin in the high temperature of 
pulmonary tuberculosis. 

Mr. J. F. Dobson showed a short and thickened Appendix, 
showing a Diverticulum at its Base, removed from a man 
who had had two attacks of appendicitis. A tag of 
omentum was adherent to the diverticulum. 

Dr. T. Churton and Mr. H. Littdewood showed a case 
of Stenosis of the (Esophagus in a child, with skiagram by 
Dr. L. A. Rowden. 

Dr. A. D. Sharp showed a patient with a Simple Neoplasm 
in the region of the left vocal process, right lateral 
pharyngitis, and marked hypertrophy of the lingual tonsil. 

Dr. A. L. Whitehead showed an Eyeball excised for 
growth from a case in which Calmette’s tuberculin serum 
test gave a positive result and the opsonic index was sub¬ 
normal. 

Dr. T. Wardrop Griffith showed a Heart from a patient 
who had been under his observation for 12 weekB prior to his 
death. At the necropsy very extensive vegetative endocarditis 
had been found affecting the aortic segments, leading to 
obstruction at the orifice, to insufficiency of the valve, and to 
aneurysm of the sinus of Valsalva. 

Dr. Adlan showed : (1) A Heart much hypertrophied 
and dilated showing a bulging of the wall of the left ventricle 
due to a growth in the wall, probably gummatous ; and (2) 
the Right Lung of an infant, aged eight months, showing 
several cavities in the apex. 

Mr. H. Wades showed an Anencephalic Monster. 

Dr. E. F. Trevelyan showed a case of probable quiescence 
of an Intracranial Tumour occurring in a lad, aged 18 years. 
Six months previously he had suffered from severe headache, 
vomiting, and ocular paralysis. The general symptoms had 
entirely subsided but the eye symptoms still persisted. 


ROYAL ACADEMY OF MEDICINE IN 
IRELAND. 


Section of Surgery. 

Grafting of the Fibula to the Tibia.—Poit-anasthetio 
Vomiting.—Exophthalmic Goitre. 

A meeting of this section was held on Jan. 17th, Mr. 
Seton S. Pringle being in the chair. 

Mr. R. Atkinson Stoney read notes of a case in which 
he had Grafted the Fibula to the Tibia. The patient, a 
boy, aged seven years, was admitted to the Royal City of 
Dublin Hospital on Nov. 26th, 1905, suffering from acute 
osteomyelitis of the tibia ; he had been ill for ten days and 
a huge abscess had formed involving the whole of the leg 
from the knee to the ankle. The abscess was opened 
immediately and the diaphysis of the tibia was found to 
be completely stripped of its periosteum. The necrosed 
tibia was removed by two operations, in January and in 
April. By April, 1906, the sinuses had closed and an 
involucrum had formed in the lower and upper parts of the 
leg, but there was a gap of about one and a half inches 
between the two ends, due to destruction of the periosteum, 
as the result of the virulence of the original infection. An 
operation was performed in which the neck of the fibula was 
cut across and the upper end of the lower fragment was 
implanted into the upper end of the involucrum of the tibia. 
Firm union bad now occurred and the boy was able to run 
about without the aid of a stick, though there was con¬ 
siderable shortening as the result of over a year’s loss of 
growth while the illness lasted and the ends of the tibia 
were not in contact. The operation was a modification of 
one described by Hahn in 1885, and was suggested by a case 
reported by Professor E. E. Goldmann of Freiburg in The 
Lancf.t of Jan. 13th, 1906, p. 82. There w as no tendency of 
the ankle to turn outwards.— Mr. Pringle said that the case 
was, so far as he knew, the first of the kind reported in 
Ireland, or at any rate shown at the Academy. He believed 
it was the only line of treatment w. i;h was likely in such a 
case to leave a useful limb. .... „ 

Dr. Gunn read a paper on Post-anesthetic Vomiting. He 





292 Thb Lancet,] NORTH OF ENGLAND OBSTETRICAL AND GYNAECOLOGICAL SOCIETY. [Feb. 1, 1908. 


said that as the anaesthetists had not the after treatment ot 
operative cases they only to a slight extent realised what a 
troublesome complaint post operative vomiting might be. He 
had been nsing a method, suggested by MacArthar, of giving 
the patient frequent drinks of pure cold water right up to the 
administration of the anajsthetic, and this method had been 
entirely successful in nine cases, partially successful in 19 
cases, and bad had no result in 12 cases, out of the 40 patients 
who had been treated in this way.—Mr. Pringle said that 
he had noticed when administering anesthetics that the less 
the patient was cyanosed during the administration the 
less vomiting there was afterwards, so that it was important 
to let the patient breathe a certain amount of fresh air.— 
Dr. T. P. C. Kirkpatrick said that with regard to the pre¬ 
paration of a patient he did not look on abstinence from 
food as of such importance as thorough purgation some time 
before the ansesthetio was administered. The patients who 
usually gave most trouble with post operative vomiting were 
those who suffered from more or less chronic constipation. 
Occasionally after chloroform anrestbesia vomiting became 
so serious as to threaten the patient’s life; but this 
was exceedingly rare after ether.—Dr. W. I. db Courcy 
Wheeler said that he had tried the open method 
of administering ether and had found it very simple 
and the anaesthesia perfect. The patients never became 
cyanosed, but he had not had enough experience of the 
method to say whether the vomiting was less frequent. It 
was particularly suitable for old or fragile persons. Alco¬ 
holic patients who were difficult to aniesthetise with ether 
vomited less than others ; if the anesthesia was begun with 
chloroform and continued with ether the vomiting was far 
worse.—Sir Thomas Myles said that he himself had been 
under every anaesthetic known. He had always insisted on 
having a cup of tea before the operation, and he was well 
purged out He had never vomited or had a fit of sickness. 
He was inclined to think that the sickness was due to some¬ 
thing inherent in the patient.—Mr. Taylor said that it had 
been his habit to give morphine either immediately before the 
anesthetic or before the patient left the table ; less anaesthetic 
was then required and there was less vomiting. 

Sir Thomas Myles read a short paper on a case of 
Exophthalmic Goitre which he believed to have been cured 
by a diet of milk obtained from thyroidectomised goats. 
The patient was a married woman, 25 years old, and the 
symptoms had been developing for more than a year. All 
the well-marked features of the disease were present and 
there had been a progressive loss of strength and colour. 
The goats were operated on by Professor Mettam of the 
Veterinary College and when, two days later, the little 
wound in the neck had heated the goats were sent to the 
patient who resided in the country. At the end of a month 
the improvement was very marked and at the present 
moment the enlargement of the thyroid was barely per¬ 
ceptible and the exophthalmos had disappeared. For the 
last few months the milk diet had been supplemented by the 
use of Morck’s tablets and by the administration of small 
doses of iron and arsenic.—Mr. Taylor said that the method 
had been tried on the continent some years ago and a powder 
made from the milk of thyroidectomised goats could be 
bought, but the professors on the continent had not spoken 
much in its favour. 


North of England Obstetrical and Gynaeco¬ 
logical SOCIETY. —The annual meeting of this society was 
held at Manchester on Jan. 17th.—Dr. A J. Wallace 
(Liverpool) was elected President for 1908, and the 
other office-bearers were duly elected.—Dr. E. 0. Croft 
(Leeds), the retiring President, gave a short valedictory 
address in which he discussed “ The Woman of the Future 
from a Gynaecologist’s Point of View,” in the course of which 
he suggested picturing in mind a typical healthy woman in 
the more or less distant future, and estimating the probability 
of her enjoying an immunity from many of the physical and 
mental disaffections as known to the gynaecologist of the 
present day. The gynaecologist of that day would require the 
command of a much higher knowledge of prophylaxis and of 
the conditions of normal health, and such knowledge would 
have to become an integral part of his mental equipment. 
The indications of such a development were referred to and 
exemplified. Rapid advances were liable to be associated 
with exuberances of rapid growth and feeble vitality. 
These exuberances were temporary hindrances and were 
more liable to form in the process of mental than physical 
development. They chiefly appeared in the form of 


eccentricities of various kinds. The various classes of 
gynecological disease were reviewed in the light of 
their ultimate avoidance. The large class of inflammatory 
affections which were mainly associated with microbial 
infection of varying degrees were to be looked upon as 
avoidable, as also were many of the diseases of pregnancy 
and abnormalities of labour. The eradication of the 
venereal infectious diseases was not being dealt with at 
all at the present day. It was to be hoped that a more 
common-sense view would be taken of the matter in a more 
enlightened future. The prevention of puerperal infection 
seemed to be a difficult lesson in spite of its simplicity. It 
was suggested that the ultimate solution of the question 
would be in the hands of the suffering women-kind. When 
they themselves fully realised the position they would 
demand the remedy, and the demand would be more quickly 
met. With regard to the possibility of dealing with the 
apparently hopeless conditions of mal-development, the sug¬ 
gestions of Dr. J. W. Ballantyne and the subject of eugenesis 
were referred to. There was no clue to the prophylaxis of the 
new growths of the female organs, such as cystic disease, 
fibroids, and cancer. Referring to fibroids, the brilliant 
results of a curative kind obtained by operation during 
recent years, while of enormous immediate value, had 
practically paralysed all research into the etiology and 
nature of these growths. More work was being done regard¬ 
ing cancer, but the high degree of technical skill required of 
the operator and the pathologist had rather tended to create 
a chasm between the two which was difficult to bridge. Both 
were liable to be lacking in the opportunity for the observa¬ 
tion of the living habits and phenomena of the disease as it 
progressed in the patient. 

Harveian Society.— A meeting of this society 

was held on Jan. 23rd, Dr. G. A. Sutherland being in the 
chair.—The evening was devoted to the showing of clinical 
cases and pathological specimens. Dr. Sidney P. Phillips 
showed: 1. A case of Splenic Ansemia in a Child. The 
liver, spleen, and lymphatic glands were enlarged and 
the blood showed the usual signs of anaemia but no leuco- 
cytosis—The case was discussed by Dr. Sutherland.—2. A 
case of Landry’s Paralysis in which recovery had taken place. 
—Mr. W. H. Clayton-Greene showed: 1. A case in which 
Rupture of the Liver had occurred from abdominal injury. An 
operation was performed within seven hours of the accident 
and recovery followed. 2. A specimen of Cirsoid Aneurysm 
of the Arm and Forearm. The arm had been amputated 
owing to the extensive involvement of the vessels. This was 
discussed by Mr. V. W. Low.—Dr. YVillcox showed : 1. A case 
of Greatly Enlarged Lymphatic Glands on Both Sides of the 
Neck which he regarded as due to lymphadenoma, with 
tuberculous infection superadded, the latter having been 
proved by investigations of the opsonio index. The case was 
discussed by Dr. Sutherland. 2. A case of Enlarged Liver 
and Spleen with Leucodermia. This was regarded as 
cirrhosis of the liver.—Dr. F. Langmead discussed the case. 
—Dr. Langmead showed a case of Third Nerve Paralysis, 
which was discussed by Dr. Sutherland.—Dr. D. W. Carmalt- 
.Tones showed a case of Arteriosclerosis with a Vascular 
Lesion giving rise to a crossed sensory lesion.—Mr. Low 
showed a case of Charcot’s Disease of the Knee-joint with 
spontaneous fracture of the tibia on the same side. There 
were well-marked signs of tabes dorsalis.—Mr. T. Crisp 
English showed : (1) A case of Charcot’s Disease of 
the Ankle Joint, which was discussed by Mr. Kelly; 
and (2) a specimen of Large Fibroma of the Breast.— 
Mr. Lawrence Jones described (1) a case of Musculo Spiral 
Paralysis ; and (2) a specimen of Ureteric Calculus.—Mr. 
S. Maynard Smith showed a case of Injury to the Brachial 
Plexus followed by a root paralysis which recovered after 
operation.—The case was discussed by Dr. Willcox.—Mr. B. 
Morris showed a skiagram of a Supernumerary Thumb.— 
Dr. C. Singer described the drawings, microscopical and 
pathological specimens, of a case of Exophthalmic Goitre 
which had recently been under his care. 

Nottingham Medico-Chirtjrgical Society.— 

A meeting of this society was held on Jan. 22nd, Dr. W, 
Hunter being in the chair.—Dr. C. H. Cattle and Dr. J. R. 
Edward showed a man, aged 35 years, who had made a good 
recovery after operation and drainage of an Abscess of the 
LuDg in the Left Infra scapular Region. The exact mode of 
origin of the condition was uncertain but it was most 
probably a sequela of pleuro pneumonia. Although he at 
one time expectorated from 12 to 18 ounces of pus per diem 




Thx Lancet,] 


REVIEWS AND NOTICES OF BOOKS. 


[Feb. 1, 1908. 293 


the greatest difficulty occurred in localising the abscess, 
which was then treated like an empyema.—Mr. R. Wood 
showed a female patient the subject of Myocarditis and 
Dropsy. Much improvement had followed the local applica¬ 
tion of tincture of strophanthus and belladonna over the 
heart.—Mr. H. Bell Tawse read a paper on Some Complica¬ 
tions and Dangers of Nasal Surgery. He pointed out the 
mishaps which might occur in dealing with the middle turbi¬ 
nate and emphasised the importance of having free access to 
it by preliminary removal of deviations and spurs, advocating 
Killian's submucous resection as the best all-round method 
of dealing with them. Ethmoidal curetting for nasal 
polypi and ethmoidal suppuration was exhaustively dis¬ 
cussed and cases were cited to illustrate such complications 
as necrosis of the frontal and superior maxillary bones, 
injury to the cribriform plate, and suppurative meningitis. 
He looked on the operation as unjustifiable in anyone over 
60 years of age. He considered that in many cases of frontal 
sinus suppuration the dangers of radical operation out¬ 
weighed the advantages, but hoped some means of prevent¬ 
ing disasters like osteo-myelitis of the skull and meningitis 
would soon be found. Operations on the maxillary antrum 
were shown to be very free from complications and such 
post operative sequela; as dry rhinitis, ozfena, infection of 
healthy sinuses, middle-ear trouble, and the nervous break¬ 
down which occasionally occurred during a tedious after- 
treatment were briefly reviewed.—The paper was discussed 
by Mr. W. M. Willis, Mr. J. Mackie, Mr. A. R. Tweedie, 
Dr. Hunter, and others, and Mr. Tawse replied. 

Aberdeen Medico-Chirurgical Society.—A 

clinical meeting of this society was held on Jan. 9th, 
Dr. George Williamson, the President, being in the-chair.— 
Dr J. F. Christie showed cases of Lupus Erythematosus, 
Erythema of the Face, Luetic Skin Lesions of the Face, and 
Pemphigus Vulgaris.—Dr. A. W. Mackintosh, for Dr. G. M. 
Edmond, showed a case of Cerebral Tumour with a history of 
four and a half years. He also showed cases of Hodgkin’B 
Disease and of Peripheral Neuritis.—Dr. A. R. Galloway 
showed three cases illustrating Cataract, a case of Moderate 
Myopia with fundus changes, and a case of Optic 
Atrophy. He also showed a well-marked case of Persistent 
Pupillary Membranes.—Dr. C H. Usher exhibited drawings 
of a somewhat similar case—Dr. P. Howie showed a case of 
Telangiectasis of the right axilla and upper arm. This 
patient had recently suffered from a suppurating gland in 
the right axilla which opened through the centre of the 
tumour without the occurrence of haemorrhage.—Dr. G. Rose 
Bhowed several cases of Congenital Dislocation of the Hip 
and of Club Foot. He also showed a case of Infantile 
Paralysis involving the quadriceps extensor cruris.—Dr. 
F. Kelly, for Mr. H. M W. Gray, showed cases of Resection 
of the Elbow for tuberculous disease and injury, and two 
cases of extensive burns treated by preliminary scrubbing 
under an anaesthetic with subsequent dusting with equal 
parts of carbonate of bismuth and boric acid. 


$ebietos anb ftoIkes of ^ooks. 

Surgery, its Principles and Pructice. By Various Authors. 
Edited by William Williams Keen, M.D., LL.D , 
Professor of the Principles of Surgery and of Clinical 
Surgery. Jefferson Medical College, Philadelphia. Vol. II. 
With 572 text illustrations and nine coloured plates. 
London and Philadelphia: W. B. Saunders Company. 
1907. Pp. 920. Price 30s. net. 

We welcome the appearance of the second volume of 
this valuable system of surgery. The subjects dealt with in 
it include the bones, joints, muscles, and tendons; ortho¬ 
paedic surgery ; and the surgery of the lymphatic system, the 
skin, and the nervous system. Dr. E. H. Nichols of Boston 
has contributed the chapter on Diseases of the Bones and he 
commences with a useful account of the structure of bone, 
for it is on the peculiarities of its structure that the special 
characteristics of the pathology of diseases of bone depend. 
We agree fully with the author that the correct interpreta¬ 
tion of x ray photographs of bones is exceedingly difficult 
and this applies both to traumatic conditions and to those 


lesions resulting from disease. The author puts it well : “ In 
cases in which the clinical diagnosis is difficult, the x ray 
examination is simply one of several means which must be 
employed, each of which must be given its relative value as a 
method of diagnosis. In some cases not only is diagnosis by the 
x ray difficult, but the x ray examination may be absolutely 
misleading. In other words, the x ray is an enormouB 
advantage in the diagnosis of lesions of boDes, but its value 
has been greatly over-estimated, and the possibility of its 
giving an entirely erroneous impression must not be over¬ 
looked, especially in medico-legal cases.” This extract 
expresses very clearly the value and the dangers of the x rays 
as a diagnostic aid. The account of the diseases of bone is 
good but rather too brief. 

Dr. D. N. Eisendrath of Chicago has written on Fractures. 
This is the most important article in the book and occupies 
more than 200 pages ; it is clearly written and leaves lit tle to be 
desired. The Surgery of the Joints has been divided between 
Dr. Nichols, who has written on the pathology, and Dr. 
R. W. Lovett, who has taken the rest of the subject—i.e., the 
clinical part. There is little need for comment but in the 
account of the signs of early tuberculosis of the hip-joint it 
should have been mentioned that one cause of the loss of the 
gluteal fold is the flexion of the joint which is always 
present. Even in a healthy hip a very little flexion of the 
hip-joint entirely obliterates the fold. Later, of course, 
the atrophy of the muscles makes more marked the flatten¬ 
ing of the hip. 

Dr. Eisendrath's article on Dislocations is almost as good 
as bis article on fractures and the illustrations are excellent. 
The only criticism which we have to make is that there is no 
good reason why passive movement of a joint after reduction 
of a dislocation should be delayed for a fortnight. The sooner 
passive movement is commenced the better, for delay can only 
favour the formation of adhesions. After the fortnight's rest 
we are told that 15 minutes' passive movement twice a day 
is required. No such energetic treatment is needed if 
gentle passive movement has been started early, and though 
at first the movement is not free from pain the to al amount 
of pain felt is much less than when passive movement is 
delayed for a fortnight. 

Dr. J. F. Binnie's short article on the Surgery of Muscles, 
Tendons, and Burs® contains all that is required We are 
glad to see that he rejects entirely the “ hernial ” theory of 
a “ganglion.” It is a collagenous degeneration in connexion 
withatendon-sheatb, occurring probably in a synovial fringe. 
Dr. Lovett has undertaken the section on Orlhopardie 
Surgery. It is often difficult to say with exactness what 
should, and what should not, be included under this head. 
Here we find caries and other deformities of the spine, 
irfantile paralysis, congenital dislocations, club-foot, and 
rachitic deformities. A very good account is given of 
Lorenz’s method of treating congenital disease of the hip. 
Dr. F. H. Gerrish has contributed the chapter on the Surgery 
of the Lymphatic System. The most important poition of 
this section is that which deals with elephantiasis ; it is well 
illustrated. 

The fact that the chapter on the Surgery of the Skin and 
its Appendages is by Dr. John A. Fordyce is sufficient to 
guarantee that it is well written. In the account of rodent 
ulcer the value of radium certainly deserves mentioD, as in 
the hands of many the radium treatment has displaced most 
other forms of treatment for this condition. The value 
of ionic medication of many cutaneous abnormalities 
should at least have been referred to. The remainder 
of the volume is devoted to the Surgery of the Nervous 
System, Dr. W. G. Spiller writing on the pathology 
of the subject, Dr. George Woolsey on the surgery of 
the nerves. Dr. F. X, Dercum on traumatic neurasthenia, 
hysteria, and insanity following injuries. Dr Da Costa on 
e2 



294 The Lancet,] 


REVIEWS AND NOTICES OF BOOKS. 


[Feb. 1,1906. 


the surgery of insanity, and Dr. Woolsey on the surgery of 
the spine ; the subjects are treated very satisfactorily. 

Where all are so good it is a little invidious perhaps to 
single out any individual article for special praise but we 
may perhaps mention that we think Dr. Eisendrath’s paper 
on fractures is especially good. 


Bamdbvch der Oyndkologic. By Various Authors. Edited 
by J. Veit. Second revised edition. With numerous 
illustrations. Vol. I, pp. 836. Wiesbaden: J. F. 
Bergmann. 1907. Price M. 16 60, or 16s. 9<i. 

Since the first edition of this work appeared four of the 
contributors have unfortunately died—namely, Gebhard, 
Gessner, Ldhlein, and Viertel—and for this edition their 
places have been taken by Fritsch, Frommel, Nagel, and 
Winternitz. This volume deals with the prevention of 
infection in gynaecology, displacements of the uterus, and 
fibromyomata of that organ. The first section, on the pre¬ 
vention of infection, is written by K. Franz of Jena. For 
the disinfection of the hands he recommends a modification 
of Filrbringer's method and the use of rubber gloves. The 
risk of infection from the skin of the patient during the 
operation is prevented by covering the patient entirely with 
a sterile covering to an opening in which the edges of the 
incision in the skin are fastened by clip forceps. Catgut 
sterilised by cumol is recommended as an ideal suture 
material whenever it can be used. 

The article on the normal and abnormal positions of the 
uterus is contributed by Otto Kiistner of Breslau. It contains 
a very complete account of the symptoms and treatment of 
all the displacements of the uterus, especially the operative 
treatment of prolapse of that organ. The coloured drawings 
depicting the various stages of different operations are 
exceedingly good, as are also the numerous drawings 
of sections of the pelvis in the different stages of pro¬ 
lapse of the uterus. R. Meyer of Berlin discusses the 
anatomy and origin of myomata and fibromata of the uterus. 
The author apparently favours Ribbert’s theory of the origin 
of fibromyomata from young muscle cells embryonic in 
character in so far as they are young, and he states that all 
grades of development can be traced between such young 
muscle cells and the cells composing small growing fibroid 
tumours. The important question as to the mode of origin 
of adenomyomata of the uterus is very fully considered. 
The etiology, symptoms, diagnosis, and prognosis of these 
tumours are considered by the editor who also describes 
the palliative treatment and the operative treatment of 
such growths when undertaken by the vagina. The elec¬ 
trical treatment is described shortly by R. Schaeffer of 
Berlin. 

The last two sections, the most valuable in the work, 
are contributed by R. Olshausen of Berlin and deal with 
the various abdominal operations which may be performed 
for uterine fibromata and the diagnosis and treatment of 
pregnancy when complicated by the presence of such 
growths. The relative value of the different modes of 
carrying out the abdominal operations is discussed in detail, 
and the conclusion is come to that abdominal supravaginal 
amputation is as a rule preferable to the operation of total 
hysterectomy in these cases. To anyone who wishes to read 
a judicious and able account of the risks which a patient may 
or may not run with a pregnancy in a uterus containing 
fibroid tumours we can strongly recommend this last article 
in the volume. The author's immense experience enables him 
to point out very clearly the important problems involved in 
the treatment of these cases. 

This Becond edition well maintains the high standard 
of merit attained by the first and this volume is a very 
valuable addition to the German literature on gynae¬ 
cology. 


LIBRARY TABLE. 

A Text-boot of Clinical Anatomy for Students and Practi¬ 
tioners. By Daniel N. Eisendhath, A.B., M.D., Adjunct 
Professor of Surgery in the Medical Department of the 
University of Illinois; attending Surgeon to the Cook 
County Hospital, Chicago. Second edition. London and 
Philadelphia: W. B. Saunders Company. 1907. Pp. 535. 
Price 21*. net —This second edition of Dr. Eisendrath’s 
Clinical Anatomy is said to have been “ thoroughly 
revised ” but we regret to find that mistakes are 
still numerous. The illustrations, though beautifully 
executed, are in several instances technically incorrect; 
for example, on p. 176, the commencement of the 
inferior vena cava is represented as taking place to the left 
of, and almost on a level with, the umbilicus; next, on 
p. 185, only three synovial sheaths are allotted to the extensor 
tendons of the wrist and fingers, whereas there ought to be 
six, while one of the compartments is labelled as being 
the “common tendon-sheath of the extensors of the 
middle, ring, and little fingers.” Again, Fig. 37, p. 121, 
showing “surface markings of principal structures of neck 
and of thorax in child," is, we consider/valueless, for the 
outline of the sternum, the ribs, and the clavicle is omitted, 
the ascending aorta is placed too far to the left, and the 
innominate artery is twice as long as it ought to be. 
In the section on the Abdomen there are again 3ome 
errors. The union of the cystic and hepatic ducts 
does not take place near the lower border of the 
first part of the duodenum, as shown in Fig. 73, and the 
duodeno jejunal flexure is not usually situated below the 
lower pole of the left kidney, as appears in Fig. 69. The 
book is well bound and printed on good paper but in our 
opinion is still in need of revision. 

The Office of Midwife (in England and -Wales') under the 
Mid-mires Act, 1902. By STANLEY B. Atkinson, M.A., 
LL.M. Cantab., M.B., B.Sc. Lond., of the Inner Temple, 
Barrister-at-Law. London : Baillifcre, Tindall, and Cox. 
1907. Pp. 123. Price 3*. 6 d. net.—Dr. Atkinson has done 
a considerable service to all those interested in the working 
of the Midwives Act, 1902, in writing this little book. He 
has gathered a large amount of very useful and interesting 
information. In the first part he traces the evolution of the 
midwife from the period when women were licensed by the 
bishops or their chancellors to practise midwifery, up to the 
time of the institution of the Central Midwives Board. He 
informs us that Bishop Bonner in the year 1554 is supposed 
first to have granted these licences. The explanation given 
of this early ecclesiastical control is the necessary presence 
of the midwife at what is the first and not infrequently the 
last breath of human life. Midwives were instructed care¬ 
fully by the clergy as to the necessity, the manner, and the 
exact words of emergency infant baptism. The author gives 
a most interesting review embracing the evolution not only 
of the midwife but also that of the man-midwife, the early 
development of lying-in hospitals, and the progress of 
midwifery in the nineteenth century. It will no doubt 
be a matter of surprise to those medical men who have 
no special knowledge of the subject to learn that it was only 
as late as the year 1852 that the Royal College of Surgeons 
of England obtained a supplementary charter enabling it 
to examine 1 ‘ persons ” for a diploma, Licentiate in Mid¬ 
wifery of the Royal College of Surgeons of England, and 
it was not until the Medical Act, 1886, Seotion 2, became 
law that a triple qualification in medicine, surgery, and 
midwifery was essential before the registration could take 
place of the would-be medical practitioner. In Chapter II., 
on the Prospects and Present Position of Midwives, Dr. 
Atkinson points out how few midwives are likely to be left 
in practice in some parts of the country if the local super¬ 
vising authorities strictly put into force the powers conferred 




The Lancet,] 


REVIEWS AND NOTICES OF BOOKS. 


[Feb. l, 1908 295 


upon them by the Act—namely, that after April 1st, 1910, 
no woman may habitually and for gain attend women in 
childbirth unless she is certified under the Act. In Part II. 
the provisions of the Act are very fully considered and in 
Part III. are given the rules framed under Section 3 of the 
Act for its proper administration, and approved by the Privy 
Council. The book concludes with a very interesting literary 
appendix. Dr. Atkinson is to be congratulated upon having 
written a most useful book containing a large amount Of 
information on the subject of midwives and the Midwives 
Act not readily to be obtained elsewhere. 

Ilazell's Annual far 190S : A Oyclopadio Rtonrd of Man 
and Topics of the Day. Edited by William Palmer. 
London : Hoddor and Stoughton. 1908. Pp. 604. Price 
3s. M. net ,—Hazell's Annual has an established reputation 
amongst year-books and there is as much information as 
usual in the 600 pages of the present issue. The political 
section is carefully compiled and there are a great many 
facts of value to men engaged in a hundred kinds of com¬ 
merce. A somewhat curious effect is produced by the fact 
that this book is absolutely alphabetically arranged; thus 
we find in juxtaposition the headings Costa Rica ; County 
Councils Association ; Crane, Walter; Cremation ; Crete. 
Such medical information as the book contains is trust¬ 
worthy and Includes a brief review of the outstanding 
medical events of 1907, written with knowledge, and an 
obituary list of distinguished medical men. We venture to 
suggest that the Royal Society of Medicine might find a 
place in a list of “ Scientific Societies and Institutions ” 
which claims to give particulars of “the more important and 
active ” of these bodies, even though the list “ does not 
pretend to be exhaustive.” The Royal Society of Medicine 
is most certainly both as important and active as, let us say, 
the Palseontographical or Ethnological Societies. 

A Treatise on Surgery. By GEORGE RYERSON Fowler, 
M.D.,_Examiner in Surgery, Board of Medical Examiners of the 
RegentB of the University of the State of New York; 
Emeritus Professor of Surgery in the New York Policlinic ; 
Surgeon to the Methodist Episcopal Hospital ; Surgeon in 
Chief to the Brooklyn Hospital ; Surgeon to the German 
Hospital. Containing 888 text illustrations and four coloured 
plates, all original. London and Philadelphia: W. B. 
Saunders Company. 1906. Vol. I., pp. 722. Vol. II., 
pp. 714. Price £3 3s. net.—It requires no small degree of 
courage for a surgeon nowadays to undertake the writing of 
a treatise on surgery. Even text-books for students are now 
large, but a complete treatise on the science and art of 
surgery is indeed an enormous undertaking. The amount of 
time which these volumes must have taken must have 
been very great, for the work is fully ahead of the present 
day, and the references which the author gives show that 
he is conversant with the chief current literature. The most 
striking point about the work is the wealth of illustration 
and we meet with none of the old illustrations which have 
done duty so often before. Here they are all original 
and they have evidently been chosen with great care. A few 
points oall for criticism. It is stated concerning retro¬ 
pharyngeal abscess that “with the exception of the rather 
rare form of the latter resulting from phlegmonous inflamma¬ 
tion of the submucous tissue or suppurating lymphadenitis 
of a retropharyngeal lymphatic gland, retropharyngeal 
abscess arises almost exclusively from Pott’s disease in the 
cervical region.” This statement does not give a correct 
idea of the relative frequency of the causes of abscess 
behind the pharynx ; in this country at least the cases not 
due to caries form a large proportion of the whole. No hint 
even is given that the abscess can be drained very satis¬ 
factorily through an incision behind the sterno-mastoid. In 
the description of the operation of wiring a fractured 
patella the author says, “irrigation must not be employed.” 


Whether irrigation should be used or not depends on the 
solution employed; a strong irritating antiseptic would be 
harmful but hot normal saline solution could do no harm. 
In the description of Pirogoif's amputation the section of 
the os calcls is described as being made through the plantar 
incision, and then it is said “ or from behind forwards and 
downwards, according to Gunther's modification ”; this 
description can only apply when the os calois is sawn from 
above after the ankle-joint has been opened. But these are 
only small matters and we approve highly of the work as 
very suitable for anyone in general practice whe wishes to 
keep abreast with the present position in surgery. 

On Osseous Formations in and about Mascha due to Injury. 
By Robert Jones, F.R.C.S. Edin., and David Morgan, 
M.B.—This monograph consists of a reprint of a series of 
articles which appeared in the Archives of the Roentgen Ray 
during 1905 and 1906. Gathered together in this form we 
have a very valuable treatise on this subject, embodying as it 
does a synopsis of all the cases which have been recorded 
of this condition by observers at home and abroad. 
The present state of the pathology, diagnosis, and treat¬ 
ment of the disease is very fully related and not the least 
attractive part is the series of some two dozen radiographs 
taken from the more interesting of the cases which came 
under the observation of the authors themselves. These 
have been reproduced in a manner whioh is worthy of much 
praise. We are not aware if the monograph is obtainable 
in the ordinary way but we can commend it to the careful 
study of those who are fortunate enough to receive a copy. 

A Primer of Psychology and Mental Disease. By C. B. 
Burr, M.D. Third edition. Philadelphia : F. A. Davis 
Company. 1906. Pp. 183. Price $1.25 net.—This manual 
has already passed through two editions and in the 
preface of the present volume the author states that 
he has re-written the parts dealing with the various 
insanities to bring them into line with the more modem 
classification of mental disorders. The book seems to 
have been written primarily for “use In training schools 
for attendants and nurses,” but Dr. Burr has also 
endeavoured to adapt it for the medical student and 
practitioner. It is most difficult to embrace the requirements 
of both the lay and the professional reader, for either the 
book must be too technical for the former or too elementary 
for the latter, and this is rather the case in the present 
manual. The opening remarks of the psychological portion 
presuppose some knowledge of the subject, otherwise they 
would be almost unintelligible, for the descriptions are very 
condensed. Certain important subjects seem to be omitted—■ 
for example, we can find no special remarks about attention. 
The second part of the book is devoted to a brief description 
of insanity. The author largely follows Kraepelin's classifi¬ 
cation and some of his accounts of the various mental dis¬ 
orders are lucid. In others the subjeot-matter is so condensed 
that the student will have difficulty in grasping the import¬ 
ant points. For example, in paranoia the author does not 
point out that the characteristic mental attitude of the 
patient is that the delusions become progressively more 
systematised throughout the illness ; it may be implied in 
the description but it is not definitely stated. The chapters 
devoted to the medical and nursing management of cases are 
good and they will be found very helpful to the beginner. 
In fact, this remark applies generally to this manual, for it 
may be said fairly to fulfil itB object which is that of an 
elementary account of " mind, normal and diseased.” 

La Pratique de la Mcdecine. Par W. Oslkb, Professeur 
Royal A l'Universitd d'Oxford. Traduction Franqaiae sur 
la 6° Ciition, par leB Docteurs M. Salomon, chef de Clinique 
4 la Faculty, et Louis Lazard, ancien interne de l’HOpital 
de Rothschild. Preface du Dr. Pierre Marie. Paris: G. 
Steinheil. 1908. Pp. 1224. Prix Fr.25.—This interesting 




296 The Lancet,] 


REVIEWS AND NOTIOE8 OF BOOKS. 


[Feb. 1 , 1903 . 


publication is a worthy product of the entente cordials which 
binds together all nations in the world of science. Dr. 
Osier’s Text-book of Medicine is probably known to most 
of onr readers and as we have reviewed it through six 
editions there is no need to allude at present to the matter 
of the book but only to the manner of its presentation. We 
may say, in a word, that Dr. Osier’s work lends itself to trans¬ 
lation admirably, and has been admirably translated. Indeed, 
many French students might read it and were it not for the 
title-page think it to be a French treatise. This we sus¬ 
pect to be due to Dr. Osier’s exceptional knowledge of 
pure English and ability to say exactly what he means in 
plain and well-balanced phrases which leave his translators 
no doubt of their only possible counterpart in French. The 
result is that the translation is almost literal and the success 
of the work from a French point of view is made greater by 
the clear manner in which the author arranges his sections, 
which entirely agrees with the French method of teaching. 
Dr. Marie in a little prefatory eulogy of Dr. Osier refers to 
him as 1 ‘ r6 au Canada, et par consequent de nationality 
anglaise ” ; possibly “nationality britannique ” would be 
a more acceptable term to many of our fellow-subjects. 
English students might do well to buy their text-book in this 
French form, as it would improve both their medicine and 
their French, and we can assure them that medical works 
written in that language afford the easiest French that a 
medical man can Sod to read. 


JOURNALS AND MAGAZINES. 

The Annals of Tropical Medicine and Parasitology. 
Vol. I„ No. 3. November, 1907. London: Williams 
and Norgate. Liverpool : At the University Press. Pp. 207, 
illustrated. Price 7*. 6 d. The first paper in the present 
number is a continuation of the communication Con¬ 
cerning Certain Parasite Protozoa observed in Africa, 
by the late J. Everett Dutton, M.B. Viet., John L. 
Todd, B A , M.D. McGill, and E. N. Tobey, A.B., 
A.M., M.D. Harvard. It deals with parasitic protozoa 
found in some other mammals than those described in the 
first part of this communication, with others found in birds, 
reptiles, fishes, amphibia, and in arthropoda. Although 
these parasites are not apparently connected with any disease 
occurring in man and the descriptions are in themselves more 
or less incomplete and disconnected, the recording of the 
observations made will probably prove of considerable value 
in the future. It may well be that some of these parasites 
may be found to live in the human body. At any rate, 
facts connected with the life-history of this class of 
parasites in animals other than man will very probably 
serve as a guide in the study of human parasites. The 
matter contained in the communication, however, is of 
such a technical and specialised nature that it would 
be out of place to deal with it here at any length 
Dr. C. W. Branch of St. Vincent contributes a valuable 
and interesting paper on Yaws in the West Indies. Dr. 
Branch, who has had a wide experience of the disease, is 
definitely inclined to the view expressed by Mr. Jonathan 
Hutchinson that “ yaws ” is identical with “syphilis." He 
admits, however, of some doubt on this point. His attitude 
is more or less completely expressed in the following 
passage: “If ‘yaws’ is not ‘syphilis’ then there is still 
abundant indication that the treatment is the same and we 
should insist on the early and persevering use of mercury ; for 
the time for treatment of ‘ syphilis ’ is in the early secondary 
stage, and by inference the same must be true of ‘yaws.’ ” 
Dr. Branch criticises adversely what Sir P. Manson says 
with regard to “yaws.” Sir P. Manson stated that the primary 
sore, the affection of the foetus, the adenitis, the exanthem, 
the alopecia, the absence of itching, the iritis, the affection 
of the permanent teeth, the bone and eye affections, the 


congenital lesions, the polymorphism of the eruption, the 
nerve lesions, and the gummata of “ syphilU ” are all wanting 
in “yaws.” Dr. Branch states definitely that there is no 
doubt whatever about the occurrence of the primary sore. 
He is equally conclusive in his contradication of all the 
other points with some slight exceptions, which he attri¬ 
butes to the difference in susceptibility between black and 
white races of men. He deals exhaustively with the 
“ frambeesial ” eruption and he brings much evidence and 
many arguments to show that this is identical with the 
papillomata, condylomata, and rhagades of “syphilis.” 
Dr. Anton Breinl contributes a short note on the morpho¬ 
logy and Life-History of Spirochseta duttoni. Dr. Breinl's 
conclusion is that just before the crisis of the disease 
the spirochmtse seem to disintegrate, several of them 
coiling up into skeins, the majority of which are distri¬ 
buted in the spleen. Some of them become encysted and 
break up into several small bodies, out of which the 
new generation of spirochajta is evolved. The first part 
of a communication on the Cytology of the Trypano¬ 
somes, by Professor J. E. Salvin-Moore and Dr. Breinl, 
forms the last article in this number of the Annals. A 
preliminary account of the observations relating to the 
Trypanosoma gambiense contained in the present paper was 
published in The Lancet of May 4th, 1907, p. 1219. In the 
Annals a more exhaustive account of the morphology and 
life cycle of Trypansoma gambiense is given and Trypano¬ 
soma brucei and Trypanosoma equinum are also dealt with. 
The paper is very fully illustrated. Among other things, 
the authors suggest very Btrongly that the life cycle of 
Trypanosoma gambiense at any rate is complete in one host 
only and is in no way dependent for its completion upon the 
transference of the parasites into the blood of any other host. 
It would seem, in fact, that the transference by flies in the 
case of sleeping sickness may have no more significance with 
respect to the life cycle of the parasites than in the case of 
the transference of dourine from horse to horse by means 
of flies. The transference of sleeping sickness in fact when 
it is brought about by flies is in the nature of a direct 
inoculation of blood, and this inoculation might well be, 
and probably is, brought about by other means as well as 
by flies. 

In the British Journal of Dermatology for November, 1907, 
Dr. J. D. Rolleston makes an interesting communication 
upon Herpes Facialis in Diphtheria. His observations were 
based upon 1370 cases of that disease whioh had been verified 
bacteriologically, and of these 4 • 2 per cent, developed herpes 
on the face. In the great majority of cases it was labial but 
the cheeks, chin, and nostril were occasionally attacked. 
The sexes were about equally affected and its incidence 
increased in frequency until the twentieth year. It was 
always an early symptom and was not definitely related to 
the same side of the face as that on which the diphtheritic 
process was present in the fauces. In Dr. Rolleston’s 
experience it is more likely to occur in the more severe cases, 
although Orsi regards it as a favourable sign. Dr. Rolleston 
agrees that it occurs more frequently in non-diphtberitic 
angina than in diphtheria, as he has observed it in 13'1 per 
oent. of the former olass of case, which comprised quinsy, 
Vincent’s angina, and herpes of the fauces. 

The West London Medical Journal. —The most important 
of the original communications in the January number of this 
periodical is perhaps that by Mr. W. Sampson Handley on 
Chronic Appendicitis in Women. The author points out 
that this condition differs from acute appendicitis in that the 
peritoneum is not affected and is of opinion that it is a 
frequent cause of right-sided “ovarian ” pain in women. Dr. 
J. A. Mansell Moullin writes on Uterine Fibroids and appa¬ 
rently holds that operation is called for in all cases; and 
Dr. Samuel West contributes a clinical lecture on Pericardial 





Thb Lancet,] 


REVIEWS AND NOTICES OF BOOKS.—NEW INVENTIONS. 


[Feb. 1, 1908. 297 


Effusion. Two cases of Empyema in which recovery took 
place after simple aspiration are recorded by Mr. Herbert W. 
Chambers. 

University College, London, Union Magazine. — The 
December issue of this magazine does not contain any 
directly medical material. There are, however, several 
references to the adventures of medical members of the 
College In connexion with the celebrations of the Brown 
Dog’s effigy, a theme which seems to have moved the writers 
to outbursts of rhyme, no doubt on the principle that “si 
natura negat, facit indignatio versus.” 

St. Thomas's Hospital Gazette.—A. Presidential Addres. 
■delivered by Dr. J. J. Perkins before the Medical and 
Physical Society of the Hospital forms the main substance of 
the December issue of this journal. Dr. Perkins reviews the 
history of our knowledge of tuberculosis as an infective 
disease and points out that evidence is accumulating in 
favour of the origin of many cases in an intestinal infection 
by bacilli of bovine origin. An abstract of some remarks 
made by Dr. J. B. Leathes in opening a discussion on 
Diabetes gives an interesting summary of some recent wotk 
by Pfliiger on this subject, the tendency of which is to 
discard the theory of a pancreatic secretion as at fault in 
this condition, and to revive the view propounded of old by 
Thiroloix and others that the disturbance following pan¬ 
createctomy is really due to interference with nerves which 
control the glycogenic function of the liver. 

Guy's Hospital Gazette .—A clinical lecture by Dr. W. Hale 
White published in the December number of this magazine 
deals with the diagnosis of an abdominal swelling which 
presented the characters usually associated with a pancreatic 
cyst. Dr. Hale White points out that this is a rare con¬ 
dition, only one case of a single cyst having occurred in 
6708 necropsies (there were also one case of hydatid of the 
pancreas and two of smaller multiple cysts). The tumour 
in this instance proved to be a sarcoma growing from the 
back of the abdomen but its point of origin was not exactly 
determined. In the January issue is published a clinical 
lecture by Mr. A. W. Ormond on Injuries to the Eye, in which 
he records two cases successfully treated by the Haab 
magnet. • 

London Hospital Gazette .—The medical matters dealt with 
in the December number of this magazine are rather frag¬ 
mentary in form. The first article is part of a clinical 
lecture by Mr. J. Hutchinson, jon., on Umbilical Hernia and 
a later contribution is a continuation of Dr. F. J. Smith’s 
review of the medical aspects of the recent Workmen’s Com¬ 
pensation Act. The clinical supplement contains an abstract 
of some remarks by Dr. J. Biernacki on Diagnosis of Common 
Fevers but except in the case of diphtheria the summary is 
so brief as to afford little help. 

St. Mary's Hospital Gazette .—A paper read before the 
Hospital Medical Society by Dr. Reginald H. Miller deals 
learnedly with acute poliomyelits and some allied conditions, 
notably polio-encephalitis, which is suggested as a cause of 
some cases of rapidly fatal illness occurring in institutions. 
The use of such terms as “ polio encephalomyelitis” and 
“ the cerebello-rubro-spinal system ” suggests that the 
neurologists are running the dermatologists close in the 
matter of polysyllabic nomenclature. 

The Broad Way, or Westminster Hospital Gazette .—The 
editorial notes in the December issue of this gazette are chiefly 
devoted to the “ Brown dog” disturbances. Serious medical 
matter is only represented by a continuation of Lieutenant 
C. G. Browne’s paper on the treatment of Byphilis in the army, 
the value of iodipin being here noted, as well as that of the 
Zittman treatment in obstinate cases, while the suggestion 
is made that intramuscular injection might be more often 
employed in out-patient practice. 


St. George's Hospital Gazette .—With the December 
number is included a good portrait of Sir T. Clifford Allbuit 
who is au old St. George's man. An interesting account is 
given by Dr. H. D. Rolleston of the methods of medical 
education prevalent in America; apparently a smaller 
amount of systematic lectures is inflicted on students there 
than here, but more laboratory work is required. The 
system of examination is also different and Dr. Rolleston 
seems to think that on the whole it is better than ours. 


$Uto Indentions. 


THE IMPROVED “IDEAL” INHALER FOR ETHYL 
CHLORIDE AND OTHER ANAESTHETICS. 

The features of Mr. Vernon Knowles’s inhaler (made 
by the Dental Manufacturing Company, Lexington-street, 
London, W.) are : 1. Its adaptability for the use of 
ethyl chloride alone, with nitrous oxide, ether, chloro¬ 
form, or mixtures of chloroform and ether. 2. As it 
gives complete control of the amount of anaesthetic 
given it increases the safety of the patient. In the case 
of chloroform it does not supply a measured quantity 
of vapour but allows the anaesthetist to use the drop method 
which with skill gives a fairly accurate dosage. 3. The 
extremely wide bore supplied prevents any distress in breath¬ 
ing. 4. The apparatus is so constructed that its component 
parts can be rapidly dissociated and sterilised. The appa¬ 
ratus consists of a celluloid face-piece fitted with studs. Two 
air pads of small and large sizes are supplied which are 
attachable to the studs and thus do not get out of position 
when once adjusted. One face-piece can be made in this 
manner to suffice for children and adults. The face piece fits 
on to the apparatus and has a collar with two milled rings 
which prevent its rotation. The horizontal arm. that which 
carries the face-piece, is provided with two valves, one 
for air and the other for the anaesthetic ; as the former 
is closed the latter is opened, and these enable the 
anaesthetist to give the anaesthetic slowly and gradually. 
The handle or lever which controls these valves un¬ 
screws and allows the inner barrel to be withdrawn for 


Fig. 1. 



cleansing. Two inner barrels are supplied, one for use when 
nitrous oxide is employed, the second for all other anaes¬ 
thetics. These barrels when out of use are kept in closed 
metal cases which prevent them becoming soiled. The outer 
valve c (Figs. 1 and 2) is placed between the lever r which 
works the valves and d the feed-funnel which communicates 
with the sponge-holder g. It will be seen in Fig. 2 that a 
space (H h) surrounds the sponge-holder and this insures free 
respiration even when the sponge is in position. As the 
patient’s exhalations pass around the sponge there is less 
liability to its freezing than was the case when all the air 
had to pass through the sponge saturated with ethyl chloride 
or other anaesthetic. The feed-funnel D is used when the 





298 The Lancet.] NEW INVENTIONS.—PROTECTION AGAINST FIRE IN HOSPITALS. 


[Feb. 1, 1908. 


patient is sitting, K when the patient is in the dorsal or lateral 
decubitus, while the dummy cup L receives the screw-plug M 
when D and K are in use. These funnels are guarded by fine 
meshed metal diaphragms to prevent glass dust entering 


Fig. 2. 



H H i 


L..„..J 

when the tube breaker is employed. Fig. 3 shows the 
cylinder which is used when N 2 0 is to be administered. 
It is provided with three-way valves. The lever B being 
at 0 air is respired ; at 4 the inspiratory and expira¬ 
tory valves c and A are put into action ; when turned 

Fig. 3. 


B 



further to-and-fro breathing is allowed. The gas is 
admitted through the tap at the distal end of the bag. 
When ethyl chloride is to be used concurrently with N..O the 
sponge-holder G is inserted and the antcsthetic is introduced 
through n or K. For the N 2 0 and ether sequence anaasthesia 
can be induced as above and then tne N.O cylinder 

Fig. 4. 


v 



exchanged for the general anaesthetic cylinder or, what is 
simpler, the last, named can b- used throughout., to and-fro 
breathing being allowed from the outset. The ether attach¬ 
ment shown in Fig 4 is extremely ingenious and easily con¬ 
trolled. It is screwed into K,and on turning the screw v the 


ether passes down and wets the sponge. The receiver is fed' 
by apertures controlled by z. It is made of metal and glass 
so that the ether is always in view. 

It is suggested by the inventor that for chloroform and its 
mixtures the anmsthetic should be placed in this receiver and 
be allowed to pass drop by drop at any desired rate upon the 
sponge; when so used the bag must be detached. It is to 
be pointed out that no breath contamination takes place, so 
that there need be no waste by anaesthetic residues. Mr. 
Vernon Knowles has modified Dr. Dudley Buxton's gag by 
introducing a double action release catch so as to be upper¬ 
most whichever side the gag is used. By the pressure of a 
button the ratchet is at once freed. It works extremely 
well and can be easily manipulated by either hand holding 
the gag. This specially designed stand which holds the 
little glass capsules of ethyl chloride is most convenient and 
should be appreciated by all who use this amesthetic. 


DIAGRAMS FOR TESTING BINOCULAR VISION AND 
FOR USE IN THE TREATMENT OF SQUINT. 

When an object is viewed with both eyes an image of it 
is produced on each retina. In consequence of the fusing of 
these images persons who possess binocular single vision see 
only one object and not two, but this faculty is not infre¬ 
quently impaired owing to a want of harmony in the motility 
or refraction of the two eyes and a certain amount of 
binocular double vision is the result. A similar effect is 
produced if one eye is slightly displaced by pressure with 
the finger. Binocular tingle vision is an essential condition 
of stereoscopic vision or the perception of depth in solid 
bodies or curved surfaces, and its presence or absence may 
accordingly be tested by means of stereoscopic pictures. 
We have received from tho publishing house of Wilhelm 
Engelmann, in Leipsic, a very convenient set of 20 pairs 
of diagrams selected for this purpose by Dr. W. Hausmann, 
together with a holder in which they may be placed at various- 
distances apart indicated by a millimetre scale. The 
diagrams are of a simple kind, consisting only of circular 
and rectilinear figures and dots partly black on a white back¬ 
ground and partly the converse of this. The two diagrams of 
each pair are on separate cards measuring about 2 inches 
by 3 inches. They can be viewed in any ordinary 
stereoscope, but for accurate work a special form of 
stereoscope can be obtained from Mr. Felix Tornier, 
Konigsplatz 6, Leipsic. It allows ready movement of the 
cards in several directions and is provided with tinted glasses 
to equalise the images when there is a difference in the visual 
acuity of the two eyes. The price of the 20 pairs of cards is 
2 marks and that of the special stereoscope is 11 marks. 


THE REPORT OF THE COMMITTEE OP 
KING EDWARD’S HOSPITAL FUND 
APPOINTED TO SUGGEST MEANS 
FOR SECURING PROTECTION 
AGAINST FIRE IN 
* HOSPITALS. 


This report was briefly noticed in The Lancet of 
! Nov. 30th last but the subject is of such importance as to 
demand fuller consideration than was then given to it. The 
following is the text of the Appendices A and B. 

A. 

Points which should h t. Borne tw Mind ry Hospital Com¬ 
mittees when Framing Regulations. 

1. It is important to have some arrangement for summoning those 
who should be alarmed. In arranging the method for alarm it ia 
necessary to avoid startling the patients unnecessarily. Police whistles 
distributed are worth consideration and would have the effect of 
summoning police aid as well. Every endeavour should be made, how¬ 
ever, only to dist urb the affected area. 

2. Each building containing patients should have means of Imme¬ 
diately dispatching information to the. nearest fire brigade or police 
station and the nurses nr others in charge should be instructed as to 
tho proper mode of instantly Bending for this external aid without 
waiting to see whether their own local appliances are sufficient or not. 
If the hospital is not on the telephone the staff should Know where 
the nearest fire alarm post in the street is located and how to use it. 
This information should be given on the card of printed regulations^ 
In order to save expense an offer might he made to the fire brigade 
authority to allow a public fire alarm to be placed at tho hospital gate, 
which would be available for use by the public as well as by the 
hospital officials. If the hospital is on the telephone, the London fire 


















The Lancet,] 


PROTECTION AGAINST FIRE IN HOSPITALS. 


[Feb. 1,1908 . 299 


'brigade should be called by telephone and by lire alarm post in the 
street. The following slip should be posted near the telephone, 
if any:— 

“ Ik Case of Fire.” 

King up in the usual way. 

Say •* Put me on the fire brigade.” 

When answered say— 

“ Fire at Hospital, street,” Ac .—and any 

•detail that your presence of mind dictates, viz. : Largo—small—roof— 
basement—Ac. 

3. The regulations of the hospital should provide organisation that 
will immediately stay “panic' 1 and guide the patients to safety. If 
alternative staircases'are not available, anything like » “ cul do sac ’ 
where several are accommodated particularly on upper floors, requires 
special attention and consideration. 

4. livery hospital should have within its walla some “first aid” 
apparatus to deal with the outbreak. As the probable position of any 
outbreak can generally be foretold, the risks should be located and 
studied beforehand. Roof, kitchen, storerooms, cupboards, heating 
places, workshops, laundry. Ac., are examples of likely danger points. 
Fireplaces and guards, gas fittings (especially swinging gas fittings), 
•curtains, rubbish collect ions, and places where candles and matches are 
used near clot hing and bedding, should also be studied. Fire drills 
adapted to the special danger of the particular hospital should be 
<juietly arranged periodically. This location of risks is the essence of 
effective fire drill. Certain of the staff should be detailed to handle 
the hospital tiro appliances, and they should know this is their job. 
They should be so selected that some will always be present. The 
whole number should periodically be summoned to the different “ fire 
risks" for drill. An ordinary mop and bucket will prove useful in the ! 
early stages to splash water and anyone can use them. Should the 
fire be due to electricity or upset of oil.be careful in applying water, 
but rather endeavour to smother with sand or wet blauket till the 
brigade arrives. 

5. Printed Instructions should be posted up freely, so that all are 
reminded that fire is a possible contingency. These instructions should 
deal with all the foregoing points, with any additions or amplifications 
appropriate to the particular hospital or to its appliances. 

B. 

PolKTB WHICH SHOULD BE REMEMBERED BV THE STAFF WHEW AW 

Alarm takes Place. 

1. On the discovery of a fire or on smelling smoke the staff and 
employees should not run about aimlessly or shout or shriek, Ac., but 
-quietlv think and act on the instructions for raising the alarm. 

2. The first object is to prevent “panic” among the patients and 
visitors, if any. 

3. If the fire brigade has been called the actual lire damage should 
not be much in the thoughts of the staff. It is imperative to see to 
the removal of patients who are in danger to safety, which is. as 
a rule, out of the smoke area, and preferably outside the building 
involved if a comparatively small one, or into a separate block if a 
livrge one. In a densely smoky atmosphere a wet tlaunel over the face 
is beneficial. 

4. Those detailed for appliances should go to their duty at once and 
•eudeavour to check the progress of the fire. It would be as well also 
for someone in authority on the spot to detail those who are to remove 
patients and also t hose who are to receive them and see to their proper 
•clothing and comfort. 

N.B.—As far as ihe details of the actual steps to be taken when an 
Alarm takes place are concerned the printed regulat ions drawn up by 
the individual hospital and t he periodic tire drills should ensure that 
«very member of the staff knows what is his or her duty in the event 
of an alarm 01 fire. 

While all will be able to appreciate the points emphasised 
by such authorities as the Commissioners—both formerly 
chiefs of the London Fire Brigade—we have ventured to add 
a few comments arising from a perusal of the suggestions 
made therein. 

Appendix A. 

<'!lante 1 .—Police whistles may not be without merit, 
though to many they are indistinguishable from cab-calls. 
Automatic thermometric alarms might be useful if fixed in 
store rooms, workshops, and places removed from the 
constant presence of the attendants, such alarms to ring, 
say, in the porters' lodge or engine room where someone is 
always on duty. From this point there should be telephonic 
communication with the rest of the building and with the 
nearest fire stations. There are several of these automatic 
tire alarms in use throughout the country, those operated by 
the expansion of a metal slip possibly being preferred. As 
an example the following is a description of one of the best 
known alarms—viz., “The Pearson Automatic Fire Alarm.” 
At certain points where the risk is considered greatest or 
where there is the least chance of detection a small 
instrument is fixed called a thermostat, with this contact is 
made and an electrical circuit is formed by the expansion of 
a small metal strip capable of being so finely adjusted that a 
connexion can be made at any desired temperature. These 
are wired in parallel on looped circuits connected to an 
indicator. Should any undue heat occur where the thermo¬ 
stat is fixed a bell rings and the position of tbe one affected 
is shown on the indicator. At the point at which the 
indicator is fixed, say tbe porters' lodge, one of three courses 
may be adopted : 1. A private telephone can be installed by 
tbe General Post Office for an annual charge of, say, 40s. to 
-60s. direct to an indicator at tbe nesurest district fire station. 


2. A wire may connect to tbe central office of the fire alarm 
company, where a duplicate indicator receives the alarm 
consecutively with tbe indicator at the hospital. The 
operator then telephones by a private wire to the nearest fire 
station. 3. Communication may be made to the fire station 
by the regular telephone servioe as explained in the 
committee’s report. 

Direot communication with the life station is preferable 
for a hospital where there is someone always on duty near 
the telephone and indicator, as all delays or misunderstand¬ 
ings incident to the telephone are avoided This direct 
system is adopted by several London hospitals independently 
of the automatic alarm. Instantly on pressing a button or 
liftiug the telephone receiver a shutter falls on the indicator 
at the fire station giving the name of the hospital, while a 
bell rings till the call is answered. Should the call be at 
night the fireman on duty presses a lever which rings a bell 
in each of the men's rooms, and at the same time switches on 
all lights. At once an engine and an escape are turned out. 
While this is being done lie calls up the central fire station of 
the district and by telephone gives notice of the fire. The 
central fire station then gives notice to the other district 
stations in its circuit, thus : On the ceiling of each district 
station are fixed a red and a green electric lamp : by pressing 
one or two buttons at the central station all bells are set 
ringing at the district stations called and either one or both 
of these lights are switched on, red for an engine or green 
for an escape. The men hurrying down at once see what is 
required and all help to despatch the team wanted. Mean¬ 
while, instructions as to the locality of the fire are received 
by telephone. Thus within a minute of the call five 
or six engines with esoap-'s can be sent to a fire without 
denuding any one station ot its resources. Bach central 
office is in direct communication with the headquarters 
in Southwark, which can instruct other central stations 
should it be necessary to send more help from their district 
branches. 

Again, electric bells might be fixed from various points, 
say from the nurses’ duty rooms, to ring in connexion with 
fire indicators at some such point as above mentioned. Such 
bells should be te.ted daily and batteries examined. 

Clause 2 —These suggestions are distinctly good. Flare- 
lights, snch as are in use in the navy for lighting bnoys at sea 
when thrown to a man overboard, might be fixed at several 
prominent external points and fired by triggers in tbe building. 
These flares might be partially inclosed in metal boxes, 
perforated with the word “Fire.” Or, again, steam or 
pneumatic whistles might be fixed externally to each ward 
or section. Direct communication with the nearest district 
tire station by a special wire and bell is tt e best and surest 
way. We understand that in America for a moderate annual 
fee any large building can be placed in direct communica¬ 
tion with the nearesL district station. In the station is a 
large dial round which are the names of the institutions 
connected with the station. A bell rings and a poiuter moves 
round the dial and stops at tbe name whence the call came, 
which is answered back. 

Clause 3 .—Everything depends upon organisation if panic 
is to be avoided. Those in authority should confer with some 
responsible fireman whose opinion is of value as to possible 
risks and the best methods of organising the staff. Tbe staff 
should be trained and drilled at their work, not forgetting 
tbe practice of the removal of members acting as patients 
properly clad. Many students and others associated with 
hospitals might gain valuable experience in this work by 
joining one of tbe many suburban fire brigades, if only for a 
short time. Alternative staircases are now mostly provided 
in new buildings owing to tbe action of count.y councils and 
local authorities. Those patients whose powers of locomo¬ 
tion are most defective should have preference of others as 
to the most favourable position for exit in the event of an 
outbreak. 

Clause If .—A point requiring very serious consideration is a 
difficulty with regard to training a fire staff owing to the 
heavy charges made by some water authorities for break¬ 
ing the seal of a fire hydrant, thereby tending to prevent 
efficiency in the staff and the testing of the hose and valve. 
In some cases the annual charge for these mains is snch as 
to prevent the connecting up of fire appliances provided 
in new buildings. If hand grenades or tubes containing 
ohemicals are relied on practice is necessary in tbe use of 
them. There is a knack in directing their contents to the 
right spot which is not to be acquired on the first attempt 
during moments of excitement. Xhe suggested pail of water 



300 The Lancet,] 


MEDICINE AND THE LAW. 


[Feb. 1, 1908. 


and mop are likely to prove of much greater value. Fire- 
and sand-pails ought certainly to be placed at points in 
readiness. Clothing and spare blankets should be distributed 
in various parts of the building for the patients’ use in an 
emergency and not concentrated in one store to which access 
might be impossible. Asbestos blinds or curtains might be 
fixed ready to be drawn across staircase or corridor openings 
or on the several landings round the lifts ; this would tend 
to localise a fire and check draught and smoke while the lift 
was in use for the removal of patients. 

Appendix B. 

Clauie 1 .—Frequent drill can alone prevent confusion in 
the event of an outbreak. 

Clauie 2 .—A calm demeanour in the staff and the assurance 
that means are being adopted for their safety are most 
necessary to obviate panic amongst the patients. 

Clauie S —Especial care should be exercised that persons 
of a suitable temperament only are selected for this most 
important duty of conveying the patients to a place of safety. 
A cheap form of smoke-mask might well be kept in each of 
the patient’s lockers. In addition to the superintendent and 
deputy of the staff brigade there should be a first and 
second in command of each ward who in the event of a fire 
in their particular ward should, under the general superin¬ 
tendent, take the command of the staff and direct the 
removal of their patients till their ward was cleared. These 
should be taught the best possible exit in varying circum¬ 
stances in the event of their ward being threatened. 

The report should be of value in leading those responsible 
for the safety of others under their charge to review the 
risks to which their particular buildings are subjected. The 
suggestion of the Commissioners in the body of the report 
that they should be consulted as to the site and details of 
any proposed new hospital deserves consideration, though 
this is practically done in London by the County Council. 
The insistence of the Commissioners as to absolute cleanli¬ 
ness should be, in the case of hospitals, unnecessary. 

General rtmarkt —In the construction of buildings used as 
hospitals the following points are generally observed and 
cannot be too strongly insisted on :—1. The use as far as 
possible of incombustible materials. 2. The division of the 
building into more or lees disconnected sections. 3. The 
avoidance of long corridors. 4 The provision of emergency 
exits. 5. The avoidance of all airspaces in floors, and round 
door and window frames, which last should be solid, not 
hollow as is necessary when sliding sashes are used. 6. The 
use of fire-resisting paints, care being taken that the wood¬ 
work is first thoroughly dry ; such paint not to contain zinc 
chloride, as is sometimes the case, the fumes from which, 
given off when burning being insupportable by human beings. 
7. The use of distemper and lime-white as a protection 
to woodwork. The avoidance of tarred felt and wood 
boarding beneath the slates. The use of small pipes 
and radiators now in vogue for the circulation of hot 
water minimises the risk of fire travelling along the 
channels hitherto necessary for the larger pipes. In 
any case in all troughs and channels, for pipes or wires, 
baffleB should be placed to cheok the advance of fire by 
such means. We may refer our readers on these points to an 
article published in The Lancet of Jan. 31st, 1903, p. 314, 
shortly after the Colney Hatch disaster. 

In this connexion we are reminded that on Feb. 31st, 
1903, at a meeting of the Metropolitan Asylums Board the 
working committee presented a report on the provision of 
water for protection against fire in the 29 hospitals, asylums, 
and institutions under its charge. Out of these 29 institu¬ 
tions eight, or over 27 per cent., were found to be more or 
less deficient. It wou’d be interesting to know that these 
defectB have since been remedied. 


MEDICINE AND THE LAW. 


Citposal of Infected Bodies. 

A somewhat unusual application was recently made 
to the Birmii ghain magistrates by a solicitor on behalf 
of the Birmingham medi al officer of health. He a-ked for 
an order to remove the body of a man from a private house 
to the mortuary. The body in question was that of a 
married man, 27 years of age, who died on Jan. 9th from 


consumption of the lungs, an infectious disease. The widow, 
who was left with three children, resided with another 
family of three at a back house in Bordesley, and there¬ 
fore there were seven persons living in the same room where 
the body lay uncoftlned. Evidence was given by the 
assistant medical officer of health of the city, who stated 
that it was necessary for the body to be removed. The 
widow, who gave her consent to the course which it was pro¬ 
posed to take, was trying to collect 30s. in order to pay for 
the burial. The magistrates made an order for the removal of 
the bodv to the mortuary. It is enacted by Section 142 of the 
Public Health Act. 1875, that where the body of one who has 
died from any infectious disease is retained in a room in 
which persons live or sleep, or any dead body which is in such 
a state as to endanger the health of the inmates of the 
same house or room is retained in any house or room, any 
justice may, on a certificate signed by a legally qualified 
medical practitioner, order the body to be removed at the 
cost of the local authority to any mortuary provided by such 
authority and direct the same to be buried within a 
time to be limited in such older ; and unless the friends 
or relatives of the deceased undertake to bury the 
body within the time so limited and do bury the same 
it shall be the duty of the relieving officer to bury such body 
at the expense of the poor rate but any expense so incurred 
may be recovered by the relieving officer in a summary 
manner from any person legally liable to pay the expense of 
such burial. Any person obstructing the execution of an 
order made by a justice under this section is liable to a 
penalty of £5. When the local authority has provided a 
mortuary this section applies but where the Infectious 
Diseases (Prevention) Act, 1890, has been adopted the 
justice may order the body to be removed to any available 
mortuary. By Section 8 of the Infectious Diseases (Pre¬ 
vention) Act, 1890, it is provided that no person without the 
sanction in writing of the medical officer of health or of a 
registered medical practitioner shall retain unburied else¬ 
where than in a public mortuary or in a room not used at the 
time as a dwelling-place, sleeping-place, or workroom, for 
more than 48 hours, the body of any person who has died 
from any infectious disease. And by Section 10 of the same 
Act it is provided that where the body of any person who 
has died from any infectious disease remains unburied else¬ 
where than in a mortuary or in a room not used at the time 
as a dwelliDg-place, sleeping-place, or workroom for more 
than 48 hours after death without the sanction of the medical 
officer of health or a registered medical practitioner, or where 
the dead body of any person is retained in any house or 
building so as to endanger the health of the inmates of such 
bouse or building or of any adjoining or neighbouring house or 
building, any justice may on the application of the medical 
officer of health order the body to be removed at the cost of 
the local authority to any available mortuary, and direct the 
same to be buried within a time to be limited in 
the order ; and any justice may, in the case of the body 
of any person who has died from any infectious disease, 
or in any case in which he shall consider immediate burial 
necessary, direct the body to be so buried. Unless the friends 
or relatives of the deceased undertake to bury and do bury 
the body within the time limited by such order, it shall be the 
duty of the relieving officer of the relief district from which 
the body has been removed to the mortuary, or in which the 
body shall be, if it has not been so removed, to bury such 
body and any expense so incurred may be charged by the 
relieving officer in his accounts and may be recovered by 
the board of guardians in a summary manner from any 
person legally liable to pay the expenses of such burial. The 
principles of the common law (i.e., apart from statute law) 
with respect to the rights of burial were laid down by Lord 
Chief Justice Denman, as follows :— 

Every person dying in this country and not within certain exclusions 
laid down by «he ecclesiastical law has a right to Christian burial; 
and that implies the right to be carried from the place w here his body 
lies to the parish cemetery. Further, to use the words of Lord Stowell, 
“that bodies should be carried in a state of naked exposure to the 
grave would be a real offence to the living, aa well as an apparent 
indignity to the dead.” We have no doubt , t herefore, that the common 
law' casta on some one the duty of carrying to the grave, decently 
covered, the dead body of any person dying in such a Btaieot indigence 
as to leave no funds for that purpose. The feelings and interests of the 

living require this, and create the duty. It should seem that the 

individual under whose roof a poor person dies is bound to carry t he 
body decently covered to the place of burial ; tie cannot keep him on- 
buried, nor do anything whtch prevents Christian burial: he cannot 
therefore cast him out, so as to expose the body to violat ion, or to offend 
the feelingB or endanger the health of the living; and for the same 
reason he eannofc carry him uncovered to the grave.—Keg. v. Stewart, 
I 12 A. & E. 773. 





The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 301 


TUCKER v. WAKLEY AND 
ANOTHER. 


In the High Court of Justice, King’s Bench Division, at 
the Royal Courts of Justice, on Wednesday, Jan. 15ch, 
before Mr. Justice Ridley and a special jury, the case of 
Tucker r. Waki.ey and Another came on for hearing. 
Mr. H. E. Duke, K.O., and Mr. F. E. Smith (instructed by 
Messrs. F. Venn and Co.) appeared for the plaintiff. Mr. 
J. Eldon Bankes, K.C., and Mr. Hugh Fraser (instructed 
by Messrs. Potter, Sandford, and Kilvington) appeared 
for the defendants. 

Mr. F. E. Smith opened the Pleadings. 

Mr. Duke: May it please your lordship, gentlemen of the 
jury : As you have heard from the opening of the pleadings 
by my learned friend, this is an action brought to recover 
damages for a libel published by the defendant in his news¬ 
paper of the plaintiff in regard to the plaintiff's business and 
with regard to the plaintiff's character—of his business and 
as a man. The plaintiff has been carrying on the business, 
which I will mention to you more particularly in a minute or 
two, in London and throughout England for now something 
like eight or nine years. He has carried it on as he and his 
customers, I think you will find, thought reputably; he has 
carried it on with very considerable profit to himself, and he 
has carried it on, as I think 1 will satisfy you, beyond any 
sort of question, with very great and conspicuous benefit to 
people who have dealt with him—not to a few people but to 
great numbers of people, and, as you will see, if those 
averments are true with regard to the plaintiff, it is an 
exceedingly serious matter that he should be publicly accused 
of selling a remedy which is a fraud and selling it 
fraudulently and being a man whose dealings are fraudulent 
dealings. Those are the charges, with other charges, which 
the defendant, who is the registered proprietor of The 
Lancet newspaper, did not hesitate, now many months ago, 
to launch against the plaintiff without, so far as I am able to 
see, any knowledge of what the plaintiff's remedy was ; 
without any knowledge, so far as 1 am able to see, of what 
the plaintiff's mode of business was; without any knowledge 
of whether his business was honest or whether his remedy 
was beneficial. The defendant having made those charges in 
his newspaper, launched so long ago, has followed them 
up and persisted in them, and he is here, as 1 under¬ 
stand, by his counsel, and I suppose, by evidence, 
to seek to justify himself in what he has done 
The Lancet, as yon know, gentlemen, is wbat is 
called an organ of the medical profession. It is a news¬ 
paper very well known, and, I should say, in the 
general wav very well conducted. It deals with subjects of 
medical science and it deals also with the professional and 
class interests of doctors, as a profession and as a class, and 
their substantial and pecuniary interests. It is warranted 
in protecting those interests by every legitimate means, and 
you will have to ascertain in the course of this case whether 
there can be any sort of warranty in the championing of the 
professional and cKss interests of any profession, no matter 
how eminent, in dealing with a man who deals in a remedy 
in the manner in which the plaintiff in this case has been 
dealt with. I shall have to tell you something about the 
commodity the plaintiff sells. He sells it merely as a com¬ 
modity ; he does not pretend, and has never pretended, that 
he was the inventor of it, or that he is a man of medical 
skill, or that it is anything else than a specific for the treat¬ 
ment of a well-known specific ailment. It is a specific for 
the treatment of asthma. I daresay all of you have either 
experienced in yourselves or in your families, or have seen in 
other people, the disease of asthma. It is a paroxysmic 
disease which attacks the respiratory organs suddenly, or 
with some little warning, which disables the patient while 
the paroxysm lasts, and undoubtedly weakens his system and 
becomes chronic and is a source of very great misery and 
suffering to people who are subject to it. It is a well-known 
and perfectly specific ailment, with well-known and specific 
symptoms, an ailment which I think we all know is generally 
treated by something rather in the nature of mechanical than 
medicinal means—the inhalation of some sort of remedy. 
These are matters of common knowledge. I daresay you are 
well aware that in some cases powders are burnt and the 
patient inhales the fumes of them to arrest the spasmodic 


operation of this ailment. In other cases cigarettes of a 
herbal character, datura stramonium, are smoked by the 
patient. I mention these things because we all see them in 
every day life if we happen to come into contact with 
persons who are suffering from asthma. Those are the kind 
of remedies which are well known. With regard to those 
I think it will appear in the course of this trial that medical 
men fail to deal with asthma by medicinal appliances which 
go to affect the physical system and the constitution of the 
patient. I think you will find that the remedy generally has 
to be some simple and mechanical remedy applied to deal 
with the symptoms. The remedy in which the plaintiff 
deals, which be sells and has sold, is a remedy called 
“Dr. Tucker’s Asthma Specific.” 1 will tell you about 
Dr. Tucker presently. He is the brother of the plaintiff, a 
medical man of good position and repute at Mount Gilead, 
Ohio, in the United States. I will tell you presently how it 
comes that this remedy is in existence and in use, but that 
is the name of the remedy, “ Dr. Tucker's Asthma Specific." 
It consists of a liquid and a vaporiser for the purpose of 
converting that liquid into vapour which the patient can 
inhale through the nose into the throat and lungs. I think I 
mentioned to you that Dr. Tucker, who discovered the proper 
ingredients for the liquid which is here in question, is him¬ 
self a physician and the brother of the plaintiff. The 
plaintiff will tell you that Dr. Tucker, alter he bad 
entered upon his practice as a medical man, found himself 
subject to repeated and distressing attacks of asthma 
to such an extent that he was not able to carry on his 
practice continuously, and that Dr. Tucker thereupon applied 
his knowledge and skill towards the endeavour to discover 
a remedy for his own treatment in order that he might live 
the life of an ordinary professional man and not be disabled 
by these spasmodic attacks of asthma which continually 
came upon him, and he produced the liquid which is here in 
question. There are matters in regard to the composition 
of that liquid which are raised upon the pleadings in this 
action and which I will mention to you presently. They 
seem to me to be wholly irrelevant to the gross and grave 
charges which this defendant has thought fit to launch 
against the plaintiff, but as they are put upon the pleadings 
I shall deal with them in their order. I may say to you 
now that the plaintiff himself has no personal knowledge of 
the constituents of that liquid and he has never sought to 
ascertain. It was not his business to know. As to the other 
item in the treatment, the vaporiser, that is an article of 
a not unusual kind, but a very efficient article of a not 
unusual kind. I dare say you know that by applying a 
blower of some kind to some tubes in connexion with a 
bottle you are able to produce a spray. In this case the 
vaporiser and the inhaler is not an article which produces a 
spray. A spray which is injected into the air passages and 
falling into the lungs would cause distress, probably, and 
not relief, according to one’s ordinary notions of the mode 
in which you can deal with the lungs. This is a vaporiser 
and not a spray-producing apparatus. It is produced by a 
firm at Boston, I think, in the United States, appointed 
and employed for the purpose by Dr. Tucker, the 
plaintiff’s brother, and every one of the vaporisers is 
examined by Dr. Tucker himself and examined also by 
the plaintiff, who has a great deal of practical knowledge of 
this apparatus. It is quite a common place apparatus in its 
way. Its particular value arises through its particular 
efficiency from the care with which it is manufactured and 
with which it is inspected. Here you have it (producing 
same). A vapour arises, which you canDot see probably. 
Two or three compressions of the bulb here discharge a body 
of vapour which is produced from the liquid in the bottle. 

Mr. Justice Ridley : Those are very common things. 

Mr. Duke : Very common things indeed. 

Mr. Justice Ridley : I can get it at a chemist’s shop. I 
have one in my room at the moment, not like that, but a 
simple one that I was ordered by the doctor when I had a 
bad throat. 

Mr. Duke : That is probably called a spray. 

Mr. Justice Ridley : Yes, I think it was called a spray. 
You fix it into a bottle. 

Mr. Duke : That is the type of thing which produces a 
spray. This apparatus produces a vapour which is intended 
not to be deposited on the throat in the way a gargle is, but 
to be inhaled into the lungs. 

Mr. Justice Ridley : The one I had was fixed into a bottle 
containing the liquid. 

Mr. Duke : Yes; that is done here. Your lordship can 




302 The Lancet ] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1,1908. 


see the liquid in the bottle. Here is the liquid ; here is the 
vaporiser, and the vapour is discharged into the nose, and 
with a little practice it can be inhaled into the luDgs. As 
my lord said, there is nothing special about the design of 
the spray and, so far as the apparatus concerned as a 
vaporiser, the only thing there is special about it is the care 
with which it is constructed, so that it shall produce vapour 
and not spray, vapour being the thing which is required for 
this purpose. No doubt the most valuable part of the remedy 
is this liquid, which was the discovery of the plaintiff's 
brother. 

Mr. Justice Ridley : You say it is vapour and not spray ? 

Mr. Duke: Vapour and not spray; it produces a vapour. 
The plaintiff understands the mode of operating it, and I 
daresay in the course of his evidence he may be able to show 
the distinction of it, but practically this produces a dry 
product; it produces a vapour, the dampness of which you 
do not discover. Of course, it must be damp because the 
particles of the liquid are dispersed very finely, but if you 
discharge it against blotting-paper I think you will find that 
instead of damping the blotting-paper so that you see the 
wetness upon it it will leave the blotting-paper with an 
appearance which you could barely distinguish, if you could 
at all, from its previous appearance. It scatters the particles 
of the fluid into a very fine state of distribution. As 1 was 
saying, I have no doubt apart from the care in the 
mechanical production of the vaporiser which is necessary 
for the efficient action of that apparatus, the most valuable 
part of Dr. Tucker’s remedy is the liquid, the constituents of 
which he discovered and the constituents of which the 
defendants seek to discuss here. They profess to have 
discovered what the constituents are. I am not concerned 
to know whether they have or not, but they profess to 
discuss them here; and 1 suppose if the plaintiff bad 
a valuable discovery and had an effective remedy, so far 
as any special knowledge the plaintiff had, if they are 
able to establish their proposition, if they do not destroy 
the plaintiff's character, at any rate destroy to some extent, 
or impair the value to him of the remedy which he is selling 
under circumstances which I will tell you, that is not a very 
material matter. That is the treatment, as it is called, 
which the plaintiff deals in. The plaintiff, for several years 
after hiB brother had made what he regarded as his discovery 
in the composition of the liquid which is used in the 
treatment, was engaged, under his brother’s supervision, in 
the business part of the transaction of dealing with the 
remedy in the United States. In the year 1899 he came to 
England with a power of attorney from his brother—his 
brother had had an agent in this country—and either 
practically established or took over the business of selling 
this specific in this country, and since the year 1899 the 
plaintiff has made it his business to sell this specific in this 
country. His mode of dealing with the specific and the mode 
of carrying on business is what is first of all assailed in the 
libel which the defendent has published. His dealings are 
alleged by the defendant to be fraudulent—at least, the 
defendant does not condescend to any detail of any charge of 
fraud, but he says the plaintiff’s dealings are such that it is 
fair comment upon him to say that his dealings are 
fraudulent. I do not quite understand myself how it 
can be a fair comment upon a man to say that 
his dealings are fraudulent unless they are fraudulent, 
and it may be that in the course of this case some 
submission may have to he made to my lord, and 
my lord's ruling obtained as to whether it is possible 
for a defendant who has alleged fraud and fraudulent 
dealing against another man to come into court and say, 
“Well, whether your dealings are fraudulent or not it is a fair 
comment upon you to say that they are fraudulent dealings.” 
This is the position among others which the defendant in 
this action has taken up. I shall have a word or two more 
to say to you about that later, but it is an astounding posi¬ 
tion, and fatal, of course, to the reputations of all men who 
happen to be assailed if it is enough to come into court and 
say, “Well, I consider your dealings are fraudulent, whether 
they are fraudulent or not.” 

The plaintiff cim« to this country with his brother’s power 
of attorney in 1899. Since that time be has had, and has 
used, the exclusive right of supplying bis brother's remedy. 
Gentlemen, when I come to read the libel to you in this case 
you will see that the defendant in this case when he pub¬ 
lished his libel did not know anything about the plaintiff. 
Let me tell you this, which I shall follow up presently : The 
plaintiff has never advertised this remtdy in the newspapers. 


It is a common thing that specific remedies, whether they are 
valuable or whether they are spurious (there are valuable 
remedies and there are spurious remedies) are advertised in 
newspapers, and mere rubbish is passed off which is quite 
useless in some cases—at least, 60 it is said, and probably 
quite truly said, and the public are defrauded by that means. 
The plaintiff has not advertised, and does not advertise, in 
the newspapers. He has a pamphlet written, I think, by 
Dr. Tucker, and he has some terms of dealing which I shall 
show you presently, and he lias Instructions for the use 
of the inhaler. The use of the inhaler is simple enough 
if you understand it, but if either of you tries for the 
first time to inhale into your lungs a vapour through your 
nose you will find yon need a little practice to do it ; 
it is not quite so simple as it might be. There is a natural 
indisposition of the internal organs to receive anything 
from the outside ; at any rate, it Is not simple without 
instructions. The plaintiff has this pamphlet which is here, 
about which presently he will go into the box and be cross- 
examined. He has the terms of business which are here 
and he has instructions for the use of the epecific, and he 
has a considerable number of agents whom he appoints for 
the purpose of selling his remedy, and, as far as one can 
see, those are the methods of honest business. Besides the 
pamphlet to which I refer and the other papers and the 
services of the agents, he has the recommendation of persons 
who have become informed of the usefulness of the specific 
and who largely recommend it, and by those means, without 
advertisement in the newspapers, without any other resort 
to the means of publicity than those I have mentioned to 
you, the plaintiff since the year 1899 has built up, as be will 
tell you, a large lucrative business. There is one other thing 
which I ought to tell you which lies at the bottom of the 
plaintiff’s methods of business. When an applicant desires 
to try this specific he receives it for a fortnight on 
trial gratis. I know this speech will sound to you, or 
may sound to you—it will not justly when you know the 
facts—as something of the nature of a puff or panegyric 
on the plaintiff's business. Gentlemen, the plaintiff has 
not sought to come here and 1 am bound to, tell you 
everything that will show that this attack on the plaintiff 
is groundless. The plaintiff, upon an application for 
this specific, supplies it for a fortnight on trial and 
all that happens with regard to it is contained in the terms 
of business which are here. Perhaps I might hand them up, 
because I shall have to refer to them. At the end of the 
pamphlet, after Dr. Tucker’s account of the remedy and 
recommendation of it, there is a memorandum. Perhaps I 
had better read the whole of it, because I do not know quite 
where it is suggested the fraud on the part of the plaintiff 
lurks in these business dealings : “Memorandum. 1, Time 
of trial, two weeks in United Kingdom only. 2, Price of 
treatment, consisting of Atomiser, wood case, and four ounces 
of fluid, £3." I have something to say to you about that 
presently ; it is said to be a high price. It would be a high 
price if the specific were rubbish, but if the specific is, as I 
think I shall show you by overwhelming and unquestionable 
evidence, a specific which defeats the oncoming attacks of 
asthma, the specific is, of course, of very great value, and 
the discoverer of it, and those who exercise his rights, are 
entitled to the reward of having possession of them. “ 3, To 
be paid for at end of two weeks, if satisfactory. 4, If not 
satisfactory at the expiration of the trial, the outfit, with 
what fluid there may be left, to be returned by Parcel Post. 
5, One half-ounce of (laid will be sent with the Atomizer for 
trial, which is not included in the four ounces. 6, No more 
fluid will be sent for trial; you will be careful and not spill 
it. Keep a cork in nozzle of Atomizer when not in use. 7, If 
you do not wish to continue the treatment after two weeks’ 
trial, return the Atomizer, with what fluid there may be left; 
if you desire to continue the treatment, remit £3. 8, As soon 
as the treatment is paid for I will send you two ounces of 
fluid by post, and the other two ounces on application when 
needed. The fluid precipitates a sediment by long standing, 
which is liable to choke the liquid tube, which will explain 
why only two ounces are sent at one time. 9, After the 
four ounces of fluid is exhausted it will cost you eight 
shillings per ounce, which lasts from two to four months. 
10, Extra bulbs for the Atomizer, 2». each. 11, Extra liquid 
tubes, 2*. each. Atomizer to be sent in to have the tube 
adjusted properly. 12, Cash must accompany all orders for 
fluid, bulbs, and tubes. 13, When sending telegrams, give 
initials and sufficient address. 14. Postage to foreign 
countries to be paid by patient. (Signed) A. Q. Tucker, 




The Lancet.] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1,1908. 303 


■General Manager. ‘Onaway,’ Half-Moon Lane, Herne Hill, 
London, S.E.” Whatever else may be said about those terms 
they are perfectly explicit; there is no sort of possibility of 
mistake aboni them. Mr. Tucker says to people who desire 
to be purchasers of this specific: “ Now the price will be so 
much, if you buy it; you can try it for a fortnight, and if 
you find it is not useful in your case or it is not what you 
desired to hare, send it back, and there will be an end of 
the matter ” ; and he states what the other prices will be. 
That is the memorandum of the terms of dealing. The 
person who desires to purchase, or, at any rate, to try the 
specific, finds in the pamphlet or with the pamphlet a little 
form to be filled up with his name, address, and the par¬ 
ticulars of the symptoms from which he is suffering with 
a view to seeing roughly whether the man who sends for this 
apparatus appears from what he says to be really suffering 
from asthma, because, of course, Mr. Tucker does not want 
these unusual terms of dealing, this supply of apparatus, 
and the remedy without payment for a fortnight, to be made 
the means of imposition. He wants to know a little about 
the applicant and the application, and so he has a schedule 
of questions here which the applicant can fill up and will 
fill up if he desires to have the apparatus on trial, and of 
course will not fill up if he chooses to send his £3 and 
knows all about it. Then on the back of the form of 
questions is this form : “ Patient will fill out this blank. 
Asthma case of,” so-and-so ; then “ Post Office,” so-and-so ; 

box,” so-and-so. “Number and street. County or shire. 
Province or country. Date,” this undertaking to be signed 
by the person who sends in his application to have the 
specific and the apparatus. “At the expiration of the 2 
weeks' trial, I, the undersigned, agree to pay for the treat¬ 
ment or return the Atomizer, and what fluid there may be left 
by mail charges prepaid.” Then there is a space for the 
signature. That is the ordinary way of carrying on this 
business which is attacked as a fraudulent concern. 

Mr. Justice Ridley : I do not quite follow this. The front 
part of that paper seems to be directed to inquiring whether 
the remedy has been found efficacious—some of the questions 
at all events : “ Does the remedy generally give you relief ? ” 
Does that allude to other remedies ? 

Mr. Duke : That refers to question 9 : “ What remedy are 
yon now using to relieve the attacks ? 10, Does the remedy 
generally give you relief ? ” 

Mr. Justice KidleY: He signs this paper before he gets 
the medicine ! 

Mr. Duke : The applicant signs this before he gets 
the vapouriser and the fluid on trial, and if he chooses 
to sign this and gives them particulars about himself, 
which are, at any rate, some kind of guarantee to Mr. 
Tacker that , he is a man who really does want to treat 
himself with a view to dispelling or preventing attacks of 
asthma, and to whom the treatment may be of some use, 
upon receiving this signed, Mr. Tucker sends out the 
vapouriser and the supply of fluid, and there is a period of a 
fortnight during whicn the applicant makes bis trials if he 
wants without incurring any sort of liability, and with the 
right at the end of the time, whether he dots it fairly or not, 
of packing the thing up in a parcel and putting it into the 
post with the proper parcel postage upon it and sending it 
back to Mr. Tucker and saying “Good-bye,” or leaving him 
without saying “Good-bye”—merely returning it. This is 
the mode of carrying on the plaintiff's business, and t]ie 
result of the various methods to which I have referred, the 
distribution of the pamphlet, the employment of agents, and 
this method of free trial of the remedy in order that the 
proposing purchaser may know himself upon what terms he 
is dealing, have undoubtedly been very successful to the 
plaintiff. Up to the present time since lie came to England 
in 1899 more than 25,000 of these appliances have been 
supplied. There have been more than 25,000 purchases. 
Something like half of them have taken place during the last 
three years, so that you tee the mode of doing business which 
the plaintiff pursues has had this success, that there has been 
a gradual progress during the earlier part of the time and 
an increase in the last three years, a very rapid increase 
indeed, and np to the present time a very large sale. The 
plaintiff will tell you that, sending out this apparatus and 
the fluid in tire way he does, in about one case in live 
of the cases where the apparatus and fluid are sent 
-ont the applicant return* them and there is an end of that 
matter. He finds that he is not pleased or that he cannot 
use it or that for some reason or other he does Dot consider 
dt is worth his while to buy. He may find that you can buy 


a spray apparatus or a spray producer at the chemist’s very 
cheap and that you can buy something from which a spray 
can be produced very cheap, and he may not think, on look¬ 
ing at it. that the thing is worth the money. It is impossible 
to say what are the reasons why in about one in five of the 
cases where these applicants come to the plaintiff the 
applicant does not follow the matter up but in the course of 
this fortnight of trial sends the thing back and has done 
with it. In the case of the other four fifths, what the 
plaintiff finds by experience is that they go on using the 
specific, that they give their repeat orders for the fluid, 
and that they give their .repeat orders because things 
have got worn out in the course of time for the vapouriser, 
and he will tell you that lie haB upon his books very con¬ 
siderable numbers of customers who have been customers for 
many years and who go on keeping the inhaler by them and 
keeping the specific by them in order, if there are symptoms 
of the recurrence of asthma, to prevent or cut short the 
attack. It is a very remarkable circumstance in this case that 
a very considerable number of the purchasers of this specific 
who have been purchasers for long periods of time are 
members of the medical profession. Owing to what has 
taken place in this case I shall have to bring before you, not 
very willingly on their part, some members of the medical 
profession who will tell you for what reason they have been 
buying this specific for years. One of them is Sir Stephen 
Mackenzie, the most eminent specialist, I understand, in 
diseases of the respiratory organs. I do not suggest that 
Sir Stephen Mackenzie wants to come here to give evidence 
on behalf of the plaintiff—I must withdraw that, I am told 
that Sir Stephen Mackenzie is now out of this country. It 
is sufficient, for the present to say that a customer who has 
been a purchaser of this specific for years is that eminent 
man, and there are great numbers of other doctors. IVe 
have subpeenaed them, and I am told that in the course 
of this trial we shall put them into the box to hear whether 
there is any other explanation of their repeated orders for 
this commodity except that it is an honest remedy in their 
experience of it. There is a list, I am told, of upwards of 
250 medical men in this country and on the Continent who 
have been buyers of this specific, which is attacked by 
The Lancet apparently on behalf of the medical profession 
because The Lancet regards it as necessary in the public 
interests and in the interests of the medical profession. You 
will have to consider how that may be. It is not limited to 
that considerable body of medical men ; if it becomes 
necessary to go into the matter my client will take some of 
the letters of the alphabet in his list of customers and can 
give you the names of persons of undoubted character and 
undoubted po-ition who habitually for long periods have 
been usiDg this remedy. 

Mr. Justice Ridley: It does not effect a cure so that you 
can finish with it. 

Mr. Duke ; I am told that the only mode in which you 
can cure asthma is by preventing the attack and that the 
liability to the attacks of asthma is as constant as the 
liability to catch cold but that ihe symptoms when they 
show themselves can be dispelled by the use of this 
specific. Gentlemen of the jury, that is the nature of 
the plaintiff’s business and the mode in which it has 
grown up and the extent to which it has come; and 
as you will see, if the plaintiff is ut justly attacked the 
attack Is very serious upon him in bis material interests, 
just as it iB with regard to his character and reputation 
Having mentioned these matters to you I will come to the 
particular incidents out of which the attack which has been 
made sprang and the attack itself, and tire defence which is 
sought to be set up here for making the attack and persist¬ 
ing in it. In February, 1904, a man of the i ame of Cushing 
sent in to Mr. Tucker a form in which Ire r-quested to be 
supplied on trial with the specific. He described himself as 
of (J teen's Buildings in the Borough, as of the age of 39 
years, as being by occupation a lit'er, and said he had 
asthma for seven years, and that it had begun through his 
having bror chitis, and be went into a good many particulars 
with which I need not trouble you now. Then on the back 
of the form he stated his case as the case of Alfred Cushing 
and gave the address again and did not sign the terms, but 
although he did not sign the terms tire specific was 
forwarded to him and in due course he became a purchaser, 
and from time to time between February of 1904 and the 
latter part of the year 19C6 he obtained some additional 
supplies of the fluid. The plaintiff will tell you to what extent. 
It is not a thing which rapidly exhausts itself, but it may get 





TUCKER V. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


304 The Lancet,] 

g' 

dried up or sediment may deposit, as has been pointed out; 
bnt a few drops of it produce the vapour which is required, 
as I understand, and so it is not a thing which is rapidly 
used. In the year 1906, as it is said, Cushing died and he 
died somewhat suddenly. His death is said by the de¬ 
fendants, and I daresay truly, to have been the subject of an 
inquest before one of the London coroners. Tbe defendants 
have produced newspaper extracts and things of that kind 
which make it pretty clear that CushiDg’s death was the 
Bubject of an inquest before one of the London coroners. 
What took place there I have no means of knowing except at 
second hand. It may be that the defendant will tell you 
whether anything occurred there which would have justified 
inquiry with regard to Mr. Tucker or with regard to this 
specific. Nothing could have taken place there which would 
justify an attack upon Mr. Tucker, because Mr. Tucker 
obviously could not be a party on an inquiry as to a death, 
which is what is the nature of an inquest, and he was not a 
witness and bad no sort of notice or knowledge either of the 
death of Mr. Cushing or of any inquest upon him ; but the 
defendants say that the inquest took place and 1 will tell 
you presently what further they say about it. All I ask you 
to bear in mind is that Mr. Tucker had nothing to do with 
the inquest and was not present there, so that whatever took 
place there, the proceedings being ex parte as far as Mr. 
Tucker is concerned, could only have been ground for some 
inquiry with regard to Mr. Tucker or with regard to his 
specific. In that state of facts it was that some time after¬ 
wards, I think two or three months afterwards, the defendant 
published in his newspaper the libel which is complained of 
in this action. I will read it to you. 

Mr. Ki.don Bankes : Would you mind reading it from 
The Lancet ? 

Mr. Duke : I do not mind using The Lancet. 

Mr. Eldon Bankes : I will hand you some copies of it. 

Mr. Justice Ridley : Have I got it? 

Mr. Duke : Your lordship has it in the pleadings. 

Mr. Justice Ridley : I should like to see it in 
The Lancet. (Same handed to his lordship.) 

Mr. Duke : If your lordship will refer to page 701 you 
will see it before you at tbe bottom of the left-hand column. 

Mr. Justice Ridley : Is it correctly set out in the 
pleadings ? 

Mr. Duke : Yes, I think so. 

Mr. Justice Ridley : It is much easier to read in the 
statement of claim. 

Mr. Duke : Yes ; but my learned friend wants it from the 
paper and if I can oblige my friend I will. Gentlemen, in 
the course of this case, which is not likely to end before 
lunch, I expect you will have opportunities of reading this 
again, bnt 1 will read it to you. It is under the heading of 
“ Notes, Short Comments, and Answers to Correspondents,” 
where attention concentrates for the incidents which can be 
effectively put in a small space. 

Quack Advkbtisemests. 

In the course of an inquest held at the beginning of the year It was 
atated that a lahonrer who had died from consumption had been using 
Dr. Tucker's Asthma Specific Inhaler, for which he had given, accord¬ 
ing to a newspaper report which has reached us, 3 guineas, while 
the material with which he sprayed himself cost him 8a. an ounce.— 
[Note the words “sprayed himself.”]—Dr. F. J. "Waldo, the coroner, 
rightly stigmatised this kind of dealing as a fraud, and it is a humiliating 
thing for journalists to remember that such frauds could not. be com¬ 
mitted with any profit to the quack Bave with the cooperation of tho 
press. A correspondent has recently sent us a collection of advertise¬ 
ments of so-called proprietary- medicines which he had cut from papers 
of reputation in the country, inviting our opinion of them. Our 
opinion is that the misery wrought by quacks must be unknown to a 
good many proprietors of newspapers, or they would hardly share with 
the quacks Ihe plunder extracted from the public, mainly from the 
sick poor. The remedy 1 b in the hands of the public, who have only 
to signiiy their displeasure, at resding in their journals invitations to 
he robbed and poisoned, to lind those invitations immediately cease. 
But the public are largely uninatructed and credulous, and, alaa, those 
responsible for the conduct of many of our journals take no trouble to 
enlighten them. They prefer to regard all protests against quack 
advertisements as emanating from the narrowncas of the medical pro¬ 
fession. This is certainly a convenient faith, but how it can be truly 
held by educated people passes our comprehension. 

That is the libel. It is open to everybody who pleases 
to discuss quack remedies, to discuss specifics, to say in 
proper and moderate language that it is not in the public 
interests that any kind of specific for the treatment of any 
ailment should be sold by anybody who is not a registered 


medical practitioner ; it is quite open to any man who likes 
to discuss those facts in any moderate and proper terms and 
with any strength of criticism ; but I submit to you. and I 
believe you will hear it is the law of this country, that you 
may not accuse a man of fraud, of fraudulent dealing, of 
being one of a class of people who poison and rob the 
credulous poor, without having substantial warranty for the 
charges you make; and of substantial warranty for the 
charges which are contained in this very gross libel upon the 
plaintiff when you come to examine what the defendants 
have set up in their defence in this action I think yon will 
find there is not a shadow. Jast let us see for the moment 
before I part from this what it is said. It is said, a* you 
will observe, that this kind of dealing—that is, the plaintiff's 
kind of dealing—is to be rightly stigmatised as a fraud ; and 
it is said that the people with whom the plaintiff is classed 
are people who plunder, who rob and poison the credulous 
poor ; and that all that is published by way of statement and 
observation with respect to the specific which I have been 
describing to you, with respect to tbe business which I have 
been describing to you, carried on in the manner which I 
have mentioned to you, and with regard to the plaintiff who 
will shortly go into the box before you. I told yon that it was 
pretty apparent that the editor of The Lancet, or the person 
who wrote this on behalf of the defendant, knew nothing 
about Mr. Tucker and his specific. Let ua see whether he knew 
anything. Do you notice that what he says is that it was 
correct to say that the man whose body had been the subject 
of the inquest had bought a liquid with which he “sprayed 
himself.” If he knew anything abont this remedy he must 
bave known perfectly well that the man did not spray him¬ 
self, that it was quite untrue and a gross misrepresentation 
of the fact, and that this was a treatment which produced 
a vapour, and not very palpable vapour. He must have 
known that. Then do you notice that he describes Mr. 
Tucker ss one of a class of quacks advertising in the public 
newspapers who are the public nuisance and danger he 
mentions there. I must do the proprietor and editor of 
The Lancet the justice to suppose that they did not 
gratuitously make a false charge against tbe plaintiff of 
being a quack who advertised in the newspapers and by 
means of newspaper advertisements. Y'ou see he says 
“plunder the public”; so that when you look into this 
before you hear anything from the defendant it is pretty 
clear that he did not know anything about Mr. Tucker or 
his remedy. My clients were quite willing to suppose that 
that was so. Mr. Tucker did not at once become aware of 
what had been published in The Lancet. If need be he 
will tell you bow he ultimately became aware of it; it was 
brought to bis notice. Then his solicitors, Messrs. Venn 
and Go., of whom Mr. Venn is the representative, wrote a 
perfectly proper letter to tbe editor of the defendant’s paper 
—a long letter. I am going to read it to you because it was 
written by a man, Mr. Venn, whom I will call before yon, 
who was in a position to say that his life, which had been 
practically impossible as a professional man because 
of constant attacks of asthma, had been restored 
to him as the comfortable life of an ordinary person 
by the nse of this specific, and who naturally wrote with 
some detail and with some little warmth about this matter. 
But he wrote a letter which enabled the defendant, if the 
defendant did not desire wrongfully and oppressively to 
crush the plaintiff, and wrongfully and oppressively to hold 
him up to odium, to retrace his steps. This is the letter of 
the 9th of May, 1907, to the Editor of The Lancbt : “Sir,— 
Mr. A Q. Tucker, of ‘ Onaway,’ Half Moon-lane, Herne Hill, 
has consulted us respecting a paragraph beaded * Quack 
Advertisements ’ appearing in your issue of the 9th March 
last, which has very recently come to his notice. Our client 
is the general manager in England for Dr. Tucker and has a 
considerable personal and direct interest in the sale and 
distribution of the atomizer and specific. The statement 
with reference to the inquest and to the sale of tbe inhaler 
(or atomizer) and the spraying material (or specific) that 
‘ Dr. J. F. Waldo, the Coroner, rightly stigmatised this kind 
of dealing as a fraud,’and the nse of the word ‘quack’ in 
connexion with Dr. Tucker ”—he is the plaintiff's brother— 
“ are the subject of very serious complaint by our client. No 
opportunity of being present at tbe inquest was given to our 
client. Had he been present he would have been able to 
satisfy the Coroner that the charge of fraud, if in fact such a 
charge was made, was absolutely without foundation. Onr 
client has not seen any report of the inquest which support* 
your statement that the Coroner attributed fraud or blame to 




The Lancet,] 


TUCKER v WAKLEY AND ANOTHER. 


[Fku. 1, 1908. 305 


him. It appears to us extremely unlikely that the Coroner 
would have done so in our client's absence ” (a very 
proper observation, I should think). “ Will you be good 
enough to refer us to the newspaper report upon which your 
remarks were based ? We enclose a pamphlet issued by our 
client. On page 80 you will find a memorandum of the terms 
on which the atomizer and specific are supplied to probable 
purchasers.” That is the memorandum which I read to you. 
“You will see that the atomizer and a suflicient supply of 
the specific are sent on trial without payment or deposit, the 
only liability being to return them within two weeks if not 
found satisfactory. Payment is only required if the applicant 
retains them. The atomizer and specific are both of a very 
special nature. As to their efficiency we refer you to the 
pamphlet enclosed. They have been used and recommended 
by numerous members of the medical profession in the 
United Kingdom. Our client’s business is a large and in¬ 
creasing one. He opened a London office in 1899 and has 
since 1902 resided and carried on business at his present 
address. The business has been honourably conducted 
throughout. Dr. N. Tucker is a regular graduate of the 
Bellevue Medical College of New York City, U.S.A., and is 
legally authorised to practise as a physician in the United 
States and to use the titles of Doctor and M.D. He has 
practised as a physician at Mount Gilead, Ohio, for about 27 
years. The atomizer and specific are not advertised in the 
public press. A sense of justice and right feeling should, 
we think, have led you to communicate with our client 
before making the offensive and injurious remarks con¬ 
tained in the paragraph complained of. Had you done so 
you would have received such information as would, we are 
convinced, have shown that there was not the slightest 
ground for adverse comment. A grave injury has been done 
to our client, both in reputation and in property, and we, 
on his behalf, request you to make what reparation is 
possible by publishing an ample apology for the injurious 
statements and a withdrawal of all imputations. We have 
our client's instructions to commence proceedings for obtain¬ 
ing legal redress if such an apology and withdrawal are not 
published, at latest, in your issue for the 18th inst.” ; that 
gave him nine days. “We shall be obliged by your 
acknowledging the receipt of this letter." Now, gentlemen, 
if the plaintiff's business is such a business as I have 
described to you, if his terms of dealing are in truth those 
terms of dealing which were laid before the defendant in 
the memorandum, if this specific is in any degree an honest 
preparation, what was the business of the defendant when 
the defendant got that letter showing him in what position 
he had placed, not only the plaintiff, but him, the defendant 
himself 7 His business was, as he knew nothing, apparently, 
about Mr. Tucker or Dr. Tucker, or the specific, or the mode 
of dealing which he had reprobated in such unsparing terms, 
to find out what were the facts and if he was going to con¬ 
tinue to attack Dr. Tucker and Mr. Tucker and the specific 
and the mode of dealing, to do it upon knowledge. That is 
jnst what he did not do then and what he has never done 
since. With that knowledge before him on May 13th the 
editor of The Lancet wrote this letter to the plaintiff's 
solicitors :— 

Deab Sirs, —The statements that, a labourer who had died of con¬ 
sumption had been uBing an Inhaler which cost. £3 3s. and a spray at 
8s. an ounce w-ero made at an inquest reported in the Morning 
Advertiser on January 2nd, 1907. We should like to kmiw which of 
them you challenge The documents handed to the City coroner Imre 
the title, " Dr. Tucker's Asthma Speelltc." The City coroner is 
reported t-o have said •' It Is a quack remedy," and " It is *a fraud " ■ we 
expressed our view of this language upon tiie statements before us. 

That is not true. They did not express their view of that 
language ; they say : It is a fraudulent system of dealing ; it 
is rightly stigmatised as a fraudulent system of dealing; and 
they themselves took the responsibility on themselves of 
classifying the plaintiff in this action with the rogues who 
they said plundered and poisoned the public. You will 
remember the terms of the libel. That is what they have 
done and they write to us : We should like to know whether 
a labourer who had died of consumption had been using an 
inhaler which cost £3 3s. and spray at 8». an ounce. Suppose 
it were true that a lahourer who died of consumption had 
bought an inhaler for £3 or £3 3*. and bad bought a fluid at 
8 *. an ounce how far would that go to establish a fraud upon 
anybody 7 If the labourer had been deceived by Mr. Tucker 
into buying something then, of course, Mr. Tucker could be 
stigmatised as having been fraudulent in his dealings. 
Nothing of the sort They supposed, apparently, that if it 
be true that Alfred Cushing, after trial of this specific for a 


fortnight, bought the apparatus at the price at which he was 
told he could have it and afterwards bought a new supply of 
the fluid at the price at which he was told he could have 
it, that warrants them in declaring that the plaintiff's 
business is rightly stigmatised as a fraudulent system 
of dealiog and that the plaintiff and the inventor 
of the remedy itself are to be classed and stigmatised 
in the way in which it is done in this libel. My 
clients could not accept that mode of dealing with this 
matter, and on the 14th of May they followed up this. They 
pointed out, as the newspaper, the Morning Advertiser, seems 
to have led them to point out, that upon the newspaper 
expressions which the defendant produced he was wrong. It 
was quite immaterial whether he was right or wroDg. but this 
further letter was written on the 14th of May : “ We have 
to-day seen the report of the inquest appearing in the 
Morning Advertiser for January 2nd, 1907. Replying to 
your letter, the statement made at the inquest respecting the 
price of the inhaler aDd spray was misleading by reason of 
the omission of any reference to the terms on which the 
articles were supplied to purchasers. The coroner's remark : 
* It is a quack remedy,’ is not in accordance with fact. It 
seems clear to us, from the report, that the coroner's final 
remark, ‘ But it is a fraud,’ did not relate to the inhaler and 
spray. We mentioned in our previous letter that our client 
had no opportunity of being present at the inquest.” At 
some time or other those newspaper paragraphs will be read 
to you ; but apparently the coroner had said that it was very 
wrong on the part of the public authority in this country to 
allow specific remedies which were not prescribed by doctors, 
but which could be bought at a shop, to be sent out under a 
Government stamp, and that that was a fraud, that it led 
people to suppose that the Government vouched the value of 
the remedy. Something of that kind the coroner appears to 
have said, but we shall hear. On the 2lst of May, having got 
those two answers, instead of an honest attempt either to be 
in a position to justify these charges or a withdrawal of 
them the plaintiff’s solicitors wrote and said : “Referring to 
our correspondence with the editors, we are instructed by 
Mr. A Q. Tucker to commence proceedings against you in 
respect of defamatory statements contained in your issue of 
9th March last, page 701, and shall issue the writ to morrow. 
Please send us the name of solicitors who will accept service 
of the writ on your behalf," and then this action was begun. 
Now, I will tell you shortly what the defendant has done 
in this action with a view either to mitigate or to aggravate 
the injustice which upon the facts which I have stated to 
you, I venture to say it is perfectly clear be has done Mr. 
Tucker. He came to deliver his defence on July 9th, last 
year, and what he said in his defence—the substantial part of 
it, and the only part which is material to the observations I 
have to address to you—was : “The said words are fair 
comments made bond fide without malice and in the honest 
belief that they were true on certain matters of public 
interest—viz , (a) an rnquest held by Dr. if J. Waldo, the 
City Coroner at Southwark, on Jan. 1st, 1907, on the body of 
a labourer named Alfred Albert Cushing and the statements 
and evidence given at the said inquest and in particular the 
evidence of Dr. G. A. Paton that the death of the said Alfred 
Albert Cushing resulted from old-standing and advanced con¬ 
sumption and the evidence of the deceased's widow that 
the deceased used according to printed instructions 
produced before the said coroner an inhaler known as 
Dr. Tucker's atomizer which cost three guineas and 
a spray known as Dr. Tucker's Asthma Specific which 
cost 8s. an ounce and the following statement 
of the coroner: ‘Tucker’s Asthma Specific appears to be 

an American thing . GentlemeD, this is what I call 

a quack remedy. I have had a number of cases of 
quack medicines in connexion with which credulous people 
are deceived by seeing the Government proprietary article 
stamp on them and are deluded into believing that the 
Government guarantee the contents. They get a very rich 
harvest out of the sale of the stamps'—that is obviously the 
Government—‘but the sooner they do away with the stamps 
the better, so that the public may be undeceived . any¬ 

way, gentlemen, the remedy [meaning Tucker's asthma 
specific] is a fraud.’ (A) The sale to the public at the price 
of 3 guineas of Dr. Tucker’s atomizer and at the price of 
8s. aD ounce of his asthma specific. The constituents of the 
said specific are cocaine and atropine (which are poisons and 
dangerous if used without medical advice), sodium nitrite, 
glycerine, oil of gaultheria, and water. Quantities of these 
constituents sufficient to make up one ounce of the said 






306 The Lancet,] 


TUCKER r. WAKLEY AND ANOTHER. 


[Feb. 1, 1906. 


specific, together with a suitable spraying instrument, couid 
be obtained from any chemist at a cost of 8s. to 9s. (c) Ad¬ 

vertisements of so-called proprietary medicines.” That was 
the defence which they put in at that time. Let us under¬ 
stand what was the meaning of it. What they had said was : 
Your, Mr. Tucker’s, system of dealing in this specific is a 
system of fraudulent dealing. The only defence, as I under¬ 
stand the law—but I am speaking with unfeigned respect to 
what you will hear from the B inch in the matter—the only 
defence which a man can effectually make when he has 
aocused another man of a system of fraudulent dealing is to 
say : you were guilty of a system of fraudulent dealing. 
That defence the defendant has not dared to make, did not 
dare to make then, and has not dared to make now ; but he 
has played round it to suggest the defence which he dare 
not honestly raise. 

Mr. Justice Ridley : He says that the fraud suggested by 
the coroner is the fraud arising out of the fact that there is 
a Government stamp on the inhaler. 

Mr. Duke : So he says. 

Mr. J ustice Ridley : That is right, is it not, Mr. Bankes ? 

Mr. Eldon Bankes : No, my lord, not quite. 

Mr. Duke : I do not quite know. It is ingenious and 
it may be a little subtle, but we shall get to the bottom of it. 

Mr. Justice Ridley : That is the first part of it, but there 
may be something more in it. I think there is another 
element in it under the head ( b ). 

Mr. Duke : Yes ; I was going to take them seriatim and 
see what he does say. I was suggesting at the moment that 
it is not enough unless there is an allegation that there is a 
fraud. 

Mr. Justice Ridley: Then that fraud is quite a different 
fraud from ihat which is suggested in the article. 

Mr. Duke : Absolutely, and it is not the plaintiff's fraud. 

Mr. Justice Ridley : That will be for the jury. It is quite 
true. I must not say that. 

Mr. Duke : I have to point out what is the nature of the 
issues which are raised here, and how it is attempted to 
get rid of the consequence of an open and deliberate 
charge of fraud upon the plaintiff in his system of 
dealing in thisspecifio. A charge of a fraudulent system of 
dealing, a charge of plundering the public by means of dis¬ 
honest advertisements, and of poisoning the public— 
poisoning the credulous, ignorant people. That is the charge. 
Now 1 am going to see what he says about it, to Bee what 
excuse he has got ; because justification he does not pretend 
be has cot, although lie will have to before he is going to get 
out of this matter. He says it was fair comment—that iB to 
say: "Yours was a trairuulent system of dealing” was 
fair comment upon this. There was an inquest held, says 
he ; it was proved at the inquest that a man called Cushing 
was a labourer, and that he had been using an inhaler for 
which he gave three guineas, and a fluid for which he gave 
eight shillings an ounce ; that he was suffering from advanced 
consumption, and that the coroner said that he bad had a 
number of cases where the people had been deceived by the 
Government stamp upon proprietary articles, and that the 
Government ought to stop it because it deceived people into 
supposing, which was not the fact, that the Government gave 
some sort of voucher for the value of the article on which 
the stamp was. Then he goes on to speak of the other 
matter which was outside of the inquest, that the plaintiff 
sells the inhaler and the specific at the price at which he in 
fact sells them, and that other people who may be rascals 
for all I kuow—I am not going to try their character—other 
people of whom he has given ns a tremendously long list, 
who advertise in the papers all sorts of remedies—I am not 
going to mention one of them—which have all sorts of 
notorieties—that those people are fraudulent quacks. T’ou 
follow that my client’s apparatus and liquid are expensive, 
and other people publish fraudulent advertisements of quack 
medicines ; and then he says: If that is true, if Cushing 
did in fact die of consumption after he had been using your 
asthma specific for about two years, and if he in fact paid 
the price we mention for it, and if the coroner said that the 
use of the Government stamp deceived poor people and ought 
to be stopped, and if you do sell this stuff at a high price 
whereas the ingredients could be bought at a low price, 
and it other people publish fraudulent quack advertisements, 
then we, the proprietors of The Lancet, are entitled to say 
about you, the plaintiff, that you carry on a fraudulent 
business, you rob, you poison the public, and to hold you up 
to odium in that way. Anything less like the charge they 
made than the materials upon which they sought to justify 


it would be bird to see. I venture to say that it would be 
impossible that a charge of carrying on a fraudulent business 
by fraudulent dishonest methods could be supported upon 
what is suggested to have taken place at this inquest and 
what is suggested to have been said by the coroner. 

It may be these defendants, if they go so far, will call the 
coroner. I desire to speak with respect of every man who 
holds a public office in this country. For my part I cannot 
imagine that any coroner, whether in London or in the 
remotest part of England, who was inquiring into the death 
of a man who died of consumption, could have felt himself 
justified, in the absence of some other man about whom he 
knew nothing, in declaring that he found that other man 
guilty of being a fraudulent rascal, carrying on a fraudulent 
business, and robbing and poisoning the public. I cannot 
conceive that any coroner would forget the instincts of 
judicial office—a minor judicial office—or the instincts of 
fair play among men, so far as to say such a thing as that 
about a man whom he had never seen, with regard to a 
specific of which probably be did not know, under circum¬ 
stances which were not before him for trial; but we shall 
see. I say that because the defendants, not being apparently 
satisfied that the pretended defences which are set up in 
what I have read to you would clear them of the attack of 
which they had been guilty towards the plaintiff, on 
Nov. 21st last, after a lapse of four or five months, in which 
they could make honest and patient and unprejudiced inquiry, 
and could find out whether the man carried on his business 
as a respectable firm of solicitors had told them he did carry 
it on, by this method of not selling these articles except upon 
trial, or at any rate offering them for trial in order that 
people might know what they were doing—after having four 
months for ascertaining that, I will teli you what they did. 
They did not amend their defence by saying that they 
regretted they were wrong, or by saying tuey found they 
were right, and that the plaintiff did cany on a 
business by fraudulent means. No, they added a little 
more venom to this pretended plea of fair comment 
—a plea which was an abuse of the right of plead¬ 
ing, a plea of matters which if they were to be pleaded 
to attack the plaintiff’s character ought to be pleaded as 
matters of fact and not as matters of statement in the 
plaintiff's absence. But they went on to add that the 
plaintiff’s specific was used by Cushing according to the 
plaintiff’s printed directions—that was harmless enough— 
and that the coroner said “ Tucker's asthma specific appears 

to be an American thing. Gentlemen, this is what I 

call a quack remedy. Anyway, gentlemen, the remedy 

is a fraud.” Four months after they had delivered their 
defence and seven months after they had published their 
libel they said they had discovered that the coroner had said 
that tliia was a quack remedy and that the remedy, meaning 
Tucker’s asthma specific, is a fraud, and then they left it 
there. They do not venture to sey: This is a pretended 
remedy, it is spurious, it is ineffective, or anything of that 
sort ; but they say that the coroner said this. They cannot 
shelter themselves behind the coroner. They have said: 
" Y’ou, Tucker, the plaintiff, cany on a fraudulent system of 
business." That is one thing they have said, and they have 
said these other matters and they cannot shelter themselves 
behind such a statement as that, if it was ever made, which 
I take the liberty of doubting, if it was ever made by a person 
who had no right to make it, because he had not had the people 
before him upon whose conduct it was suggested he proceeds 
to pass this severe censure. But that is the way in which 
they have left it, and so they say that if the coroner in fact 
said that this was a quack remedy and that he regarded it as 
a fraud, if he said that in his privileged position—rather, I 
think, by way of abuse of a privileged position, but that is 
beside the mark—if he said that then we, the proprietors 
of The Lancet, are entitled to take onr newspaper and to 
publish to the medical profession among whom you have 
numerous customers, that you, Tucker, who deal in England 
in this remedy, carry on your business by a fraudulent 
system of dealing, that you are the representative in 
England of a man who is a quack—that is, this medical man 
in America—and that your remedy itself is a quack remedy 
and a fraud. If they think they can shelter themselves 
behind anything, whether it was said or it was not said, or 
behind the coroner, they will find themselves, I believe, 
grievously mistaken before they have done with this case. 
But upon those issues they have left this case to be tried. 
They have taken care to avoid giving Mr. Tucker an 
opportunity of dealing as he would have been glad to 







The Lancet,] 


TUCKEB t>. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 307 


deal with any charges which they thought tit to make 
upon their own responsibility, and they have sheltered 
themselves behind what they say was the opinion of the 
coroter, whereas what they have charged is not a matter 
of opinion but a matter of fact—namely, a fraudulent course 
of dealing and a fraudulent system of business. That 
is the outline stated at greater length than I intended 
to have taken up in dealing with this case. The grievance 
which the plaintiff complains of is the grievance of the 
charge of fraud which I have mentioned before. With the 
assistance of my learned friend I shall call a considerable 
bodyof evidence before you to show what the plaintiff’s mode 
of doing his business has been, and the value, in any sense 
in which you can speak of value, to the persons who have 
applied his remedy has been, and when you have heard that 
evidence and heard any further excuses which the defendant 
may find to be available to him it will be your business to 
say what amends ought to be made to the plaintiff in respect 
of this charge of carrying on a fraudulent business, made in 
the first instance, I am willing to believe, in ignorance of 
what the plaintiff’s method of business really was, but in 
substance persisted in under various cloaks and covers down 
to the present time. My learned friend and I will call this 
evidence before you and you will hear what the defendant 
has to say. My lord, there are a couple of witnesses whom I 
should like, if I may, to interpose before the plaintiff because 
I cannot keep them. One of them is the Earl of Harewood 
and the other is a member of the Bar. 

Mr. Justice Rloley : Very well. 

Mr. Alexander Dingwall Bateson, examined by Mr. 
Smith. —You are a member of the Bar 1 —I am. 

I think from childhood you have been liable to asthmatic 
attacks !—Until I bought Mr. Tucker’s specific. 

At what age as far as you can recollect did your constitu¬ 
tional tendency to these attacks develop itself ?—To my 
certain knowledge at eight years of age. 

And from that age how long was it until you heard of Dr. 
Tucker's remedy !—I think it is about four or five years ago, 
but I am not quite sure of the actual date. 

Mr. Justice Ridley : That was the first time when you 
bought that remedy'(—The first time. 

About four or five years ago ?—I think it is about four or 
five years ago, but Mr. Tucker will be able to tell exactly 
from his books. 

Mr. Smith : I do not know whether you would mind 
telling us how old you are now ! -Rising 42. 

So that for about 30 or 35 years you were suffering from 
asthma and you did not know of Dr. Tucker’s remedy ?— 
That Is so. 

Will you tell my lord and the jury what degree of trouble 
you had from asthma before you heard of Dr. Tucker’s 
specific ?—As I grew older it was getting worse, and 
constantly for weeks together I could hardly sleep at all. 
I could do my work duriDg the day but at night it was very 
troublesome. After I bought this specific 1 have been able 
to sleep perfectly well and I have never had any trouble from 
the asthma at all. 

8o it was proving a real difficulty in your way before 1 —It 
was getting more and more troublesome and I thought really 
getting serious. 

Before you came across Dr. Tucker's remedy did you 
consult any doctors 1 —Well, my earliest recollections are 
being under Sir William Jenner, and as a child I used to go 
and see him from time to time nearly up to the time of his 
death, I think. Since then I have not bothered very much 
with doctors at all. 

Even with his advice did you get the relief which you have 
had since you have used Tucker’s remedy i —No, I had 
recurring attacks in the same way. I daresay there was a 
certain amount of relief from time to time, but I never was 
free from severe attacks. 

Has the use of Dr. Tucker’s specific involved a growing 
use'/—Oh, no ; the longer I use it the less I use it, it one may 
say so ; the longer I have had it, the less I find I have had 
to use it. 

You get relief more easily?—I really hardly require it 
at all. 

Something has been said about the price of this specific. 
What price do you pay for one instalment, so to speak, of 
this specific ?—I pay about 8s. every 12 or 18 months. 

Is the amount which is Bent to you adequate for that 
period ?—It is the ounce quantity ; I get the ounce quantity 
and I pay my 8s. 

And in your experience you find that lasts you 12 or 18 


months ?—I think so ; certainly 12 months, and I think 
more. 

Will you tell my lord and the jury how you came to give 
evidence in this case —I saw some proceedings in the Court 
of Appeal with regard, as I thought, to an attempt to dis¬ 
cover what the secret was, and, seeing that the case had 
reference to this remedy, I told you that I could give evi¬ 
dence as to how satisfactory the remedy was. 

You volunteered it ?—Certainly, absolutely. 

Cross-examined by Mr. Eldon Bankes : There is nothing 
on the bottles which you have purchased to indicate what 
this stuff contains '?—No. 

Have you been using it without knowing that it contains 
two poisons, cocaine and atropine !—I have been told by 
various doctors that it contains poisons, but all the doctors 
have fed me on poisons ever since I started. 

We will see in a moment; but it is common knowledge, 
is it not, in the medical profession that this Tucker’s 
specific does contain poisons ?—Well, they say so, but I do 
not think they know. 

We will see. At any rate, this has been put into your 
hands without any warning that it contains either cocaine 
or atropine ?—I would not like to say that. I am not at all 
sure that somebody had not suggested that it contained 
cocaine. 

1 mean so far as Mr. Tucker is concerned ?—I never asked 
him. 

And there is nothing on the bottles to indicate that it 
should be used with caution ?—None at all; there is nothing 
on the bottles at all as far as I remember. 

So far as you are concerned it so happens that you have 
used it with caution and you have used it very infrequently ? 
— N ot at all ; I have not used it with any caution and I have 
used it whenever I wanted it. 

Mercifully for you, you have not required to use it very 
often !—I did when I first started. 

How often did you use it then ?—Constantly, especially at 
night. 

1 suppose yours is a case of true asthma, is it not ? Have 
the doctors ever told you that ’—The doctors have never 
been able to tell mq what it is. 

Is your heart sound so far as you know l —I have been 
passed as a first-class life by the insurance office year after 
year quite recently. 

Do you know the danger of using cocaine if your heart is 
unsound?—I have used cocaine. I used cocaine to a large 
extent at one time under doctor’s orders for bay fever. 

Of course under a doctor’s advice and under a doctor’s 
supervision ’—Not supervision. 

Under his advice ?—Under his advice ; and it is very nasty 
stuff. 

This stuff tastes sweet, does it not 1—There is no trace of 
cocaine in this that I could detect, although I have taken 
plenty of it. 

So far as it has a taste it is a sweet taste, is not it 1 —I 
should say none. 

Mr. Justice Ridley : Cocaine is the stuff that is used for 
taking away pain in a tooth, is it not ! 

Mr. Eldon Bankes : They used to use it until they found 
the danger of it. 

Mr. Justice Ridley : I think they use it for that. 

Mr Eldon Bankes : They used to, but they have found it 
dangerous. 

The Witness : I think I bad some the other day from a 
dentist. 

Mr Eldon Bankes : I think I can show that it is one of 
the most dangerous poisons which you could possibly put 
into anyone's hands. 

Mr. Justice Ridley : There has been a development about 
this lately. There is a sort of remedy known as Fellows’s 
syrup of hypophosphites ; that contains poisons and I dis¬ 
covered the other day that they have fouDd it necessary to 
mark it as poisonous and you have to sign the book for it, 
but it certainly was not done two or three years ago. It is 
a perfectly well-known article and has been on the market 
for years and years. 

Mr. Eldon Bankes : There is no doubt that there Is no 
right to sell this. It comes under the Pharmacy Act and 
this is largely sold absolutely contrary to the Act of 
Parliament. 

Mr. Justice Ridley : When the poisons have been in small 
quantities 1 think it will be found it is a fact that they have 
disregarded the Pharmacy Act. 

Mr. Eldon Bankes : I will not anticipate. 





308 The Lancet,] 


TUCKER ». WAKLEY AND ANOTHER. 


[Feb. 1, 1938. 


r Mr. Justice Ridley : That was 'an instance which came 
under my observation ; I daresay there are others. - ^ 

Mr. Smith : Your lordship will hear evidence, no doubt. 

Re-examined by Mr. Smith. —I understand that in your 
pre-Tucker days, if I may so express it, you had several 
pnisons recommended to you by the medical faculty?—Sir 
William Jenner fed me mostly on arsenic and other doctors 
have given me chlorodyne. I could not tell yon the name 
of any doctor who has given me that, but I believe chloro¬ 
dyne is mostly laudanum. 

Mr. Justice Ridley : But although they are poisons, in 
minute quantities they are perfectly well recognised by 
doctors ; so is strychnine. 

Mr. Smith : Yes, so I understand. 

Mr. Eldon Bankes: Yes. 

Mr. Justice Ridley: That is the poison which is in 
Fellows’s svrup. 

Mr. Smith (to the Witness) : As for cocaine, I will just 
ask you one question. Was cocaine prescribed to you for 
asthma or not?—It was a suggestion which a doctor once 
made to me for hay fever as a relief. 

It was rather suggested by my learned friend that you 
showed some unusual degree of care in your use of this 
atomiser ; was that so ?—Absolutely no. 

Is it an instrument which it is easy to use either with great 
care or with negligence ?—I should have thought you could 
only use it in one way, and it could only be a question of the 
amount of use. and I have never shrunk from using it as 
often as ever I wanted it— I mean three or four times an 
honr. 

You might pinch that rubber ball carefully or negligently, 
but beyond that is there any way of using it carefully or 
negligently ? 

Mr. Eldon Bankes : It is a question of frequency. 

The Witness : I understood the question was a question of 
frequency, and as far as frequency is concerned l used it as 
frequently as ever 1 wished to and I have never exercised the 
least care. 

Mr. Smith : When you first began to use it in order to 
deal with these night attacks what was the frequency of the 
use you had to make, roughly ?—It might be three or four 
times in half an hour or even oftener, but the relief comes so 
quickly that you do not want to go on using it for hour after 
hour because, so far as I am concerned, relief always comes 
very quickly. You would not go on using it for hours 
because the relief is so quick. 

Mr. Eldon Bankes : Unless you have got the cocaine 
habit. 

Mr. Smith : Is that my friend’s suggestion? 

The Witness : I do not follow that. 

Mr. Eldon Bankes : We will discuss it afterwards. 

The Witness: I have not got the cocaine habit from the 
use of it so far as I know. 

Bertram Earl of Ashburnham, examined by Mr. Smith. 
—Would you mind telling us how old you are?—Not at all; 
67 years old. 

Have you for some years past suffered from asthmatic or 
quasi-asthmatic trouble?—Yes, for five or six years past at 
least 

What has been the nature of your attacks ?—Very violent 
attacks of breathlessness. 

Does it come on in the day or in the night time?— 
Principally in the day ; it never comes on at night; it comes 
on in the daytime, and never when I am at rest, and I 
think that is what distinguishes it from true asthma. 

It does not come on when you are lying down but when 
you are up in the day ?—Yes. 

During those years have you had almost constant trouble 
with it ?—Constantly in bad weather, yes. 

Have you tried many treatments?—A good number of 
different kinds, yes. 

What treatment, for instance, have you tried before you 
tried Dr. Tucker’s?—On one occasion I was advised to go to 
the waters of Mont d’Or in France, said to be very good 
arsenical waters, and afterwards a course of Nauheim baths 
here in London, but neither of them did me much good ; they 
were both beneficial to the general health but of no benefit 
to the special complaint. 

Have you consulted many doctors ?—Yes, several. 

I take it generally you have tried ail kinds of remedies?— 
Practically speaking I should think all recognised remedies, 
and all under medical advice. 


I want to take you back to a year or two ago. Do yon 
remember having an acute attack in London a year or two 
ago?—It was a year ago last November or December 
possibly. 

I am not sure whether you were on your way from the 
Continent. YYere yon in London on a visit?—I had 
promised to come here to attend the debates or the 
Education Bill. London is a place which disagrees with 
me, as a rule, in winter, and I keep away from it as much 
as I can, but I was obliged practically to be here and I 
was rather afraid I should have to go on account of this 
complaint. 

You tell us you had a severe attack during that time 1 — 
Y'es. “Attack” is not perhaps the proper word for it 
because I was not laid up, but I was constantly suffering. 

Breathlessness ?—Breathlessness. 

Did you consult anyone ?—I consulted Dr. Mitchell Bruce 
of Harley-street. 

Was that the first time you had been to see him ?—No, off 
and on I had seen him for a good many years—I daresay 20 
years, or more perhaps. 

What advice did Dr. Mitchell Bruce give you?—Dr. 
Mitchell Bruce gave me a tonic to take internally but for 
the breathlessness he said he could only recommend Mr. 
Tucker’s cure. 

Had you heard of Mr. Tucker’s cure before ?—Y’es, I had 
been advised by a doctor in Paris about two or three years 
before to try it. 

I do not know whether you recollect who that doctor was ? 
—His name was Muller, a French doctor. 

Did Dr. Mitchell Bruce tell you where you could get Dr. 
Tucker’s cure ?—He told me it could be procured from Mr. 
Tucker himself ; it was not sold by any chemist. 

Did you know his address ?—No, and Dr. Bruce could not 
tell me. 

How did you find it?—Dr. Bruce advised me to go to 
various chemists, and he said possibly I might be ableto find 
it, but he could not be sure. 

To take it shortly, you did in fact, I think, find it from 
some chemist ?—I found it from Messrs. Savory and Moore. 

Did you go to Mr. Tucker’s house in Herne Hill the same 
day that you were successful in obtaining the address ?—I 
took the train at once from Victoria Station and went down 
to Herne Hill. 

Whom did you see at Mr. Tucker’s house ?—I saw a lady. 

I think she showed you the atomiser ?—She showed me the 
atomiser and gave me some explanation of it, and probably 
allowed me to try it, but that I cannot distinctly remember. 

Did you take it on this trial system or did you buy it 
outright ?—I bought it outright. 

do not know whether y knew of the trial system ?—I 
knew of the trial system. 

Since then what use have you made of the atomiser and this 
specific 1 —I have used it constantly, except in very fine, warm 
weather. In summer I get on, as a rule, without it, but at 
this time of the year I am never without it, especially when 
I am in London. 

What has been your experience of its effect on your breath 
troubles ?—It remedies them absolutely. 

To what extent during the attacks which you have had 
since you have got it have you used the specific?—Whenever 
I have been able to. I have always used it. 

Whenever you have had an attack?—Whenever I have had 
an attack. 

Have you ever experienced the slightest ill-result from 
using it ?—No, never the slightest. 

Has your experience been or not, that the effect wears out 
with frequent use?—No, quite the reverse. 1 think that 1 
am distinctly better than l was a year ago. I am not cured 
and do not pretend to be, but I am distinctly better. 

How long does an ounce of specific last ? That is 8s. 
worth, is it not ?—I cannot recollect the price exactly. 

Never mind the price. Do you recollect about bow long 
one lot of it lasts ?—A very long time, but I could not 
exactly tell you how loug. I think I have only once had to 
buy any more since I first got it. It lasts for a very long 
time. 

So that you are still using the same atomiser and you liave 
had one renewal of the specific ?— I think I have had one 
renewal of the specific. I do not like to be sure because 
I am on my oath, but I can only recollect one. 

So that a year's treatment or over a year’s treatment cost 
you a little over £3?—Yes. I may say I still have a bottle 
which has not been opened yet. 




The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908 , 309 


So that a year's treatment which yon say has been 
beneficial has cost yon a little more than £3 ?—A little more 
than £3. 

How does that compare with what yon were paying to 
doctors for this same ailment before ? 

Mr. Eldon Bankes : I object to that. 

Mr. Justice Ridley : I do not think jou need ask that. 

Mr Smith : Very good. At any rate, have you regretted 
the £3 r.bat you have spent on this ? 

Mr. Eldon Bankes : I object. 

Mr. Smith : Surely I am entitled to ask that. He says 
that he spent £3 on this atomiser. He has given us bis 
experience of the use of it, and I ask him whether he regrets 
the £3 that he spent on it. It is not worth while persisting 
in if my iriend objects. 

Mr. Justice Ridley : Yon need not ask that question 
either, I should think, because if he has got relief from 
asthma he certainly does not regret it. 

Mr. Smith : Perhaps so, my lord. 

Crott examined by Mr. Eldon Bankes —Can you give me 
an idea how often you nse this wheu you are troubled with 
these attacks 1 Is it once a day, or once a week, or once a 
fortnight?—It would be whenever I have an attack. 

Does that often come—every day .'—Sometimes perhaps 
six or seven times a day. 

Would you use the atomiser on that occasion six or seven 
timeB in the day ?—Yes. 

Then perhaps you would not use it again for a fortnight ?— 
I should think myself very lucky if that was to happen to me 
in winter. 

But it might be you would not use it again for a week 7— 
I should think myself very lucky again if that happened to 
me when I was in London. 

London is a place which does not suit you ?—London is not 
a favourable place for me. 1 came up yesterday afternoon 
and I should think I have used it perhaps three times. 

But when you are in the country you can go on for a long 
time?—Y'es, when I am in the country. 

Sometimes a fortnight and sometimes even more ?—Yes, in 
the summer. I would rather put it in this way, that I do 
not use it except when I want it. 

I only want to let the jury know how often you do want it, 
taking one week with another 7—Pretty constantly. I would 
rather put it in that way, if I may be allowed. 

I understand it was Dr. Mitchell Bruce who mentioned it 
to you. Did he indicate to you that he knew anything about 
it, or did he merely say: “You had better try Tucker”?— 
He more than implied that be knew all about it. He did not 
pretend to know its composition, but when Dr. Mitchell 
Bruce orders a thing I think he implies that he knows some¬ 
thing of it. 

He did not know where it could be obtained, I under¬ 
stand 7—No. 

Y’ou went down to Herne Hill and there you saw a lady ?— 
Yes. 

Did she ask you at all what was the matter with you, or 
was she merely a vendor 1 Did she ask you whether you had 
got any complaint for which it was suitable, or did you 
merely ask for it and was it supplied ?—I think I entered into 
some detail. I do not know whether she asked me or whether 
I volunteered it, but I certainly gave it. 

And she supplied the atomiser ?—She supplied the atomiser 
and a certain quantity of the specific. 

Was any information given to you that it contained any 
cocaine?—No. 

Or atropine 7—Or atropine. 

Was there no indication upon any of the bottles or boxes 
that were given to you that it contained poisons ?—No. 

Mr. Justice Ridley : I do not think you told us how long 
you have suffered.—I do not know exactly how long, but I 
should say more or less five or six years. 

That was the period of time ?—Before I knew of Dr. 
Tucker’s remedy. 

Henry Ultck Lascelles, Earl op Ha rewood, examined 
by Mr. Smith. —Have you been liable for some time to 
asthmatic or quasi-asthmatic trouble ?—Not quasi—asthmatic 
trouble, yes. 

About how long have you had trouble of that kind?—I 
have suffered more or less for the last six or seven years I 
should think certainly, but not lately. 

During the earlier part of this six or seven years did you 
take advice as to your ailment?—Y’es, I tried every sort of 


thing. It was entirely the result of influenza with me— 
repeated attacks of influenza. 

Did you take medical advice as well?—Yes. 

Did you get relief ?—No, not much, not from doctors. 

How long is it since you first heard of Dr. Tucker's 
specific ?—I do not exactly remember, but I think about six 
or seven years ago. 

Do you happen to recollect how you came to hear of it 
first ?—Yes, perfeotly. I think it was recommended to me 
by a lady whom I happened to sit next to at dinner and who 
told me it bad done her husband a great deal of good. 

It was recommended to you privately by a lady and did 
you then try it ?—Yes, I tried it at once. I sent for it. 

Wbat effect has it had on your trouble ?—The effect that 
it has on my asthma is that if-1 inhale Dr. Tucker's remedy 
for five minutes, say, at night, in about half an hour my 
breathing becomes quite clear and I can go to sleep. 

Have yon found the relief consistent ?—Yes, consistent. 

And in those five or six years that you have been using it 
have you experienced the slightest ill-effect from it 7—Not 
the slightest. 

Mr. Justice Ridley : I think you said you had suffered 
six or seven years from it, but not lately ’—Not lately, or 
only very slightly for the last year or year and a half. 

Is that since you have got this remedy ?—I cannot say 
whether it is this remedy. I attribute it to my not having 
had a cold for a year and a half. It is the cold that brings it 
on. 

Mr. Smith : A cold brings on an attack of this quasi- 
aBthma 7—Yes, or influenza. 

Whenever you have had these attacks you have found 
relief in the manner which you have described 7—Yes. 

Mr. Justice Ridley : It is as long as five or six years ago 
that you got the remedy !—I think so ; 1 cannot fix the 
exact date without referring to accounts, but I think it was 
about that time ago. 

Mr. Smith : If you had any trouble at all at the present 
time you would use it ?—Certainly. 

Crott-examined by Mr. Eldon Bankes. —Did you obtain it 
through the post ?—Yes, through the post. 

Did you answer the questions which we know are sent out 
to persons ?—Y’es, as far as I remember I did the first time I 
sent for it. 

Did you understand that those were questions which were 
submitted by somebody in order to ascertain whether the 
specifio was suitable for your case ?—Yes, that is what I 
understood. 

Then you bought it and it has given you relief 7—Y’es. 

Was there anything upon the bottle or any of the boxes to 
indicate that it contained poisons ?—No, I have not an idea 
wbat it contains. 

You had no idea, for instance, that it contained cocaine 7— 
No, I have since been informed that it does. 

I mean at the time you were using it 7—No. 

I understand that these attacks which you have had have 
been the result of cold?—Cold or influenza, generally 
influenza. 

Have you used the specific constantly or only occasionally 
when the attack came on 7—Occasionally. 

Re examined by Mr. Duke. —The mode of using this thing 
is to convert the fluid into a vapour, I think ?—Y’es. 

During the five or six years that you have used the vapour 
produced in the inhaler have you ever found any sort of ill 
effect from it?—No, none. 

Nothing of the nature of the action of poison ?—No, none. 

Aucustus Quackenbush Tucker, examined by Mr. 
Smith.— Where do you carry on business?—At Herne Hill. 

I think your wife and daughter live with you ?—My 
daughter is the onlv assistant I have. 

How old are you ?—68. 

Where were you born ?—In the .State of New York. 

Mr. Justice Ridley : Does that matter much ? 

Mr. Smith : I want to ask him a few questions about his 
early career, which I should think your lordship will think 
does matter. 

Mr. Justice Ridlf.y : The particular place of his birth 
does not affect his career. 

Mr. Smith : No, but the fact that he was bom in the 
States I think does. 

Mr. Justice Ridley (to the witness): Y’ou are a native 
of the United States ?—Yes. 

E 3 





310 The Lancet,] 


TUCKER t>. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


Mr. Smith : I think yon commenced your life by teachug 
at a public school ?—Yes. 

Did you, after various other occupations, help your 
brother in his work in the United States ?—I did. 

What is your brother's name ?—Nathan Tucker. 

In what part of the United States does he carry on his 
profession ?—In the State of Ohio. 

What assistance were you giving him ?—I took the 
commercial side of the business and was introducing the 
remedy. 

During what years were you attending to the commercial 
side of the business ?—From 1889 to 1899. 

Ten years ?—Ten years. 

During that time were you ever brought into contact 
with people suffering from asthma iu selling these things !— 

I was travelling from city to city picking out extreme cases 
and giving them a two weeks' trial free. 

So that you were brought constantly in touch with 
people suffering from asthma ?—I was. 

I want to ask you a few questions about your brother. 
Of what age is your brother now ?—He is 70. 

Where did he study medicine ?—At the Bellevue Hos¬ 
pital Medical College, New York City. 

Do you recollect how long he was there?—He was there 
two years. 

Where did he go after that ?—That was his last medical 
college. 

What was the first one ? I want to have the medical course 
he went through.—He spent two years in Northern New 
York. 

Mr. Justice Ridley : What is Northern New York ! 

Mr. Smith : Just explain that.—There is the State of New 
Y’ork and the city of New York. Our home was 200 miles 
north of New York city. 

Did he study medicine there ?—He studied medicine there. 

Mr. Eldon Bankes : At bis home?—Under a Dr. Allen 
for three years. 

Mr. Smith : Is that a common course to adopt in the 
United States ?—It was at that time. 

It was some considerable time ago .’—It was in 1866 that 
he finished his course. 

He spent three years as you have told us with Dr. Allen in 
Northern New York and after this he went to the Bellevue 
Hospital Medical College at New York 1 —Y’es. 

You have told us he was there for two years ?—Yes. 

What was the length of time necessary in order to graduate 
at Bellevue Hospital ?—At that time they allowed a person 
to graduate with two full years provided he entered at a 
certain standard which was accomplished by the three years’ 
previous study. 

With that qualification two years actual course at the 
hospital was sufficient to justify graduation if the examina¬ 
tion were passed ?—Y’es. 

Did your brother graduate ? —He did. 

With the degree of Doctor of Medicine?—Yes. 

I think that was on the 1st March, 1866 ?—Yes. 

Will you tell us about the college ? What is the standing 
of this college ? 

Mr. Eldon Bankes : I object to all this. 

Mr. Duke: We will leave it for cross examination. I do 
not think it will be suggested that Dr. Tucker iB not a 
reputable man in the United States. 

Mr. Justice Ridley : We cannot go into the history of the 
college unless Mr. Bankes wants it. 

Mr. Smith : I think your brother commenced a general 
practice as a physician in 1866 ?—He did. 

Where did he commence practising ?—In Mount Gilead, 
Ohio. 

For how long did he continue to carry on a general local 
practice?—Up till about 1890, and then this business took 
his attention and he followed this speciality. 

What special line do you mean ?—Diseases of the respira- 
tary organs, asthma, bronchitis, and so on. 

Do you know how he first came to specialise in these 
diseases?—It was the result of 20 years’experimenting on 
himself that he obtained this remedy. 

How was he led to commence those experiments ?—By the 
extreme suffering that he underwent. 

Do you recollect when he first began to suffer from asthma 
in a severe form himself?—It was about 1870 that the asthma 
became very severe. There were slight attacks previously 
to that. 

From 1870 to 1890 did he suffer almost continuously from 
the disease ?—Yes, for months at a time he never could lie 
down. 


Mr. Eldon Bankes : 1 do not want to interpose as to any. 
thing that is relevant, but does this matter? 

Mr. Duke : I think this is material. 

Mr. Justice Ridley : You can take this generally. 

Mr. Smith : I will take it as shortly as I can. 

Mr. Justice Ridley : I do not think you have gone too far 
at present. 

Mr. Smith : During those years from 1870 to 1890 you 
have told us he was experimenting on himself. I want you 
to tell my lord and the jury with what result?—He kept 
getting worse for some years. I think for the first ten 
years he kept getting worse and then he changed his ideas 
as to the cause of asthma and commenced treating it directly 
as a local trouble. 

The general view of the profession being- 

Mr. Eldon Bankes : We cannot have that from this 
gentleman. 

Mr. Smith : At any rate, your brother formed the view at 
that time that it was a local trouble ?—He did. 

Which did he discover first, the specific or the atomiser?— 
The specific was discovered before this atomiser was dis¬ 
covered. 

Having got this specific what was the object of the 
atomiser ?—He wanted an atomiser which was durable 
and which would produce a perfect vapour, and that led him 
to experiment with this atomiser until it was produced. 

Why is it important to have a vapour and not moisture ? 
—Because it must be inhaled through the bronchial tubes 
into the lungs, and if it were not vapour it could not be 
done. 

Mr. Eldon Bankes: You do not suggest a vapour is not 
moisture ? 

Mr. Duke : Of course, in a scientific sense it is a moisture, 
but it is not a coarse moisture. 

Mr. Justice Ridley : It is a fog. 

Mr. Duke : I should think that describes it quite 
accurately. 

Mr. Smith : Do you recollect when it was that he evolved 
the atomiser in its present form ?—It was about 1891 or 1892 
that this instrument was produced, bnt not exactly as it is 
now. Substantially it was the same. 

Have you examined other atomisers which are in use ?— 
Yes. 

It is said that one just like yours can be bought at any 
chemist for 'a very small price. Have you seen any of 
these which you have tested in any chemists which resembles 
yours?—I have not. 

If you are asked about it you will be able to point out 
differences ?—I would. 

Differences in the product, in the result?—Yes. 

What is the distinction between a spraying instrument and 
your atomiser ?—A spray would fill the throat with a quantity 
of liquid. This instrument of ours converts that liquid into 
a vapour. I can soon show that better, perhaps, than 
describe it. 

Mr. Justice Ridley : I suppose it is turned into minute 
particles so that you cannot see it, but it must be there. 

Mr. Eldon Bankes : You can see it quite clearly if you 
hold it up to the light. 

Mr. Smith : May the witness do it ? 

Mr. Eldon Bankes : The pamphlet says that you are not 
doing it properly unless you see the smoke coming out of 
your mouth (to the witness) That is so, is it not ?—No, it 
is not strictly true, but partially true. 

Mr. Justice Ridley : Is that in the pamphlet 

Mr. Duke: I think it is in the directions, not in the 
pamphlet. 

Mr. Smith ; (To the witness) What is that spray which 
you have there ?—This is another atomiser. 

Is that as good a one as you know, apart from yours?—It 
is as to the product produced ; it is all that you could ask for ; 
but the quantity in volume is almost infinitesimal. 

As compared with the other ?—As compared with mine. 

Mr. Eldon Bankes : Would you mind identifying that. 
Is that Oppenheimer’s ? 

Mr. Smith : You call that Oppenheimer's atomiser, do 
you not ?—That is the name by which it is known. 

Mr. Justice Ridley : Is that going to produce spray ?—It 
produces a vapour, hut in very, very small quantity. If I had 
some of the medicine here I could charge it and show you, 
but I do not suppose any of you could see it, it would be so 
fine. 

Show us yours.—(The witness illustrated the working of 
the atomiser.)—I am in a bad position, a dark corner. I do 
not know whether you can see it very well. 




The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb, 1,1908. 311 


Mr. Jastice Ridley: Can you see it, gentlemen ?—Tbe 
Jury : Yes. 

The Witness : I will use it as 1 was doing and as I 
instruct patients to do. (The witness illustrated the use of 
the atomiser.) The fact that it comes from my mouth is 
absolutely proof that it has been in my lungs. That answers 
the question you raised. 

Mr. Justice Ridley : Could it not go through your mouth 
without goiDg into the lungs ?—No. 

There is no passage, is there .’—If you notice what 1 am 
doing I take this vapour up one side and air at the other. 
I am inhaling while I am pressing the bulb. Watch me once 
more. (The witness repeated the illustration.) When I 
come to breathe out. a small portion of the vapour comes 
out with the air. I am coating the mucous lining from the 
end of my nose into the lungs with that liquid. 

Mr. Justice Ridley : There must be a passage there which 
the vapour could come through at the back of your mouth I—■ 
I do not know. It might be done, but I could not do it. 
One might be expert enough. 

Mr Justice Ridley : If you smoke- 

The Witness : You caD blow it out of your nostrils ; that 
is right. But if you take it into your nostrils- 

Mr. Justice Ridley : Y’ou can go one way but you cannot 
go the other. 

Mr. Duke: Yes; that is so. He could not discharge 
the quantity of vapour and hold it in any receptacle except¬ 
ing his lungs. 

Mr. Justice Ridley : I understand that iB his reason. 

Mr. Duke : That is the reason of it. 

Mr. Eldon Bankes : Is that what he says really or is that 
what you say, Mr. Duke ? 

Mr. Duke : Yes; that is what I understand. 

Mr. Justice Ridley : That proves it must have been in 
your lungs. 

Mr. Eldon Bankes : But his mouth is big enough to hold 
that quantity of vapour. My friend says there is no other 
receptacle. 

Mr. Justice Ridley : I am only taking down what he says. 

Mr. Er.DON Bankes : I am quite willing to accept it that 
that is what he says. 

Mr. Smith : Is it a very important point in the merits of 
an atomiser that there should be a powerful discharge when 
you press that ball?—In order to reach all the air spaces 
through the nasal organs and bronchial tubes yon must have 
a good volume of vapour. 

I just want to ask you one more question about Oppen- 
heimer's atomiser. Would it be suitable for use with your 
specific, for instance ?—It could be used, but it would take 
so long to get any amount of it that if your attack was very 
bad it would undoubtedly fail. It might relieve any mild 
attack. 

Y’ou have tested, I think, three other instruments which 
have been purchased in chemists’ shops of a similar kind ? 
—There are several others. This is, I think, counted one of 
the best. 

Oppenheimer’s ?—Yes. 

Taking it shortly, in the case of all those others which you 
have tested, do the same distinctions apply at least to the 
same extent ?—There are atomisers, and plenty of them, 
which produce a spray, that we coaid not use at all. This 
one and some others produce vapour but it is in very minute 
quantities 

Who manufactures the atomiser for your brother?—It is 
manufactured by Codman and Shurtleff of Boston, U.8.A. 

Are they a well-known firm ?—They are. 

What is their business ?—Manufacturers of surgical 
instruments. 

About how many of these instruments are turned out every 
month ?—We have a standing order of 400 of these sent to 
me and the same number sent to my brother in the 
States. 

Mr Eldon Bankes: We cannot have the brother’s 
business. 

Mr. Smith : Except so far as it is in his knowledge. 

Mr. Eldon Bankes : He cannot know. 

Mr. Smith : He can tell, at any rate, during the time that 
he was with his brother. However, it is not of very much 
importance. 

So far as you are concerned you say, quite apart from your 
brother’s house, you have 400 a month sent to you ?—There 
1 b a standing order of 400 a month. 

What is your sphere of influence at the present time, so to 
speak? 


Mr. Justice Ridley : Sphere of influence is a peculiar 
phrase, is it Dot ? 

Mr. Smith : I think your lordship will understand it. 

Over what part of the world do you sell this specific and 
the atomiser?—We send it in all parts of the world, except- 
ting North America, for the reason that this is the best 
distributing centre. 

London is !—Yes. 

Mr. Justice Ridley : Do you send it all from this house at 
Hene Hill ?—I send it from Herne Hill to every country on 
the globe, except North America. 

Mr. Smith : Who deals with the North American demand ? 
—My brother. 

Mr. Justice Ridley : 400 atomisers arrive at this house 
monthly ? (indicating photograph on circular).—Y es. 

Mr. Smith : How long have yon been in London attend¬ 
ing to the English and European business?—1 came here in 
August, 1899. 

Did you come over to establish the agency ?—I did. 

With the exception of a short visit to the States shortly 
afterwards have you been here ever since ?—Yes, it has been 
my home. 

Where did yon open your first office !—At 51, Holborn 
Viaduct. 

When was that!—I opened the office there on August 16th, 
1899. 

Have you an office in London now ?—No ; all business is 
done at Herne Hill. 

Who has the profits of the business which is done at Herne 
Hill ?—I have them myself. 

How is the account settled as between yourself snd your 
brother ?—I purchase everything from him except the rubber 
bulb and the glass bottle. This rubber bulb is made in 
London. 

And the glass cup?—The glass bottle is made in France. 

But all the parts of the atomiser you get from your 
brother ?—My brother. 

At what price do you get them ?—The instrument without 
the bulb and without the glass costs me SI.87 cents in 
Ohio. 

What is the relation to cost price of that sum ?—I am 
supposed to get everything at actual cost from the manu¬ 
facturer excepting medicine. 

The medicine is not in the S1.87 cents ?—No ; that is not 
in it at all. 

Mr. Smith : How about the payment for the specific ? 
What payment did you make to your brother for the specific ? 
—Do you mean as to the price paid ?—Y’es. 

Mr. Justice Ridley : Is it not made up here in England?— 
No, made in Ohio; all made by my brother. This medicine 
costs me $14 a quart in Mount Gilead, Ohio. 

How much do the indiarubber bulbs and the glass 
bottles cost yon ?—The bulbs cost me 10 id. each without 
this metal valve (indicating), which costs me in the 
States 2 d. 

Mr. Justice Ridley: That is in the SI.87 cants?—No ; 
that is not included in the SI.87 cents. 

Mr. Smith : It is a small item additional to the 
SI.87 cents. 

Mr. Justice Ridley : I will leave it out then. 

Mr. Smith : So that it comes to this, that all the rest of 
the atomiser, excepting the bnlb, the glass bottle, and that 
little valve, are obtained from your brother ?—Yes. 

You have told us the price of the indiarubber ball and the 
glass thing. 

Mr. Eldon Bankes: No, he has not told us that. 

Mr. Smith : Will you tell me, please, what the price of the 
glass bottle is ?—I am not absolutely certain as to just the 
exact cost but my recollection is that it is 1 id. apiece. Of 
course, I buy them in great quantities. It is somewhere 
between that and 2d. 

Who pays for the carriage of the atomisers from the 
States ?—I do. 

In what sized cases do you get them and how frequently ? 
—I get four shipments a month. 

That is of the atomisers alone ?—The atomisers and 
medicine. 

They come together, do they ?—They usually come 
together. 

Mr. Justice Ridley : The medicine comes in those bottles ? 
—The medicine comes in quart bottles. 

You fill them up here ?—I fill the bottles up here, yes. 

Mr. Smith : The specific comes in quart bottles from the 
States ?—Y’es. 




312 Tub Lancet,] 


TUCKER v. WAKLET AND ANOTHER. 


[Feb. 1, 1908. 


And some o£ the parts of the atomiser also come from the 
States ?—Yes. 

And it is completed with the other parts from the 
continent; I think that is clear !—Yes. 

How many shipments a month do yon say yon have ?— 
Abont four. 

Can you tell ns what the average payment for carriage 
would be on one monthly shipment ?—t get 100 of these 
packed in a box like this at each shipment and abont 
32 quarts of medicine. For those two lots I pay from £1 to 
£1 4s. or £1 5s. It varies somewhat but it is somewhere 
about £1 3s. I would say as the cost for each shipment. 
That is the cost from New Y'ork State; that is the ocean 
freight. 

How about the State charges on the other side !—It is a 
little more from Ohio to New York State than it is across the 
ocean. It is 800 miles by rail. 

So far as regards the parts of the atomiser which are 
obtained from the continent, do you pay for the carriage of 
those indiarobber balls and glass bottles ?—Yes ; I pay for all 
that. 

How often do you have a consignment containing the 
indiarnbber balls and the glass bottles?—Y’ou understand 
that the rubber balls are made here in London. 

But the glass bottles in France?—The glass bottles in 
France. 

How often do you get a consignment of glass bottles ?— 
Abont once in four months. 

Is that a large case or not ?—Yea ; it runs I think about 
25 gross. 

Do you remember roughly what the cost of carriage of 
that would be ?—No ; I do not know. It is not a very great 
amount; I think some five or six shillings or something like 
that. 

How long did you stay in the office at Holborn Viaduct, 
which was the first one yon took when you came over to this 
country ?—I stayed there nearly three years ; I left there in 
June, 1902. 

Are you sure it was 1902 ? You may be right but I have it 
1903.—It was 1902, June. 

Where did you go after you left Holborn Viaduct ?—I went 
to Herne Hill. 

Have you been there ever since?—Y'es. 

I think you use the house as a residence and to carry on 
the business ?—Yes. 

Mr. Justice Ridley: You do not want any dispensary; 
all you want to do is to decant the liquor into the bottles ?— 
That is all. It is a distributing centre. 

Mr. Smith : When your lordship sees the volume of busi¬ 
ness your lordship sees there must be conveniences for distri¬ 
buting. 

Mr. Justice Ridley : When I look at this picture there 
seems to be no convenience there ; it is a villa. I have a 
picture of it. 

The Witness : That is my dwelling-house and four rooms 
devoted to business on the ground floor. 

It looks as if it were devoted to enjoyment.—Well, it 
does. 

There is no notice—a board or anything. 

Mr. Smith : You do not advertise, I think, either on your 
door or anywhere else, do you ?—My name is on the gate-post 
so that strangers may know when they reach the house. 

But that is the only advertisement you have apart from 
this pamphlet!—Yes ; I do not put anything outside except 
merely my name, A. Q Tucker. 

While I am upon that I will just ask you the question, Do 
you advertise at all in the newspapers ?—I do not. 

I want to ask you about the gross yearly receipts since the 
time when you started your business. I think you have a 
book here, have you not ?—Y'es. 

Mr. Justice Ridley : Y'ou do not have anything up on the 
blind or anything of that kind ; yon do not have any notice 
up at all ; it is simply a private house ?—That is all. 

Mr. Smith: Simply “A. Q. Tucker ”?—“ A. Q. Tucker ” 
is on the gate-post. 

While I am getting the gross receipts can you tell my 
lord and jury how many of there atomisers you have sold 
time you commenced business?—We have sold upwards 
rf 25,000 and the names are entered on our books as 
patrons. 

Mr. Justice Ridley: All fresh patrons ?—Patrons that I 
have gathered up in the seven years since I commenced here. 

Bat some people wear out an atomiser and have to bny 
another ?—Yes ; a great many of them have two. 


Mr. Smith So that they would not all represent different 
customers ?—Yes ; but I have that many different patrons— 
over 25,000. 

Y’ou have the books so that my friend can see them if he 
wishes to ?■—The books are here and they can be seen. 

You have 25,000 different patronB? — Y r es. 

Which you say would represent a much larger number of 
atomisers sold?—Y’es, much larger. Many business men 
have one at their house and one at their place of business. 

Mr. Eldon Baxkes : You might give us the summary of 
the receipts. 

Mr. Smith : My learned friend allows me to give your 
lordship a summary. 

Mr. Eldon Bankes : YVe have had inspection of the 
books. They disclose them in their affidavit. If the 
summary agrees with mine I have no objection to putting 
it in. 

Mr. Smith : I will give your lordship the figures for the 
year 1899 

Mr. Eldon Bankes : Are these the gross receipts ? 

Mr. Smith : Y'es, the gross receipts. He began business 
in August, 1899, and up to Dec. 31st in the first year of 
business the figures were £402 18s., gross receipts; in 1900, 
£3672 7s. 5(7. ; in 1901, £8785 11*. 10(7. ; in 1902, 
£11,070 2*. 11(7. ; in 1903, £14,982 2*. 1 d. ; in 1904, 
£17,25L 0*. 11 d. ; in 1905, £19,585 14*. 3d. ; in 1906, 
£19,641 8*. 5(7. 

1 do not think you have been able to take out the last 
month or so of 1907 and your figures so far as they are taken 
out- 

Mr. Eldon Bankes : To what date ? 

Mr. Smith : Y'ou shall have it. As far as the figures are 
taken out -and I will give my friend the exact date in a 
moment—the figures for 1907 are £18,498 17*. 10(7. I do 
not know whether you can tell me the date or whether 1 
must get it from the book.—No, I cannot. 

It has been done by an accountant, and you do not know. 
I want you to help me as far as you can in discovering the 
cost price to you of the atomiser and the specific and the 
accessories. 1 think you have one of Dr. Tucker’s weekly 
statements of account, have you not ?—There is a book there 
which you had which contains the weekly report of every 
week since we started. 

I want you to take any week at random, but I just want 
my lord and the jury to see how the statement of account, as 
between your brother and yourself, is made up.—1 am fearful 
that the book is not here. 

Mr. Eldon Bankeb : 1 must object to it going in without 
the book for the moment. I am not certain I have Been this. 
W hat is it you want ! 

Mr. Smith : I want his estimate of the cost price to him 
as arrived at by the account with Dr. Tucker. I do not care 
about it, and I will leave it to my friend to ask about. 

Mr. Justice Ridley: I do not know whether we shall 
want that. I have appreciated that there are some questions 
in the libel which point to the price being material. 

Mr. Eldon Bankes : Yes, it is material to get the figures. 

Mr. Justice Ridley : 1 think so, but I was not quite sure 
how far it was material. 

Mr. Smith : If it is still persisted in and relied on as part 
of the defence- 

Mr. Justioe Ridley : One seesat once that the £3chargcd 
is not charged on the face of it as anything like the price of 
it; it is a charge for the cure as well. 

Mr. Smith : Yes. 

Mr. Justice Ridley: To give it to a man for a fortnight 
and then ask him to pay £3 means the cure as well as the 
article. 

Mr. Smith : Quite. 

Mr. Justice Ridley : However, you may go into it if you 
like; the jury will deal with all that. (To the jury) I tell 
you, gentlemen, that £3 is out of all question, not the price 
of one of these atomisers ; it is not anything like it. £3 
must be far beyond the proper value of any one of these 
things. 

Mr. Smith : Yes, of course. There is no concealment 
about that, obviously. 

Mr. Justice Ridley : It is intended to be the price of the 
cure I should have thought, but we shall see what Mr. 
Bankes says. The man agrees to pay in a fortnight and if 
he does not choose to pay he sends it back again and does not 
pay ; if it is of any use he does. 

Mr. Smith : Some case apparently still is made abont the 
cost of the thing and I think I should just like to ask him 





The Lancet,] 


TUCKER «>. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 3 1 3 


what it costs him ; I will not ask in detail, bnt I will leave 
it to my friend to cross-examine him and I can develop it, 
if necessary, when I re-examine him. (Docnment handed to 
the witness.) 

First of all, is that a weekly account taken qnite at 
random?—This is an actual invoice made by my brother 
dated Oct. 19th, 1907. 

Does that fairly represent what an average shipment would 
be ?—This individual one is a little larger than the average 
and yet very little, too. There are 200 atomisers in this one 
shipment. 

What is the price to you, as shown in the bills, of 200 
atomisers ?—356 dollars. That does not include the bulb or 
bottle. 

Mr. Er.r>ON Bankes : No, we follow that. 

Mr. Smith : What is the charge there for testing and 
packing?— $6. That includes the package and the testing 
and packing. 

Mr. Justice Ridley: You take a dollar at 4*., do you 
not ?—It is nearly that; it is 4*. 2 d. 

Mr. Eldon Bankes : I have taken it at 4s. 2d. and I think 
it shows that the cost of the atomiser as invoiced to him is 
Is. 8 d. or 7i. 9d. 

Mr. Smith : I have taken it at 4*. 2d. and I think that is 
substantially correct. 

Mr. Eldon Bankes : Then we agree about that; it is 
invoiced to him at 7s. 9 d. 

Mr. Smith : I will have that checked ; I think it is so. 

In the week you have before you I think the amount of 
specific shipped was 33 quarts and 24 ounces ?—Yes. 

What is the charge for that?—It is $540, but there is a 
discount from that of 867 and 50 cents. 

How does the discount arise ?—That discount arises to 
cover wastage. 

Mr. Eldon Bankes : Need we trouble about it? We only 
want to get the accurate figures. 

Mr. Justice Ridley : What does it work out at? 

Mr. Eldon Bankes: It works out at U 6 d. an ounce. 

Mr. Smith : I think that is substantially right, but 
your lordship will not take it for the moment as agreed. 
I will have it worked out, but I think it is about 
right. 

The Witness : The amount of the fluid, 33 quarts 24 
ounces, cost to me in Ohio $473.50 cents. 

Then there are 36 bottles and corks ?—Yes. 

What is the figure you have for them ?—$6.12 cents. 

Then there are the metal valves. There are ten gross of 
them, I think ?—There are no metal valves in this invoice. I 
think they have got them mixed in some way. 

Have you not taken out the metal valves for the same 
week ? If you have not, you will tell me so. Have you not 
worked it out for the same week ?—It is about 3d. for these 
little valves for putting into the end of the indiarubber. 
They come from the States, all of them. 

Have you got the boxes there as coming from the States ? 
—Yes, $5. 

And the express to New York ?—88 58 cents. 

Mr. Justice Ridley : What is that ?—Express to New York 
from Ohio ; that is the railroad charges. 

Wbat does that give us as a total ?—The total is 
$854 20 cents., that is after deducting the discount on the 
fluid. 

That is not taking into consideration the glass bottles nor 
the corks ?—No. 

Mr. Justice Ridley: It leaves one with no idea of what 
the price of each particular article is—not the slightest. 

Mr. Smith : It does in a way. 

Mr. Justice Ridley : If you can give me the result follow¬ 
ing from that I shall be much obliged. I have it partly. I 
have the specific at Is. 6 d. an ounce, and the atomisers at 
7s 9 d. each. 

Mr. Smith : Your lordship sees in respect of those two 
articles this gives your lordship the price. 

Mr. Eldon Bankes: I do not know whether my learned 
friend would agree to this. Taking all the figures he has 
given the cost to this gentleman of the atomiser is about 9s. 

Mr. Smith : I believe it is almost exactly right. 

Mr. Eldon Bankes : Then we need not discuss about it 
because we can agree. 

Mr. Justice Ridley : Including the box and the carriage 
and everything ? 

Mr. Eldon Bankes : Including everything. 

Mr. Smith : I think that includes everything except the 
rubber bulb. 


Mr. Eldon Bankes : No, that is included too. 

Mr. Smith : Is the bottle from Paris included ? 

Mr. Eldon Bankes : Yeo. 

Mr. Smith : 1 have not the least doubt that my friend is 
right, but I have somebody who will check it. 

Mr. Eldon Bankes : We can try and agree on a figure. 

Mr. Smith : I have no doubt we shall be able to. 

Mr. Justice Ridley (to the witness) : Will you accept 
that figure as far as you are concerned ?—9s. 1 

Yes.—I think that is very much correct, but the cost of 
the fluid, I think, is more than Is. 6 d. The fact is this : a 
quart of fluid makes 28 ounces and it costs me 314 ; yon can 
figure it out for yourself. That is without any freight. 

Mr. Eldon Bankes : But he sells it by the English ounce. 

The Witness : There is a difference between the American 
ounce and the English onnce. The American ounce is a 
good deal larger than the English ounce. A quart should 
make 32 ounces—that is the American ounce—but we find 
by actual experience that it works out at about 28 ounce 
bottles from a quart. 

An English ounce or an American ounce?—An American 
ounce. 

You sell it according to the English ounce, do you not?— 
No, I sell it according to the American ounce. The bottles 
are made according to the American standard. 

Mr. Smith : In the estimates you have given me so far 
you have not dealt at all with working expenses. I want to 
ask you what your estimate is for working expenses as a 
percentage on the gross receipts.—Do you mean my office 
help ? 

Yes; offices and so forth ?—My office help is now £20 per 
week. 

That is very nearly £1000 a year. 

Mr. Justice Ridley: What does “office help” mean?— 
There are typists. I have two typistB, two bookkeepers, and 
two shippers. 

Mr. Smith : You keep those pretty busy?—Y'es. 

You yourself are able to carry on no other business at all ? 
— No ; my daughter is also associated with me. 

So that is eight of you continuously devoted to the 
business?—Y’es. 

In the case of your own time and your daughter's time 
you cannot put a figure value upon it, but in fact you spend 
your business time upon it?—Entirely. 

Does your brother, apart from any profit he makes on the 
sale of the specific, charge you anything for European 
rights ?—Nothing at all. 

He is your brother and you do not pay him for that at all ? 
—No ; nothing at all. He has a small profit on the specific 
only—nothing else. 

In your view is he dealing with you on commercial lines ? 
—He is not. 

Have you formed an estimate of the value of the rights you 
possess 7 

Mr. Eldon Bankes : I object to that. 

Mr 8mith : I submit I am entitled to ask this gentleman 
who is familiar with the circumstances under which the 
business is carried on. 

Mr. Eldon Bankes : We have the figures. 

Mr. Smith : My friend says we have got the figures, but 
that is not the point in the least. The point is this : we sell 
the atomiser and we sell the specific, and one of the points 
on which they rely is the price we charge for it. I submit I 
am entitled to get from this gentleman that his brother 
because be is his brother allows him, free of all cost, rights 
in this country which have a specific commercial value if 
they are in the hands of a stranger. I submit I am entitled 
to do that. 

Mr. Justice Ridley : I do not think you are. We have to 
form our own judgment. 

Mr. Smith : I do not know that it is of great importance, 
but I should submit I was. Here is a case in which a 
gentleman says, “ I get this from my brother ; he allows me 
to sell it without paying anything because he is my 
brother.’ 1 

Mr Justice Ridley : That is quite right. 

Mr. Smith : It was rather on those lines I was proposing 
to ask the question. 

Mr. Justice Ridley : I shall ask the jury to say what they 
think the value is. 

Mr. Smith : I do not think it is worth pressing in any 
event. 

At any rate, you pay your brother nothing, and you say in 
your judgment it has a commercial value 7—I do ; very great 





314 The Lancet,] 


TUCKER V. WAKLEY AND ANOTHER. 


[Feu. 1, 1908. 


commercial value. It will take some little time to explain 
just why he does by me as he does. 

Mr. Eldon Bankes : Well, I object to that. 

Mr. Justice Ridley : It has great commercial value; that 
is all right. 

Mr. Smith : Apart from this staff which you have ex¬ 
plained to us do you employ agents 7 —I do. 

You have told us you do not advertise at all. Do you 
rely upon your agents and customers to make your specific 
known ?—It is principally made known by my patrons who 
tell one another. My agents are simply local agents who 
take orders and send them to me to fill. 

How many agents have you got?—I do not know. 

Roughly, I mean 7—Some 40 or 50 ; it may be twice that; 
I am not sure. Many of them do but very little, but what¬ 
ever they do they get their commission on. 

I am going to ask you about that. What commission do 
you pay to your agents in case they effect sales 1 —I pay a 
commission of 12i. on each complete sale of £3, but that is 
to those who take up their time and make a business of it. 
Then we give a commission of 10 per .cent., 6»., to dealers 
who simply pass it on. 

What proportion, roughly, of your treatments, as I think 
you call it, are sold or supplied through agents'?—Our foreign 
trade i6 very largely done by foreign agents, nearly all of it. 
Here at home in the British Kingdom I do not know; it 
would be a guess—not over, perhaps, one-fifth. 

I think you have agents in most of the chief continental 
countries 7 —Yes. 

I understand you to say that you do not always pay 12s. 7 
—No. 

What is the alternative rate 7—12s. is to the one who goes 
out and hunts up customers and spends bis time and 
strength. The other is to chemists and dealers who simply 
order and pass it on and do nothing in the way of explain¬ 
ing to patients. 

It is the distinction between the chemist’s shop and the 
one who canvasses for customers 7 —Yes, not only chemists— 
shippers. 

Have you to make allowance for discount on the fluid for 
wastage in decanting, and so forth, and accidents 7 — We do. 
We guarantee safe delivery of all the fluid we send through 
the post. If it Is broken we replace it free of charge. 

I do Dot want to go into precise figures on this point. You 
have to make some deduction under that head 7 You find in 
your experience that there is a wastage under that head 7— 
Yes. 

And, in the same way, when you ship the fluid into this 
country from the States you stand, I think, the risk of 
wastage there 7—We occasionally get a quart bottle broken. 

That is your loss 7—That is my Iobs entirely. 

How long ought an ounce of fluid to last if used regularly ? 
You heard what Mr. Bateson said, that his lasted a year. I 
want to ask you, what is your experience 7 —The average 
length of time for one ounce would be three months’ daily 
use. 

From the time that you first commenced business in this 
country have you adopted the fortnight’s trial method 7 — 
Yea, invariably. 

From the very start 7—Yes; every person in the British 
Kingdom has had the privilege of a two weeks’ trial. 

Before they are allowed to have this trial I think you ask 
them the questions which my friend Mr. Duke referred to ; 
they have to fill in the question form 7—Usually they do; not 
always. 

But you usually send it on an application for a free trial 7 
—Yes. 

After they have had a fortnight’s trial, of the people who 
wish to have it, what proportion do you find come to you and 
buy them 7 — That is here in the British Kingdom 7 

Yes, of those who have tried them 7—1 should think at 
least four-fifths, but of those who return it the majority get it 
afterwards. 

You have noticed, by following their names in your books, 
that they do?—Yes. 

I do not know—you shall tell me whether you have a 
system of experimental use in the continental business 7—I 
do not. 

It is only for England 7—Nor in the colonies; it is confined 
to the British Kingdom. 

As far as any question of fluid is concerned have you at 
any time, if a customer did not like it during his fortnight’s 
trial, refused to have it back 7—Never. 

In dealing with expenditure, there is one small item I 


want to get, and that is about the Government stamp. You 
have to pay for the Government stamp 7—Y'es. 

What is the price of that 7—It is 1*. on every ounce. 

Of course, there is a deduction to be made for that. I 
want to ask, as a further deduction, about your income-tax 
returns. 

Mr. Eldon Bankes : I object to that; you cannot deduct 
your income-tax. 

Mr. Smith : I quite agree you cannot, but if it is relied on 
that this gentleman is charging an excessive price I should 
think it was useful to discover what exactly his expenditure 
was before he could get this. It is on the same footing as 
his house rent. It may be my friends are not going to rely 
on this, but if it is I should have thought I could get 
that. 

Mr. Justice Ridley : I really do not think you can. 

Mr. Eldon Bankes : You cannot arrive at profit in that 
way. 

Mr. Smith : In all cases in which these questions have 
been filled up and an application made for a free use do you 
always send it or do you read the answers to the questions 7— 
I usually look them over to see that the patient lias ’asthma 
and not heart trouble—not a diseased heart. 

In the latter case you would not be able to help him 7— 
We always say to them it wonld do them no harm but no 
permanent good. 

Do you charge the same price both to rich and poor in 
selling these atomisers?—We publish but one price, but in 
cases of charity, where the money is made np by friends, we 
reduce it one-third—£2 instead of £3. 

Have you done that in a large number of cases 7—A good 
many. 

Have you made a reduction on a second atomiser in similar 
cases too 7—Y’es, we have a standing rule that the second 
atomiser, stocked ready for use as you see it here, is 16r. 
That is only to our old patrons for their own private use. 

I want to ask you about the specific itself. Does anyone 
prepare the specific except your brother at Mount Gilead 7— 
No one else. 

Have you ever prepared any of it or are you capable of 
preparing it 7—No, never attempted it. 

Y'ou were asked a question which was afterwards dis¬ 
allowed. In fact, do you know to-day what the constituents 
of the specific are 7—I absolutely do not know. 

Have you ever held yourself out as possessing medical skill 
yourself 7—Not in the slightest; no. 

In your experience have attempts been made to determine 
the constituents by analysis 7—There have. 

Mr. Eldon Bankes : To his personal knowledge? 

Mr. Smith : Do you know of this yourself?—I have been 
told by different ones that they have attempted it. 

Mr. Eldon Bankes : Then I object to it. 

Mr. Smith (to the witness) : Did you ever send it to any¬ 
one yourself for analysis or not 7—1 never did. 

With regard to the suggestion of poison and so forth, is the 
specific used commonly by young children and young persons 
generally?—It is used by all ages from three years and 
upwards. 

Do you come across asthmatic cases as young as that 
frequently 7—I have met them as young as three years. I 
have been told by those who have it that they have had it 
since four months of age. 

At any rate, you have not supplied it to persons under 
three years of age. Have you ever known of a case in which 
it has done any injury to any such persons 7—Never. 

Has a complaint ever been made to you of all the 25,000 
customers you have had of any injury done to one of them 
by the use of this specific 7—No ; we have had a great many 
questions asked of us whether it did do certain things. 

But I am asking about complaints of injury 7—No, never a 
complaint of injury. 

As far as this question of cure goes, what is it that you tell 
my lord and the jury that this specific in your opinion can 
do?—It affords perfect relief and it arrests the paroxysm at 
once. 

Do you say that it cures or destroys the liability to 
asthma 7—Never ; I do not claim that at all. 

Some persons are more disposed to asthma than others 7— 
Certainly. 

When you call it a cure what is it you say that it cures 7— 
It cures the spasms. 

Mr. Eldon Bankes : He did not say anything. 

Mr. Smith : He calls it in his pamphlet a cure. 

Mr. Eldon Bankes : The witness's last answer was quite 




Thb Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 315 


distinct. He said, ‘‘Ido not claim that it cures asthma ” ; 
then my friend said, “ What do yon say it cures7 ” 

Mr. Smith (to the witness): Just take yonr pamphlet in 
your hands. 

Mr. Justice Ridley : He said it does not cure the liability 
to asthma. 

Mr. Smith : Yes, that is what he says. 

Mr. Eldon Bankes : I object to the form of my friend’s 
question. The witness says he does not claim that it cures 
the liability to asthma. Then my friend says, ‘‘What do 
you claim it does cure 7 ” and his answer is, “ I do not claim 
it cures anything.” 

Mr. Smith : It is so easily put right I should not have 
thought it was worth while wasting time on it at all. 

Mr. Eldon Bankes : Then put it right. 

Mr. Smith : Will you look at the first page of the 
pamphlet, the one that has the illustration. You Bay here, 
“ Specific for the perfect relief and cure of asthma and hay 
fever.” I will ask you on that, When you call it a cure there 
in what sense do you say it is a cure 7 

Mr. Eldon Bankes : I object to that. The document 
speaks for itself and the question is what people receiving 
this document will understand and not what this gentleman 
chooses to mean by it. 

Mr. Smith : The submission I make to your lordship and 
the question I tender is this : Do you cure asthma ? I am 
quite content to take it in that way if your lordship thinks 
that is a proper question. 

Mr. Justice Ridley : He says he does not. 

Mr. Smith : I understand so, and then I propose, if your 
lordship thinks it is a proper question, to ask him : “ In 
what sense do you say on this page it is a cure of 
asthma 7 " 

Mr. Justice Ridley : I think you ought to ask more 
generally—What other effect does it have on asthma beside 
relieving and arresting paroxysms 

Mr. Smith : I am obliged to your lordship ; I will put it 
Id that way. 

What other effect upon asthma has it than that of alleviat¬ 
ing the paroxysm of the attack ?—It indirectly has this 
result: the patient is able to sleep, able to eat, and able to 
exercise, which renders him much stronger and less liable to 
a recurrence of the trouble. 

What effect would a succession of attacks have upon the 
rallying power of the patient ?—It haB a tendency to destroy 
the rallying power and weakens the patient. 

You say by giving relief from the attacks it strengthens 
them ?—It strengthens them by reason of rest and absence 
of suffering. 

You say you have had many years' experience of dealing 
with asthma, although you are not a doctor I Is your 
practical view that a9thma is local or constitutional 7— 
Local. 

Apart from asthma, do you hold out your specific as being 
beneficial in other more or less analogous ailments !—It is 
equally efficacious in hay fever and a very great relief to 
nasal catarrh. 

I want to ask you about this man, Alfred CushiDg. Did 
you receive an application from the deceased man, Cushing, 
on or about the 2nd of February, 1904 7 —I did. 

Is that it 7 (Document handed to the witness.)—That is 
the one. 

“ Occupation 1—Fitter. How long have you had asthma 7— 
Seven years. Do you know the first cause of your asthma ; if 
so, state it.—Through having bronchitis. Wheu do you suffer 
most from asthma, summer or winter?—Winter. How 
frequent are your attacks ?—Very often. Are your attacks 
more severe at night than during the day ?—No. What 
remedy are you now using to relieve attacks ?—Cod-liver oil 
as tonic. Does the remedy generally give yon relief ?—Yes. 
During the intervals between the attacks is your breathing 
perfectly free and easy !—Breath always very short. Do you 
have nasal catarrh 7—Yes. Did you ever have hay fever?— 
Yes. Do you sneeze often ?—No. Do you expectorate much? 
—Yes. Do you live where malarial fever prevails, or fever 
and ague ?— No. Do you use alcoholic stimulants ? -Yes, a 
little whisky sometimes. Do you use morphine or opium?— 
No. Is your general health good?—Yes.” I will hand 
that up to your lordship. Was it on that form so filled in 
that you supplied your atomiser and specific to this man, 
Cushing, on whom the inquest was held?—I did. 

Did you send him the atomiser and the specific for trial 7 
He asked for it on trial, I think 7—He did. 

And you sent it about the 4th of February ?—I did. 


Did be keep it for a fortnight?—He did. 

So that during those 14 days he had the opportunity of 
judging for himself whether it was beneficial or not ?—He did. 

At the end of the 14 days what happened then ?—He sent 
in his £3 and we forwarded him two ounces of fluid. 

Making up the balance of four ounces ?—That was the first 
instalment. 

You sent him two to start with for a trial 7—No; we only 
give half an ounce for a trial—that is a gift. 

Can you tell me whether having bad his trial, having had 
the first instalment of the specific, he sent for more after¬ 
wards 7—He sent for the second two ounces later ; I think It 
was some six months afterwards. 

I have a letter here from him to you : 

Sir,— Please find enclosed order for one ounce of fluid. Having had 
the miafortuue to crack my glass that holds the fluid, kludly let me 
know the cost of a new one. Yours truly, 

A. Ccshino. 

I do not know whether you can tell us about when the date of 
that application was 7—I do not think I could. 

Mr. Duke : Just look and see ; there is a memorandum on 
it. (Document handed to the witness.)—I see written here 
in pencil about such a date 

Mr. Smith : Do you know who has written it ? If you do 
not we will get it from someone else.—It is one of my helpers 
in the office. 

Then he will be able to tell us. Do you know of any other 
A. Cushing on your books ?—There is no other. 

So that any order that is signed Cushing is from him ?— 
Yes. 

I think in the early part of January last you received from 
correspondents a notice of this newspaper report on the 
inquest of Cushing ?—I did. 

I need hardly ask you had you any opportunity of being 
present at the inquest or did you know that the specific was 
to be mentioned at the inquest 7—I knew nothing abont it 
until in one of my morning's mails I had about half a dozen 
clippings sent to me by my patrons. That is the first 
knowledge I had of the inquest. 

I want to ask you about your customers. Have you had 
among your customers, or your patients, I think you call 
them, medical men?—Oh, yes, a good many. 

I want yon to take your bcoks. 

Mr. Justice Ridley : I do not think it is necessary for you 
to do that now. Let Mr. Bankes do it if it is necessary. 
Cannot you take it generally ? 

Mr. Smith : May I take it a little more particularly 7 Can 
you give me a rough idea of how many medical men there 
are on your books!—There is something in the neighbour¬ 
hood of 300. 

What proportion of those are in England 7 My friend 
can ask you the names if he wants them. Do you know 
roughly what proportion are in England 7—I think less than 
half are in England. The larger number are on the con¬ 
tinent. There are no doubt many more that are medical men, 
bat they have failed to give their title, and we do not know 
Mhether they are doctors or lawyers, or who they are. 

My learned friend Mr. Duke mentioned Sir Stephen 
Mackenzie. I want you to tell me, have you supplied any 
to Sir Stephen Mackenzie 7—Yes ; he is one of our oldest 
patients. I think it is some six years since he began ; five 
years at least. 

The earliest date, I think, is July 1st, 1901 7—I think that 
was the time he got it. 

Mr. Eldon Bankes : If you are going into that will you 
have the book produced 7 

Mr. Smith : Yes. 

Mr. Justice Ridley : You must not take it merely by 
naming the doctor that I am acquainted with him. 

Mr. Smith : I will ask a question about that. Who is 
Sir Stephen Mackenzie?—I never met him personally. We 
did our business by correspondence. 1 understand he is a 
physician standing very high in his profession. 

Mr. Justice Ridley: Sir Morell Mackenzie I know.—This 
is a relative, as I understand. 

Mr. Smith : Whilst the books are being produced I will 
just ask you this question. Is this letter dated Oct. 15th, 
1907, from Sir Stephen Mackenzie 7 

Mr. Eldon Bankes: I object to that. My friend cannot 
possibly put in letters. 

Mr. Smith : It is only an order. 

Mr. Duke: The witness needs to have his memory re¬ 
freshed as to the pe iod of time when Sir Stephen 
Mackenzie was a customer. 




316 The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


Mr. Eluon Bankfs : That is another matter. 

Mr. Duke (to the witness) : Look at the date of the letter, 
that is all. (Document banded to the witness.)—Yes, I 
remember that coming in and being filed. 

What is the period ?—The date is given here, Oct. 15th, 
1907. 

Mr. Smith : Looking at that letter of 1907, can you say 
that you got an order ? 

Mr. Eldon Bankes: I object to that being put in ; it 
cannot be put in. 

Mr, Duke : We do not want to put it in. 

Mr. Justice Ridley: You Bay he is one of your oldest 
patients—that is, as far as I have got at present. 

Mr. Duke : What we proposed to do was to say on the 
witness refreshing his memory by a document that that 
custom had continued down to as lately as October, 1907. 

Mr. Eldon Bankes : Ido not object to that. 

Mr. Justice Ridley : I quite follow now. He has Baid so. 
" He is one of our oldest patients,” that means that he is 
still. 

Mr. Duke : Yes. 

Mr. Smith : You can verify that by your books if my friend 
asks you about it?—Yes. 

Have you got a book with the entries there in front of 
you ?—This is the entry here. This is volume 2. The entry 
is made here July 16th, 1901. 

Mr. Justice Ridley : Y'ou are not entitled to read the 
books, of course.—That was the time the treatment was first 
ordered. 

Mr. Justice Ridley : All you can do is you can say you 
have the books here. 

Mr. Smith : Y’es, that is all. 

Apart from your medical patrons or customers, who you 
have told us amount to about 300, I want to ask you about 
your ordinary customers and their position. Y'ou have told 
us of their numbers. Have you supplied this atomiser to 
persons in all ranks of life, including the highest?—I think 
our books show every title in the British Kingdom excepting 
the KiDg and Queen and the Primate, but I think they show 
every other. 

Mr. Justice Ridley: Perhaps they did not want any. 
Have you got the Archbishop of Y'ork ?—I cannot remember 
whether we have or not; we have a good many archbishops. 

Mr. Justice Ridley : The Primate means the Archbishop 
of Canterbury. 

Mr. Smith : If you are asked about this, you say you can 
show customers from every rank in English society, even the 
highest, excepting the King and Queen ?—Y’es. 

I think you have supplied it to many other Royal Families 
—not English ones but others ?—Y'es, we have—I think the 
Royal Family of Belgium. 

And even to the families of distinguished English judges ? 
—Y'es. 

Mr. Duke : Not, I think, to your lordship’s family, as far 
as we know. 

Mr. Justice Ridley : I have bad none myself. 

Mr. Smith : My learned friend can have the names if he 
wants them. 

Mr. Eldon Bankes : It Is new to me that you will supply 
the names of customers for such a drug as this. 

Mr. Duke ; I do not think my friend understood. My 
friend Mr. Smith said if Mr. Bankes wants this and 
challenges the names we will supply them ; we do not 
propose to publish them. 

Mr. Justice Ridley : We are gomg into the case in a 
great deal more detail than is necessary in chief. 

Mr. Duke : My learned friend will not take any point 
that is not necessary. 

Mr. Smith : Indeed, I will not. 

Mr. Justice Ridley: I should have thought to take it 
generally on your side would be sufficient until Mr. Bankes 
challenged it. 

Mr. Smith : I sm obliged to your lordship. 

Mr. Justice Ridley : We must get on at last, I suppose. 

Croat-examined by Mr. Eldon Bankes : Do I understand 
it is the fact that you have never had any medical training 
at all?—None at all. 

And do I understand you to tell the jury that you are 
selling these enormous quantities of this liquid indiscrimin¬ 
ately without knowing what it contains?—That is what I 
said. 

Selling it practically to anybody who asks for it ?—No, we 
do not. 


Well, we will see in a moment. Do you take any precau¬ 
tions as to the persons to whom you shall supply it ?—We 
supply it to everyone whom we think it would benefit, and 
if we think it would not we do not supply them; we tell 
them it is just throwing away their money. 

You supply the people whom you think it will benefit and 
you do not supply those whom you think it will not benefit; 
is that so ?—That is my position, yes. 

What classes of persons do you think that it will not 
benefit ?—A person who has consumption would not get any 
practical benefit; they may get a little relief but we do not 
advertise it for that. 

Who else ?—It is designed for just these cases only. 

Would you mind answering my question ? I am asking 
you to tell us the persons whom you think it would not 
benefit.—It would not benefit any person unless they have a 
serious catarrhal trouble. 

But are there any particular classes of persons whom you 
know it would not benefit? Y'ou mention, for instance, 
persons suffering from consumption. In your opinion, does 
this stuff of yonrs not benefit them ?—It does not. 

Let me take the case of a person suffering from a weak 
heart —They would get benefit only in this way : their 
breathing is relieved ; it relieves the heart—no more. 

Do you say that you formed the opinion that this stuff of 
yours does not benefit consumptive patients without knowing 
wbat is in it ?—I do cot thick it would. 

Listen ! You do not follow my question. You formed 
the opinion that this stuff of yours would not benefit con¬ 
sumptive patients. I ask you: Have you formed that 
opinion without knowing what your stuff contains ?—I have. 

Have you ever bad occasion to consider the English 
Pharmacy Act!—No. 

Do you know that there are very stringent provisions 
with reference to the sale of poisons in England ?—I do ; 
I suppose there are as a matter of course ; there are io all 
countries. 

Is there any reason that you can suggest to the jury why 
you have abstained from asking what is in this stuff of yours 
unless it be that you are aware of the provisions of the 
English Acts about poisons ?—I dispensed this remedy in the 
States for ten years before 1 came here. 

We will come to the States in a moment. Y'ou were on 
terms of intimacy with your brother ?—Y'es. 

Y’ou were in close conjunction with him in this business ? 
—Yes. 

Do you say you never aBked him what was in this liquid ? 
—I never did. 

Do you know now that if you complied with the English 
law you would not be able to sell this stuff ?—I do not know 
anv such thing. 

Y'ery well, we will see. Do I understand you to say you 
do cot know now that it contains cocaine ?—I do not, not of 
my own knowledge. 

Has anybody in the course of this case, while you have 
been preparing for trial, sought to ascertain whether it con¬ 
tains cocaine or not ?—I presume many of them have. 

But on yonr Ride?—I do not know what they have done. 

Do you know anything of the properties of cocaine ?—I 
suppose it to be a very powerful drug. 

Do you know that it is a drug to the effects of which 
many persons are strongly susceptible; do you know that 
about it 1 —I do not know anything about it, for I am cot a 
medical man. 

Have you ever heard of the cocaine habit ?—I have. 

Do you knpw that that is one of the most insidious habits 
that anybody can acquire?—I do. 

Worse than the alcoholic habit or worse than the morphine 
habit?—I am not prepared to judge as between that and 
morphine; I know both of them are serious. 

Mr. Justice Ridley : That means you cannot avoid taking it 7 

Mr. Eldon Bankes : Y’ou cannot avoid taking it. 

Do you know this : a cocaine habit or a morphia habit 
would be acquired by absorbing quantities of cocaine or 
morphia into your system ?—It certainly would. 

Have you sufficient medical knowledge to know that either 
of those drugs is absorbed more readily into the blood if 
inhaled than when swallowed ?—I think quite the reverse, 
but I am not a judge. 

Are you prepared to dispute that every ounce of this stuff 
of yours contains a considerable quantity of cocaine ?—I 
know nothing about it. 

Are you prepared to dispute, also, that it contains a con¬ 
siderable quantity of atropine ?—I know nothing about it. 





The Lancft,] 


TDCKER r. WAKfEY AND ANOTHER. 


[Feb. 1,1908. 31 7 


Are yuu prepareu to dispute tuat outti those are puiouuo 
scheduled to the English Pharmacy Act !—I do not know 
much about the Pharmacy Act ; I do not know that I ever 
read it. 

Listen, Sir, do you defend sending out indiscriminately 
these enormous quantities of this liquid without either 
inquiring what the constituents are or what barm they will 
do in certain cases ?—I do. 

Now let me ask you a word as to the method in which you 
carry on business. I understand it is carried on at this 
private house at Herne Hill?—Yes. 

Does your name appear in the Directory ?—In the neigh¬ 
bourhood directory it does. 

In the London Directory ?—I do not know whether it is a 
general directory of the whole city or not. 

Do you insert your name anywhere in sny commercial 
directory ?—No ; 1 think it may be in the telegraphic 
directory. 

You do not let anybody know publicly that you are carrying 
on business ?—No ; we do not advertise at all. 

You do not advertise at all in the public press ?—No. 

Is that because you do not desire public attention to be 
directed to what yon are doing ? We do not think it pays 
in the first place, and in the next place we have no occasion 
to do it. 

I am coming in a moment to what you do. You have not 
inserted yonr name anywhere in any commercial directory ! 
—No. 

And you do not advertise in the public press ?—No. 

But what you do, as I understand, is to send out large 
numbers of these pamphlets 1 —Only in response to inquiries. 

Have not you agents who are distributing these ?—Only 
when they are written to in regard to it. Instead of writing 
a letter they send the printed one in the first part of this 
book ; it is merely to save the trouble of writing letters, that 
is all. 

About how many copies have you had in each edition of 
this pamphlet?—The last edition was, I think, 25.000. 

So that you have issued these pamphlets and you have now 
arrived at the fifth edition ?—I think so, the fourth or the 
fifth. 

Has each edition been 25,000 ! —No ; only the later ones 
have been thereabouts. 

So that somehow or other you have been issuing these 
things to the extent of four editions, amounting to many 
thousands of copies ?—Yes. 

You desire people to read this to ascertain what it is you 
have got to sell them ?—We give them this to save writing a 
long letter explaining our theory of the treatment. 

This opens with a picture.—Yes. 

And it is headed “Nathan Tucker, M.D.”—Yes. 

Is that a picture of Nathan Tucker or a picture of you 1 — 
No, it is Nathan Tucker. 

Is not this a picture of yourself ?—No, it is not. 

Y'ou are very like each other.- Yes, in some respects. 

In appearance, may I say. Who wrote this ; did you write 
it, or your brother ?—The article following the picture 1 

The pamphlet, yes.—The first part of this is written by 
my brother. 

I want you to turn to page 6. Do'you find on page 6 in the 
second paragraph, “ Asthmatics who have organic heart 
disease or weak beart action can use the remedy with perfect 
safety ’’ ?—Yes. 

Have you sufficient medical knowledge to know that that 
is an absolutely incorrect statement having regard to the 
fact that this contains cocaine ?—I know that this is absolutely 
true from experience, and it is the statement of my brother, 
not mine. 

Never mind ; it Is you who issue this in Europe.—I publish 
this in Europe. 

You take the responsibility for publishing it ?—This iB 
published as an article written by Dr. Tucker. 

And it is issued by you in order to encourage the sale of 
the specific in England ?—Yes. 

On page 7 with regard to this you say: “The advice 
frequently given, • Physician, heal thyself,’ has been 
accomplished in this instance, and we now offer to suffering 
humanity the result of 20 years’ experience which has 
finally worked out a cure for asthma and hay fever as well 
as all other catarrhal diseases of the air-passages.” Are you 
there claiming for this that it effects a cure of asthma ?—A 
cure in one sense and not in another—not a cure to any 
liability to it. 

Have you explained anywhere in this pamphlet the sente 


in which you there use the word “ cure” ? We would not 
regard it as much of a compliment to a man's judgment to 
explain to him that this remedy is not designed to cure the 
tendency of the disease of asthma. 

This is the document which you send out, by which, I 
suggest to you, you claim that it cures asthma !—We claim 
that it cures the attack and it cures to a certain extent the 
recurrence, but a severe cold will develop it just as quickly 
as it did before. 

Let me read again what you say : “ We now claim ”—that 
is you and your brother?—The word “we” is used by my 
brother in the sense that it is frequently used by writers. 

“We now offer to suffering humanity the result of 20 
years’ experience which has finally worked out a cure for 
asthma.” I ask you, Would not any person reading that 
understand that what you were offering him was not a relief 
from paroxysms but a cure for his disease ?—I understand that 
you cannot cure any disease unless it is small pox or measles 
so that you cannot develop it again, and we never claimed 
to. It would be simply absurd to claim such a thing. 

There is another document you send out, is there not, the 
document which you call the instructions I—Yes. 

I want to ask you a word or two about that. This is the 
directions for use, is it not ? If you turn to page 5 you will 
see the instructions : “ How to fill the lungs with vapour.”— 
Yes. 

You say: “ How to fill the lungs with vapour in order 
to arrest an attack of asthma is the all-important ques¬ 
tion, which is easy of accomplishment when understood, 
yet we have had no little trouble in some instances to 
get patients to comprehend it. Tne first step in the opera¬ 
tion is to first exhaust all the air from the lungs. In 
order to simplify the balance of the process I will ask 
you a simple question, which is as follows: Did you 
ever expand the lungs by closing the mouth and commence 
drawing in air slowly through the nose until you have filled 
the lungs with their utmost capacity ? If so, this is juBt what 
f want you to do, but while you are doing this you are at the 
same time to be pumping in vapour with the inhaler into one 
nostril, so that while air is being taken in it carries the 
vapour along with it into the luDgs. This is all there is of 
the treatment in a nutshell. When the lungs are filled with 
air and vapour take the instrument from the nose. Now as 
you expel the air from the lungs you will notice quite a cloud 
of vapour escaping from the mouth. The vapour which 
escapes is the surplus that has failed to lodge in the air 
passages and is also a test that the vapour has reached the 
lungs. If you are unable to see any vapour escaping from the 
mouth you may know, to a certainty, that there is no vapour 
in the lungs to be expelled and that yon have failed to Inhale 
properly. Now repeat this process, the next time through 
the other nostril, and thus continue to do until relieved. 
You will find, if you stop inhaling, a little short of perfect 
relief, the spasm will gradually subside. Some can succeed 
better in filling the lungs with vapour by stopping one 
nostril with the finger while inhaling through the other side. 
The length of time required in using the Atomizer in order to 
get relief will vary from two to five minutes, according to the 
severity of the attacks. Please do not cough while inhaling, 
but wait until the spasm yields. In a short time you will 
expectorate without any effort. Coughing always avgravates 
asthma and should be suppressed, which is easily done, as the 
vapour is non-irritating. Coughing tends to keep up the 
irritation, just what we want to avoid. You are to uBe the 
Atomizer four times daily, whether you have asthma or not 
and as many times oftener as may be necessary to relieve 
the attacks. You will notice by the above instructions 
that it is necessary for the vapour to reach the lungs in 
order to arrest the attacks, heal the mucous surfaces, and 
cure the disease. Also remember that the more vapour you 
get into the lungs at one expansion the quicker you will get 
relief. You ought to be able, by practice, to compress the 
bulb from three to five times with one long drawn inspira¬ 
tion and not to breathe out during this time.” Have you 
ever made any experiments to ascertain the quantity of 
liquid which will be passed into the nostril of the patient if 
he follows your instructions ?—It would be so infinitesimally 
small that you could not estimate it. 

Have you ever made any experiment to try?—I use it 
myself daily and have for 17 years on an average at least 
four times a day. 

Have you ever made any experiment which will enable you 
to say the quantity of liquid which is atomised if you follow 
the inpt*' i ntions here detailed ! —The amount of fluid in the 



318 The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


bottle would last at least two weeks of constant nslng, four, 
five, or six times a day. 

Can you answer a simple question : Have you ever made 
any experiment to ascertain the quantity of vapour 
atomised if you follow these instructions'!—I cannot con¬ 
ceive of any method by which it could be measured, it is so 
small. 

Do you see here that you are advocating frequent use of 
the atomiser ?—We insist upon frequent use. 

Assuming that this liquid contains cocaine, 1 ask you, 
Are you not here advocating the very thing that is likely to 
produce the cocaine habit in the patient?—My experience 
proves that it does not. 

That is your answer. One other question about the cure. 
Do yon notice here in this passage that you draw a distinc¬ 
tion between arresting the attack and curing the disease ?— 
The facts are that mild cases, or many of them, are cured so 
that they never have another attack, but they are liable to, 
and much more liable to than persons who never had it. 

I am passing through these things quickly that I am going 
to make points on. On the next page, 7, I ask you for 
your explanation of this statement; you will see your advice 
to the patient : “ Eat light meals. Never allow yourself to 
eat until you have a bloated and distressed feeling in the 
stomach after meals,” which is good general advice. “If 
you are in the habit of using alcoholic stimulants, morphine, 
opium, or other narcotics, abandon their use.” Why do you 
say that 1 —Because they are very harmful to persons suffering 
from asthma especially and very harmful to all persons. 

What is the difference in effect between, we will say, 
opium and other narcotics and cocaine or atropine !- This 
was written by my brother, you understand ; it is not mine. 

I quite understand that. - And I suppose he knows what 
he is saying. 

But can you understand any honest man saying to a patient, 

‘ 1 Avoid opium and other narcotics,” and at the same moment 
giving him cocaine and atropine ; can yon understand any 
honest man doing that ?—That is a supposition, and purely 
so. I do not know that I can give you a definite answer to a 
supposition of that kind. Our experience proves that it is 
absolutely harmless. Probably no man in England has used 
as much of it as I do myself. 

These are the documents that are sent out from this private 
house of yours at Herne Hill ?—Yes. 

Do I understand that you and your brother are the persons 
who, if I may use the expression, “ sell the articles ” 1 —Yes. 

Y’ou have two typewriters who look after the correspond¬ 
ence, and you have two bookkeepers who look after the 
books ?—Yes. 

And you and your daughter do the selling ?—We dictate 
the letters that come in to our typists. 

Is there anybody in the house who has ever had any 
medical training at all ?—Not in connexion with this remedy. 

I ask you, if that is so why do you send out the list of 
questions which the person who desires to have your remedy 
haB to answer ’We send out that list of questions to 
ascertain whether the patient has asthma or something else. 

Have you medical knowledge enough to know that there 
are very many illnesses, if I may use a general expression, 
the symptoms of which are precisely the same as asthma, or 
would appear to the patient to be the same ?—It is true that 
patients themselves are sometimes deceived. 

For instance, have you sufficient medical knowledge 
to know this, that the symptoms of heart disease may be 
identical practically with the symptoms of asthma ?—I do. 

So that a patient may think he is suffering from asthma 
when he is really suffering from heart disease?—Y’es. 

Is the same thing true of a patient suffering from Bright’s 
disease ?—No, I think not. 

Have you sufficient medical knowledge to say that ?—I 
have not sufficient medical knowledge, but I have sufficient 
common-sense to know whether a man has got asthma or 
whether he has got something else. 

I am putting these questions to you and yon think that is 
a reasonable answer. Do you know the disease called 
emphysema?—Yes, what is called that. 

Are the symptoms of emphysema practically identical 
with those of asthma?—It is true that many medical men 
speak of an asthmatic as having emphysema as the result of 
asthma, and the terms are so interchangeably used and con¬ 
fused that they are not very clear. 

Then I will not take one that will enable you to have that 
confusion in your mind. Let me take phthisis ; that is a 
definite disease, is not it—consumption ?—Y’es. 


Are the symptoms of consumption practically identical 
very often in the mind of the patient with those of asthma f 
—It is possible that a person may have consumption in a 
mild form which is not fully developed, and at the same 
time have asthma. 

Is not it true that a person may be suffering from con¬ 
sumption and have symptoms which would make him believe 
that he was suffering from asthma ?—They are very different, 
but a patient might so think. 

That is all I am asking you. Let me take that. A patient 
may be suffering from heart disease and may think 
that he is suffering from asthma ; a patient may be suffering 
from phthisis and may think that he is suffering from 
asthma. The only question you ask him is, not as to his 
symptoms so that you can judge, but you ask him: “How 
long have you had asthma ? ” and then he answers. Now t 
ask you, Do you suggest to the jury that these questions can 
in any way assist you as to whether you shall Bend out this 
stuff or not ?- Sometimes they are so answered that I am in 
doubt and then I write and ask further questions and I aBk 
them for the opinion of their family physician as to their 
ailment. 

Do you not think that, as stated by one of your witnesses, 
these questions are calculated to lead patients to believe that 
they will be submitted to some person of medical knowledge 
who will be able to say whether the cure is applicable to 
their case or not ?—Those questions were written by a 
medical man. 

YVas not the object of sending them out to lead the 
patients to believe- 

No, that is not the object, to deceive them. 

I do not know whether it is the object but do you not 
realise that the effect of that is that patients would believe 
that those questions were to be submitted to some medical 
opinion before this cure was sent to them?—It is possible 
that they might so construe it. 

And, as a matter of fact, they would be received into this 
private house where there is nobody but you and your 
daughter, who do not profess any medical knowledge at all t 
-My experience has been that I am able to judge very 
accurately as to the case when I get those questions 
answered. 

The only case that I can deal with is this man Cushing, 
because those are the only questions that we have seen or 
that we know about. Let me ask you to consider what the 
questions and the answers were ? What you state on the top 
of your paper is: “Dr. Tucker’s Asthma Specific, Chief 
Dispensary. Mt. Gilead, Ohio, U.S.A. Headquarters for 
Europe: ‘Onaway,’ Half Moon-lane, Herne Hill, London, 
S.E. All correspondence should be addressed to A. Q. 
Tucker, General Manager. This blank to be filled up on 
both sides and returned.” Then you ask the man his name 
and address and you ask him his age and his occupation. 
What do you ask him that for, because, according to you, 
this remedy is applicable to anybody between the age of a few 
months and any age you can live to — Any man who follows 
stone-cutting or works in a flour mill or a warehouse is filling 
an avocation which is liable to develop asthma and aggravate 
it materially. 

YVhy do you ask his age ?—It is not so very important that 
we should have his age, yet we like to know whether we are 
dealing with a person in vigour or whether we are dealing 
with a very old person. 

But according to you it is equally applicable and you send 
it out whether he is three or whether he is 50.—That is right. 

Then why ask it ?—It is merely to know more about the 
patient—to get familiar with his case. 

Is it because you are following the form which is fre¬ 
quently followed when people try to treat patients by corre¬ 
spondence ?—The questions were asked by my brother, the 
medical man. 

By a medical man and to be submitted to a medical man ? 

Mr. Duke : He does not say his brother has them sub¬ 
mitted to him. 

Mr. Eldon BaNKES : Y'our brother had them submitted to 
him. He wrote them.—Yes. 

And they were a form which he himself used ?—Yes. 

"Name and address ; age; occupation; how loDg have 
you had asthma ? Do you know the first cause of your 
asthma? If so, state it. When do you suffer most from 
asthma, summer or winter ? How frequent are your attacks ? 
Are your attacks more severe at night than during the day '? 
What remedy are you now using to relieve attacks ’” You 
have only one remedy, have you ?—That is all. 




The Lancet.] 


TUCKER v. WAKLEY AND ANOTHER. 


[Ebb. 1 , 1908 . 319 


Then what does it matter whether the attacks are more 
severe at night than during the day if you give the man the 
same thing whatever his answer is ?—Because it brings out 
•one characteristic of the patient’s condition. Nearly all 
asthmatics are worse at night than during the day, but if it 
comes out that they are worse during the day than during the 
night it brings out this fact, that exercise has something to 
do with it. 

What does it matter to you, because yon have the same 
instructions how to use the thing for everybody, and you give 
everybody the same stuff ?—But supposing I find by these 
questions that the patient evidently does not have asthma 
at all, I then write to him and say, “ This remedy will 
probably do no good whatever.” 

Your question is, ‘‘How long have you had asthma?” 
Supposing he said, “ I have never had it.” I do not know, 
but perhaps you would say, “ I shall not send you my stuff,” 
but, if he says, “I have got asthma,” what possible ground 
is there for asking whether he has it more in the night or 
more in the day, except this, to lead him to suppose that 
somebody is going to look at this who will vary the treat¬ 
ment according to his answers ?—You cannot get a direct 
diagnosis of an asthmatic’s condition without just about those 
questions, and they do bring it out. 

What is the good of a diagnosis to you if you are going to 
give every man the same stuff and give him the same 
quantity ?—It is a question of whether we give it to him at 
all or not. 

The answer this man gave you to your question, “What 
remedy are you now using to relieve attacks ? ” is “cod-liver 
oil as a tonic.” tf you had been a medical man would not 
that indicate to you that this man was probably suffering 
from consumption and that some medical man had ordered 
him cod-liver oil because he was suffering from consump¬ 
tion!—I always expect, when I find a man is taking cod- 
liver oil, he is in a very much run-down condition and is 
being fed up. 

One of the grounds on which you would feed a man up 
would be that he is suffering from consumption ?—Yes. 

Let me understand you. Here is a man who says he is 
suffering from asthma. You told me yourself he may 
believe he is suffering from asthma but is really suffering 
from consumption. Y'ou are told be is being fed up with 
-cod-liver oil. You tell me you do not think your treatment 
is suitable for a consumptive patient, but you sent him this 
and charged him £3 for it, knowing he was a fitter.—A 
fitter ? I do not understand the term. 

Well, a man earning weekly wages. Do you attempt to 
justify that?—This man was sent this remedy for a two 
weeks’ trial and then he was to decide whether he wanted it 
-or not, and it did not -oost him one farthing. 

Now I will ask you about the two weeks’ trial. Do you 
know that the effect of cocaine is to deaden the mucous 
membrane ?—I do not know. 

Let me understand. Supposing a man suffers from these 
paroxysms of breathlessness, or whatever it is, and you 
administer cocaine to him, it will probably relieve him, 
although it may do him great harm in other respects. Do 
you follow that?—Yes. 

So that if you give a man a fortnight’s trial you know that 
the effect of this deadly drug will be to give him relief and you 
do not care the least whether it is ultimately going to hurt 
him or not ?—The facts are that it never has injured a solitary 
man yet; not one. 

So you say.—Well, find one if you can ; bring him in out 
of the 25,000. 

You must wait until I come to my evidence. The fact is, 
this man died, an iDquest was held upon him, and the fact 
was proved that he died of long-Btanding phthisis.—That 
is the report, I understand. 

And it was that fact, was it not, that you had supplied 
this treatment at £3 to this man which led to the remarks of 
the coroner, which in their turn led to our remarks'!—I do 
not know what led to your remarks. 

Very well, we will see. There is one other document. Is 
that a document which you circulate in England (same 
handed to the witness) ?—This was sent to me very recently 
and I have sent it out in a few instances when this question 
was raised in answer to the query as to what was in it. Some¬ 
times our patrons want to know, and they say they have 
been told it contains certain things detrimental to health, 
an! instead of writing a long letter I inclose this. 

Y'ou composed it ?—No ; my brother composed it. 

Was that Bent because you had heard it suggested that 


your specific contained cocaine and other drugs ?—This was 
written by my brother, printed in the States, and sent over 
here I think about a year ago. That was the first time I 
had ever seen it. It was to obviate the difficulty of writing 
long letters explaining r fleets of the medicine, if there was 
any bad effect. I do not think there have been more than 40 
or 50 of those ever left the office. It is possible there may 
have been that many. It is only in answer to inquiries that 
that has been sent out. 

This is what your brother apparently says: "We are 
occasionally asked the question, • Will the continued use of 
the asthma remedy produce any injurious effects ? ’ ” Have 
you ever heard it suggested that the continued use does 
produce injurious effects ?—I never did. 

So that this is some complaint that has been made to your 
brother that has not reached you ? 

Mr. Duke : He does not say it is a complaint; he says it is 
an inquiry. 

The Witness : The question is raised by the suggestion of 
some party who evidently is jealous of the success of this 
remedy. 

Mr. Eldon Bankes: That is what you think. It was 
their suggestion that it would, if used continuously, have 
bad effects ?—That suggestion goes out, people become 
nervous, and they write in asking questions about it. 

Have you heard of this suggestion before this case ?—Y'es. 

You have often heard of it ?—Oh, yes ; it has been at work 
ever since we started. 

You choose to put it down to jealousy )—t do. 

Bnt you have heard the suggestion that the continued use 
of your treatment does produce bad effects ?—That question 
has been raised and it has been hinted that that is the effect 
by jealous parties who are interested to curtail the sale 
of it. 

Do you know that this specific of yours has been the 
subject matter of discussions at meetings of medical men ?— 
I know it has. 

Do you know it is commonly known in the medical pro¬ 
fession for some time that this specific of yours contains 
poisons—among some medical men ?— I know there are some 
few medical men who have sought to criticise it and actually 
put the idea that it was a dangerous remedy. 

But it has come to your ears, has it not, that amongst 
certain members of the medical profession it has been known 
for some little time that it contains cocaine ?—They say it 
has ; I do not know. 

But you have heard that ?—Y'es, I have heard it. 

Do you really say that hearing the statement some time 
ago that it contained cocaine you have never taken the 
trouble to have the stuff analysed ?—I do, emphatically. 

Have you never taken the trouble to ask your brother 
whether it did contain cocaine ?—I never did. 

Is that because you were anxious not to know what it 
contained ?—I have nothing to do with compounding it in 
any way or shape. My side of the business is simply 
commercial and my brother's is the medical. 

To sell things which, if they contain cocaine, would bring 
you within the Pharmacy Act ? 

Mr. Duke : It is a question of law as to the quantity; 
whether a certain element, cocaine or other ingredients, such 
as mentioned would bring a person selling a preparation of 
this kind within the authorities depends on the amount. 

Mr. Justice Ridley : I discovered accidentally that a 
chemist who would supply you with a patent medicine 
without question a year ago would not supply it now without 
your signing a paper. 

Mr. Eldon Bankes : There is no alteration in the 
Pharmacy Act. 

Mr. Justice Ridley : But there is in the way it is 
administered. 

Mr. Eldon Bankes : It is only because it has become 
known that some of these medicinescontain these poisons. 

Mr. Justice Ridley : The medicine I mean contains 
strychnine and it was known years ago—everyone knew it, 
Fellows’s Syrup of Hypophosphites. People constantly buy 
it, and a most useful thing it is, I believe. It certainly 
contains strychnine. I was talking to a medical man about 
it the other day. Therefore, I thought people were more 
strict about it now. 

Mr. Duke : It very possibly is so ; I do not know how that 
is. Of course, if the fact be that this gentleman must 
employ a chemist to sell these things, he must employ a 
chemist. 

Mr. Justice Ridley : A chemist will not sell it to you now, 



320 The Lancet,] 


TUCKER r. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


though he would have sold it at one time without a signature ; 
but it may not apply to all chemists. 

Mr. Duke : The particular syrup your lordship is referring 
to is probably sold without any signature. 

Mr. Justice Ridley : 1 could not get it the other day. 

Mr. Duke : I have not tried the other day, hut it is not 
very long ago. 

Mr. Justice Ridley : It is not quite the same thing. It 
depends where you go, I daresay. 

Mr. Eldon Bankes (to the witness) : I put to you a 
document which you say has only come into existence 
recently. 

Mr. Justice Ridley: I suppose we shall have some general 
question to discuss here about the presence of poisons in 
these medicines. Then |it becomes a question of quantity, 
does it not, if one may clear the air .' Poison is a relative 
term. Strychnine is a drug properly administered, so is 
arsenic, and eo are all kinds of poisons ; it depends on the 
quantities. 

Mr. Eldon Bankes : My evidence is that these poisons 
are present in this liquid in considerable quaniiiies and my 
medical evidence is in such quantities that the use of this 
stuff in this indiscriminate way is a public evil. 

Mr. Duke : That is not the case that is raised on the 
pleadings. 

Mr. Justice Ridley: The reason 1 put the question was 
it seems to me that the presence in small quantities does 
not prove that they are deleterious because they are con¬ 
stantly administered in the proper proportion. 

Mr. Eldon Bankes : I quite agree. 

Is not it the fact on every possible occasion you have 
always represented to everybody who has asked the question 
that this treatment of yours is perfectly harmless .’—1 do 
absolutely. 

I have taken that statement. Now there is the letter to 
Cushing. You wrote a letter on Feb. 2nd to Cushing 
sayiDg— 

Mr. Duke : That is not in at the moment. 

Mr. Eldon Bankes : I am putting it in. 2nd February, 
1904. Your order for a two weeks' trial received and we 
will forward the outfit to you to-day by parcels post. You 
will find printed instructions in the box directing you how 
to use it and so forth.” Then at the end he Bays : “Now, 
in closing I may urge you again to read and follow the 
printed instructions sent you in the box. By doing so you 
will find the treatment both easy and pleasant to use ; it is 
perfectly harmless.” 

Mr. Duke : That letter is in. 

Mr. Eldon Bankes : Yes, that letter is in. The witness 
says, and perfectly fairly says, that is what he has always 
said to everybody. 

Mr. Justice Ridley : Have you got that letter ? 

Mr. Duke : No, that is why I was anxious it should go in. 

Mr. Justice Ridley : I suppose you have only a copy 
of it. 

Mr. Duke : If so, my learned friend will have to prove it. 

Mr. Eldon Bankes : I can get the original and I will ask 
the witness if there is any point about it. 

While that is being looked for I will ask you something 
else. You have talked about your business as between 
yourself and your brother. Do I understand that the parts of 
the atomiser which come from America and the liquid are 
both invoiced to you by your brother ?—They are. 

Bo that be charges you what sum he thinks proper and you 
pay him direct !—Y’es. 

You do not pay the manufacturer of the atomiser but you 
pay him ?—I pay him. 

The price which you pay him, I understand, roughly 
speaking, works out at about 9> for the atomiser and 
something between Is. 6 d. and 2s. an ounce for the liquid ?— 
It is something over 2s. 

We will take it for working purposes, withont desiring to 
be absolutely accurate, at about 2 j. and 9s. Would that be 
about right ?—That is about right, but it is a little under. 

Therefore your brother is prepared to sell the stuff to yon 
at that price ?—Yes, 

Do you know that the actual cost of each ounce of liquid 
is about 3d. ?—I know nothing about it—absolutely nothing. 

So that the position is, if I can prove that the cost of the 
stuff per ounce is about 3d., your brother charges you about 
2*., which is a very fair profit for the cure and everything 
else, per ounce, and you, as between you and the public, 
raise that 2s. to 8s. That is the business view of it, is not it ? 
—No, it is very different from that. 


If those are the prices that is the business view ?—That is 
on the supposition that this does not cost anything, or 
practically nothing. 

I am asking you to assume that the liquid can be bought 
aDd compounded at about 3d. an ounce.—it cannot for any 
Buch amount. 

I am going to give evidence about it. Assume that, and 
we know that your brother charges you about 2*.; when it 
arrives here you charge the general public 8s., although, so 
far as the cure is concerned, you have had nothing to do 
with that. It is your brother who has invented the cure and 
has taken the payment for that in the difference between the 
cost of the stuff and the 2s. he charges you. That is a very 
satisfactory increase of price, is it not!—On that 2s. yon 
have to put another Is. for medicine stamps. You have to 
put on the mailing cases in which it is sent, the bottle in 
which it is sent, the cost for sending it, and the carriage 
across over here. 

1 have included the carriage in the 2s.—That does not 
include it. The actual cott is over 2s. in Mount Gilead, 
Ohio, per ounce. 

You have given us some figures as to the business done, 
and you have disclosed your books to us, and we have had 
an opportunity of looking at them, and I find that you keep 
your books in this way, that you have got one column, 
amount received, and in another column you have got the 
amount deposited. Does the amount deposited mean the 
amount you have paid into the bank ?—Yes, it does. 

Are all your general expenses, apart from what you pay 
your brother by cheque, paid by you before you pay these 
amounts into the bank ?—They are not ; they are paid out of 
that which goes into the bank. 

I see. For instance: for the year 1906, your gross 
receipts are £19,641, and you paid into the bank £18,301. 
How do you account for the difference ? Are they payments 
on account of the business ?—The difference is made up by 
the payments in cash by those who call in the office. We 
receive all the way from £3 to £10 a day direct from our 
patients who come to the office, but the deposit is just what 
is deposited in the bank, and that is made up of cheques and 
postal orders. We turn no cash into the bank. 

But you pay a large proportion of your working expenses 
out of the cash you receive over the counter ?—Some parts of 
it, but most of it is paid out of the banking account. All the 
money sent to the States is sent by New York draft through 
the bank. 

That appears in your pass-book, does not it ?—Yes. 

1 have had that taken out. Is it accurate that you 
received over here in England, gross £19 611, or there¬ 
abouts ?—I do not know what I did pay him in any one year. 

Would you say about £5600 !—Yes ; it is probable that it 
is pretty nearly the thing. 

About right ?—I do not know ; it may be or may not. 

If that is right the difference represents the increased cost 
which you put upon the article over and above what you paid 
your brother for it ?—No, it would not. 

Not altogether ?—No. Here is an item that I pay : from 
£40 to £60 a month for these rubber bulbs. 

I quite agree ; and the bottles ?—Yes ; I pay from £10 a 
month for bottles, the glasses, and we have all the mailing 
cases in which this fluid is sent through the country ; they 
mount up to a large sum. The amount that is sent to my 
brother does not cover nearly all the expenses by any means ; 
the materials that enter into it I do not get from him. 

As to this gross amount of £19.641, are the agents' com¬ 
missions deducted from that before it is entered into books T 
—They are all included in that up till quite recently. I 
think it is only some eight or nine months since they were 
not included. Up to within the last eight or nine months 
all the commissions were included in the £19,000. 

May I take that the relative year’s trading in the year 
1906 the gross figures £19,641 did include the agents'com¬ 
mission?—Yes. 

But the figures which have been given us for 1907 do not 
include it ?—Since May, I think, or about that time, we cut 
them out. You understand that our business is run pre¬ 
sumably on a cash basis although we cannot quite make it 
so. Secondly, we do not keep a debtor and creditor account. 
The only accounts we have up till May are the gross receipts 
and the amount of money that 1 sent out, and there has been 
no account kept of the expense, but since May I have been 
keeping an accurate account of all expenses as well as 
income. 

Mr. Eldon Bankes : Mr. Smith gave us the figures of 




The Lancet,] 


TUOKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908 . 321 


£18,498 17*. 10J. for the year 1907 up to a certain date. 
Can you now give me the date 1 

Mr. Duke : Do you want it at the moment ! 

Mr. Eldon Bankes : I am finishing this point if you can 
give it to me. 

Just look at that letter ; that was the letter I was asking 
for; it is the Cushing letter. Is that letter issued from your 
so-called office ? (Document banded to the witness.)—It is, 
and it has special instructions for the use. 

Keep that in your hand ; that is entirely printed ?— Type¬ 
written. 

That would be sent out by one of the typists ?—It is 
printed by the printers, but it is iD a typewritten form. 

It has been typewritten, but because yon send out so many 
of them you have had it printed?—We send it with every 
trial that goes out. 

Would that be sent out by the typist, for instance, without 
any communication with you at all f—Every single treatment 
that goes out the typist puts in one of these. 

That is the one saying the treatment is absolutely harm¬ 
less ?—That is sent to every patient, or at least intended to 
be ; if it is not it is a mistake. 

Mr. Duke : The figures Mr. Smith gave were for the whole 
year 1907. 

Mr. Eldon Bankes: £18,498? 

Mr. Duke: That is under the heading of “Deposited,” 
gross receipts, £19,678. 

Mr. Eldon Bankes : I understand the gross figures for 
1907 are £19,678, but they would exclude the agents’ 
commission ’—I think since May ; that is my recollection. 

Do you say now that this business, and a very lucrative 
business it seems to me, is worked upon the terms that you 
control Great Britain and the colonies and everywhere else 
except North America '—Practically so. 

And your brother does North America ?—Yes. 

North America is not a very happy field for these enter¬ 
prises now, is it ? How many States to your knowledge have 
expressly forbidden the sale of your specific at all?—Not a 
single one. 

Let me ask you this, Massachusetts !—We have, I think, 
more in the Slate of Massachusetts than any other State in 
proportion to the population. 

Do yon disregard the law there just in the same way as 
you do in England ? 

Mr. Duke : I submit my learned friend is not entitled to 
make that statement. 

Mr. Justice Ridley : I think he may make the statement; 
of course, we cannot take it as accurate. 

Mr. Eldon Bankes : I will withdraw it. 

Mr. Justice Ridley: I suppose under the Pharmacy Act 
the word “ poisons ” largely depends on what the quantity 
is? 

Mr. Duke : It does, and it has been a matter of judicial 
decision. The allegation is an allegation of fraudulent 
mode of dealing. 

Mr. Justice Ridley : I must hear Mr. Bankes upon that, 
I think. 

Mr. Duke : I am not at all objecting that my friend is 
not entitled to investigate the matter fully, but the real 
question is whether the plaintiff conducts Mb business 
properly. 

Mr Justice Ridley : I thought that was what was alleged, 
but also it is alleged that there was the sale of poisons. 

Mr. Duke : But it only alleges that as a ground for saving 
that the plaintiff conducts his business fraudulently. Your 
lordship will see they say that the charges in the libel are 
fair comment because of various matters, and then it sums 
up with the statement, a late paragraph of the particulars, 
with the specific contents cocaine and atropine. 

Mr. Eldon Bankes : I asked you about Massachusetts. 
Do you not know of the Statute of 19C6 in the State of Massa¬ 
chusetts forbidding the sale of medicines containing cocaine, 
and directing there shall be no prosecution until the State 
Board of Health have publicly stated the medicines indi¬ 
cated ; do you know that ?—I know there was a law passed 
pertaining to that, but just what it was I do not know. 

Do you know the newspaper called the Boston Daily 
Advertiser?— I know there is such a paper. 

I ask you to look at this advertisement and see whether 
there is not here, in pursuance of the Statute- 

Mr. Duke : I must object at this point. If my learned 
friend has evideuce of an unlawful act committed in the 
State of Massachusetts against the law of the State he must 
prove the law in proper order. 


Mr. Eldon Bankes : I am prepared to prove the law. 
Mr. Barratt will come and prove the law. 

Mr. Duke : The question is this witness’s knowledge. My 
friend produces a newspaper which, so far as appears, the 
witntss has never seen and seeks to put that to the witness 
as evidence of knowledge by him. 

Mr. Justice Ridley : I think he can do that. 

Mr. Eldon Bankes: If he denies the knowledge I must 
prove it formally in the proper way. I am only asking him 
now whether of his own knowledge, in pursuance of the law, 
of which apparently he has some knowledge, he does not 
know that public advertisement has been made by the State 
Board of Health of the Commonwealth of Massachusetts 
including his particular medicine as one of those the sale of 
which is prohibited. I ask him simply. Did you know that? 

The Witness : That it is prohibited ? 

Yes ?—I do not know that it is. I know it is not, because 
the remedies are going in there every day in Massachusetts. 

Have you bad no correspondence with your brother on that 
subject 1—I am not sure whether 1 learned it from him 
in a letter, or whether I learned it through a physician whom 
I met from Brooklyn, New York, but I heard something in 
reference to it. 

Learned what?—That there was a law passed seeking to 
control the sale of poisons or proprietary medicines of all 
kinds without the formula beiDg given in full. 

Have you not since heard that your particular medicine 
has been specially excluded ?—No; and had it been of course 
I should have heard of it. 

Then I must prove it in the proper way. Do not you 
know that the same law prevails in the State of New Jersey ! 
—I do not know anything about it. 

Or any other State?—I know the sale in the States is 
simply immense : greater than mine here, much greater. My 
brother does more business than I do. 

Mr. Justice Ridley : I suppose it will be said against you 
that that is the reason of the law being passed. 

Mr. Eldon Bankes : Of course, that is my case. 

Mr. Duke; Y’our case is that be carries on his business 
fraudulently. 

Mr. Eldon Bankes : Fraudulently, I know. 

Mr. Duke: Of course, it means nothing when you come 
into court. 

Mr. Justice Ridley : As far as the libel is concerned I 
shall have to hear what Mr. Bankes says when it comes to 
a question of the meaning of it, but I certainly thought 
it was suggested that it was a fraudulent sale and it also 
suggests that it is poisonous ; but I thought the main argu¬ 
ment in the paragraph complained of was against the Press 
in assisting people to sell remedies on so large a scale by 
offering their columns for advertisements. We 6hall hear 
what Mr. Bankes says about it. He says it is tot a remedy 
because it contains poisons in an improper quantity ; and, 
secondly, it is fraudulent because the price is excessive. 

Mr. Eldon Bankes : And because it is sold by a man with 
abfolutely no qualification- 

Mr. Duke : That is not the allegation ; there is no par¬ 
ticular of that. 

Mr. Eldon Bankes : Promiscuously, under, apparently, 
the Government mgis of the stamp ; whereas really it ought 
to be labelled “ Poison,” and sold only under the restrictions 
applicable to things of that sort. 

Mr. Justice Ridi.ey : There is another point in the case 
which we shall have to deal with and that is this, that the 
coroner did not take it as being fraudulent, so far as 1 
understand, except as being sold under the cover of the 
Government stamp. 

Mr. Eldon Bankes : Your lordship will hear the coroner 
when he comes. Y’our lordship will 6ee our amended 
statement put that right. We attacked it on both grounds. 


SECOND DAY. 

Mr. Justice Ridley : I wish to say that 1 observe in the 
Timet this morning I am reported to have said that the 
proprietary medicine which I mentioned, Fellows's Syrup of 
Hypophosphites, had been marked as a poison. I never said 
it had been marked as a poison, and I am ratberapprehensive 
that the remark might be prejudicial to the medicine, 
although 1 cannot quite say what it is. What I did say was, 
whereas you could buy it freely formerly in the chemists’ 
shops, now if you go and ask for it you have to sign your 
name in the books. I do not wish to have anything reported 
from me which would be likely to have any prejudice on 



322 The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


that proprietary article, and therefore I make that remark. 
I wish people would be more accurate when they report 
what I say. Of course, it has nothing to do with the case, 
but I wish just to say that. 

Augustus Quackenbush Tucker, recalled, further cross- 
examined by Mr. Eldon Bankes.— I wanted to ask you a 
few more questions about these atomisers. Have you your 
atomiser here ?—Yes. 

And the one you produced yesterday, Oppenheimer’s?— 
Y’es. 

Did you buy that ?—I bought one, but I do not think this 
is the one. 

Y’ou can tell me, I daresay, what the retail price of that 
is ?—The one I bought was six or seven years ago. I think 
it was 6s. 6 d. or 7 s. 6 d., but 1 will not be sure which. 
t 6s. 6 d., I suggest to you?—1 think perhaps that was it. 

In regard to that atomiser, I will ask you about one or two 
more in a moment ; I do not want a great number—that one 
does produce, does it not, as fine a vapour as yours ?—I think 
it does—sufficiently fine at least. 

And the only complaint that you make about it, as I 
understand, is that each compression docs not vapourise so 
much liquid?—Well, that is true there is but little vapour 
produced. 

Have you ever tested them to see exactly what the 
difference between the two is in that respect ?—Yes, 
repeatedly. 

I suggest to you that the difference is this, that in 100 
compressions of yours which would vaporise 0 60 of liquid, 
Oppenheimer's in 100 compressions would vaporise 0 40 ?— 
I do not know about that. 

Mr. Duke : That is two of Oppenheimer’s and three of his, 
to put it simply, if I understand the formula. 

Mr. Eldon Bankes : It requires more compressions of 
Oppenheimer than it does of his. 

The Witness : I should say Oppenheimer would produce 
not more than one-fourth of what ours does. 

That is your idea ?—That is my opinion about it. 

Assuming the figures are such as I suggest, would it make 
any difference at all to the patient?—Decidedly. 

Mr. Justice Ridley : If they were 0'40 to 0‘60 ? 

Mr. Eldon Bankes : Yes, in 100 compressions, your 
lordship will see. 

Mr. Justice Ridley : I do not know how you get a 
percentage ; it is not a percentage of anything. 

Mr. Eldon Bankes : Of a grain of fluid. 

Just let me ask you to look at these two ; these are quite 
sufficient for my purpose. Are you familiar with the 
atomisers that are sold by Rogers in Oxford-street; have 
you seen those before, or similar ones ? (Two atomisers 
handed to the witness.)—I have seen something similar, not 
exactly the same. I have seen every principle of every 
atomiser that has ever been made, I think, but not all of 
different individuals. There are hundreds of them. 

Have you ever tried those ?—No, I never tried that. 

That produces a very fine vapour, does not it ?—I will tell 
you better in a moment. 

Y’ou had better take a piece of blotting paper if you ‘want 
to try that.—No, not blotting paper. 

Well, sterilised paper?—Ordinary writing paper. 

Mr. Justice Ridley: Try the Government paper; that is 
the best of all. 

The Witness (after trying atomiser) : That is a vapour: it 
is all right. 

Mr. Eldon Bankes : Now try the other one in the same 
way if you like? (The witness did so.)—That seems to be 
all right, too. 

Just hold that up; that is a very powerful one, is it not? 
—Yes. 

And as powerful as yours, apparently ? It is your liquid, I 
think, in that?—No, that is not mine. 

I beg your pardon, but that is one of the same specific 
gravity ?—The only test would be that the same liquid should 
be in both. 

I quite agree. If you have any of yours we will put it in. 
—I have not any right here. 

Just send for a little of yours and we will empty it in. 
Whilst they are fetching that let me ask you this: Y’our 
atomiser consists of two parts; that is to say, there is the 
sprayer and the vaporiser ? 

Mr. Justice Ridley: Can you identify the second one pro¬ 
duced ? 

Mr. Eldon Bankes : Yes. it is Rogers'; there are two of 


Rogers’. I have not bought any quantity. The gentleman 
fairly enough says there are any number of them made. This 
is one of your own. You put this on the top of yours and 
screw it on in order to create the vapour ?—Y’es. 

If this is taken off and then compressed there is a very 
much larger amount of liquid which will come through the 
orifice ?—It throws a spray of a large quantity of liquid. 

Have you ever seen any of your patients using it in that 
way?—1 never did. 

It has never come to your knowledge ?—No ; but I have no 
doubt some of them have done it. 

Of course, if they do that they will be able to inhale a very 
much larger quantity of liquid?—They will fill their nostril 
full and it would not go down into the bronchial tubes at all. 

Without any warning that this contains cocaine or any 
dangerous poison, if a patient got relief from it he would 
naturally think, when you have told him it is perfectly harm¬ 
less, that the more he could take the better ?—He would not 
get it past his nostril if ho used the spray. 

But inhaling it in that way it would pass into his system ? 
—Not to any extent; it would run right back out of his 
nostril; it would be a douche; that is what it would amount 
to. He would not get as much into his system as he would 
by using the other. 

Have you got your own liquid now ?—Y’es. 

Have you filled it?—This is our own. (The witness 
demonstrated.) It does not produce anything like the 
volume that it did before. 

Mr. Duke : That is to say, it would produce with the other 
liquid a large volume, but with yours it will not produce so 
much ?—There is much less volume of vapour with this fluid 
than with the other. 

Mr. Eldon Bankes: I cannot see from this distance. 

The Witness : Well, you could see the other, could not you ? 

Mr. Eldon Bankes: Yes. 

Mr. Justice Ridley: Now try your own and let us see. 
Would not that be fair ? 

Mr. Eldon Bankes: Yes. 

The Witness : (After demonstrating.) This throws a 
stronger volume of much more force. If I may be allowed 
to explain, I can show you the essential difference in these 
instruments. These instruments produce the vapour in the 
chamber ; the other instruments produce the vapour in the 
bottle and the amount of pressure that you get throwing out 
the vapour is simply the pressure of the vapour, a sufficient 
quantity of it in the bottle forces itself out by pressure, 
and that constitutes the principal difference in these instru¬ 
ments. 

Is not this the fact ? Y’ou see this yourself; it has got a 
bend in it. When you compress this you force the spray, as 
I will call it—the air pumping into the bottle creates a 
spray ?—It creates a spray in the chamber, not in the bottle. 

And then it is forced up, and the point of contact in yours 
is this point (indicating) ?—Y’es, that angle. 

And the spray is changed into vapour at that point. It is 
the point of contact that reduces the volume of it and turns 
it from spray into vapour?—Y’ou are correct in that only that 
there are two angles that it strikes instead of one. 

It is quite an immaterial point, but as you have put it to 
me I suggest to you that one of the disadvantages of yours 
as against this is this : that if you have your point of contact 
in the nozzle, and the patient is blowing very hard, it is 
quite possible that some of the spray passes through the 
nozzle: if you produce the vapour in the bottle there is no 
chance at all of the spray passing through the nozzle?—Y’ou 
are correct in this in so far if the instrument is not in proper 
condition it would be possible to throw a spray out of that 
nose-piece up here. That is quite true, but the instrument 
would not be working properly if it did so. 

Bnt if the spray is produced in the bottle that disadvantage 
is avoided ?—Yes ; but you could get no force. 

Y'ery well, that is your point. Do you not in some of yonr 
papers—I cannot put my band on it for the moment— 
represent that this liquid is quite safe because such small 
quantities of it are inhaled, and as proof of that you call 
attention to the fact that if you press the vaporiser against 
a piece of paper as you did just now no mark is made. 
Do you state that in some of the papers you sent out?—I do 
not just put it in that shape, but it is a fact. It is true that 
the infinitesimal quantity, even were it a deadly poison, 
would be harmless used in such small quantities. 

This is what I am alluding to. This is what is said in this 
paper you told me yesterday you had recently had and sent 
out recently : “ There is one thing that is not considered by 




The Lancet,] 


TUCKER IT. WAKLEY AND ANOTHER. 


[Feb. 1. 1908. 323 


physicians and others who would intimate to their friends 
that the fluid contains poison such as cocaine and is dangerous 
to use ; they fail to take into account that you can throw the 
vapour with my Atomizer against a sheet of white paper with¬ 
out even staining it, which anyone can demonstrate who may 
have one of these instruments. This being the case you can 
readily see what an infinitesimally small amount of medicine 
is taken into the circulation.” I ask you is not that written 
by somebody who is under a complete misapprehension l — 
It was written by Dr. Tucker himself. 

Yes, 1 know ; but is not the reason why no mark is made 
upon the paper that the spray is so fine that it does not 
condense, and it does not matter how long you go on spraying 
no mark would be made ?—It would if you continue long 
enough ; you could produce a slight discolouration. 

I suggest to you that this is no test at all, and no indica¬ 
tion ?—That is a matter of opinion only. 

But is not it an expression of opinion of a man who 
obviously is ignorant of the first principles of the effect of 
vapour ?—The man who wrote that stands in his profession 
as high as any man in the State of Ohio. 

Re-examined by Mr. Duke. —Do you think you would 
like to charge him with fraud because lie was mistaken when 
he wrote that, as my learned friend says he was ?—Certainly 
not. 

In your view he is not mistaken as I understand. In your 
view your brother is right about that 7—Certainly, absolutely 
right. 

I think I had better read this: “We are occasionally 
asked the question 1 Will the continued use of the asthma 
remedy produce any injurious effects! ’ In reply we will 
say, once for all, that if used according to directions no 
perceptible effects whatever can be noticed. There is one 
thing that is not considered by physicians and others who 
would intimate to their friends that the fluid contains poison 
such as cocaine and is dangerous to use ; they fail to take 
into account that you may throw the vapour with my 
Atomizer against a sheet of white paper without even 
staining it, which anyone can demonstrate who may have one 
of these instruments. This being the case you can readily 
see what an infinitesimally small amount of medicine is taken 
into the circulation. AI 90 the medicine being applied 
directly to the seat of the disease only a very small quantity 
is required to produce the desired results. This statement 
being true makes this mode of treatment the only one that 
is entirely harmless. I make the assertion that this remedy 
can be used daily a lifetime with this Atomizer without any 
perceptible effects upon the constitution whatever if used 
according to instructions. The remedy has now been in use 
about 17 years. I have yet to learn that any bad effects 
have resulted in a single instance. This fact of itself should 
be sufficient, to convince the most sceptical.” This is a 
paper which you say your brother produced comparatively 
recently of which he sent you some copies ?—Yes. 

You have sent a few of them out?—I keep that and when¬ 
ever a question comes up I inclose that in a letter instead 
of writing a long letter. 

Apparently your brother writes on the assumption that 
there is some trace of cocaine in his mixture; he seems to 
assume that ?—He takes the critic on his own ground, and 
he says : “ If there is a poison.” I think that is the idea he 
means to convey. 

If used according to directions it cannot hurt ?—That is so. 

How long ago is it to your knowledge that your brother 
began using this remedy for his own astbma?—He had this 
remedy completed in its present form in the month of 
August, 1889, and he has been using it constantly ever since. 

You say he is 70 years old ?—Yes. 

When did you see him last 1 —It is about a year ago last 
August. 

What kind of physical condition was he in. Did he seem 
at all broken down by the use of cocaine?—He and I were 
travelling through the Rocky Mountains for seven months, 
and he was as good a climber as there was in the party. 

That is when he was 68 or 69 you and he were on a climb¬ 
ing expedition in the Rocky Mountains?—Yes. 

Yon yourself are 68?—Y'es. 

In the course of your business how much and how frequently 
do you use this preparation?—I use it for instance on Sundays, 
when I have no one to call upon me, four or five times during 
the 24 hours. 

Are you subject to attacks of asthma ?—I could not live 
here at all without this remedy. 


Y'ou are naturally subject to attacks of asthma 7—Yes, and 
our whole family are chronic asthmatics, but in my profes¬ 
sional business — 

Please do not hurry. That is on Sundays when you have 
your choice about how much you use ?—Y'es. 

With regard to your chronic liability to asthma what ha* 
been your condition as to suffering from attacks of asthma 
during the time you have been living in London?—I can 
stand as much fatigue as almost any man of my age, I think. 

Does asthma ever now take hold of you ?—It would if I 
was to go out and run a foot-race of perhaps 50 yards; 
I should feel the effect. 

But you do not run foot-races?—I do not feel it to any 
extent. 

Going about in your ordinary habits as a man of 69, does 
asthma take hold of you now?—Not to any extent at all. 
It would be a slight coughing or irritation of the bronchial 
tubes, but no asthma. 

That is the manner in which you use it, because of your 
liability to astbma ?—Yes. 

With regard to your other user do you demonstrate to 
persons who are seeking to buy this apparatus the use of it ? 
—There is never a day but what I demonstrate it to some of 
those who are calling at the office. Some days I have a 
continual string of callers all day long, and I am constantly 
using it all day long showing people how to use it. I never 
hesitate a moment about doing it. I have been doing so for 
17 years. 

You did it while you were assisting your brother in his 
dealings with the specific in North America ?—Y'es. 

And you have been doing that ever since you came to 
England ?—Y'es ; more so since I came here. 

Has that been increasing since the business increased here ? 
—The climate here is harder on an asthmatic than it is in 
the States. 

So far as yonr experience is concerned, is there any ground 
whatever for the suggestion that the use of this specific 
affects the general health of the patient ?—Quite the reverse. 
It improves the health, because he can breathe properly ; it 
does not affect the health one way or the other directly, but 
indirectly it affects the health because he can breathe. 

It is suggested that the use of the specific poisons the 
system of the [atient ?—I do not look as if I have been badly 
poisoned, do I ? 

Mr. Justice Ridley : That is for the jury. 

Mr. Duke: With regard to your atomisers, have you had 
customers who have been customers ever since you began ?— 
I have. 

And who remain customers now ?—Y’es. 

You see them from time to time ?—Many of them I see 
quite often. 

Is there one of your customers who shows any kind of 
symptoms that my learned friend has referred to of being a 
poisoned person ?—Not one. 

Have you ever heard either from your patients or the 
relatives of your patients any suggestion of that kind ?— 
Nothing of the kind. 

Did you ever hear it at all from any person who was 
practically concerned in the use of this remedy—who was 
using this remedy ?—No, I never heard it at all nothing of 
the kind. 

My learned friend asked you about the Oppenheimcr 
atomiser. Messrs. Oppenheimer are people in a large way in 
the drug trade in the supplying of the matters which doctors 
and chemists use for the cure of ailments ?—I understand so, 
yes. 

Mr. Ei.don Bankes : I must object to this. I did not put 
in Oppenheimer's atomiser. Tucker produced it in the box. 

Mr. Duke : I thought my learned friend produced it. 

Mr. Justice RIDLEY : No ; he said it was the only one he 
had come across that would produce vapour and not spray. 

Mr. Duke : I thought my learned friend had produced it. 

Mr. Justice Ridley: Mr. Baukes put a question ubout it 
just now. 

Mr. Eldon Bankes : But only as to its strength and how 
it acted as compared with his. 

Mr. Duke : Well I will not raise any controversy about it. 

There are undoubtedly a great many of these atomisers ?— 
The world is full of them. 

Do you find that there are preparations being advertised 
to compete with your brother's preparation ?—Lots of them ; 
they have been at it for years. 

Do you find among your patients that they become aware 
of it ?—Y'es. 



324 The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb 1, 1908. 


Do they or not give up the use of your brother's prepara¬ 
tion after having tried these others i—I do not know that 
any of them have given up ours to use others, but I know 
they have tried it out of curiosity and dropped it at once. 

How long will one of your atomisers last ?—Some of them 
have been in use six or seven years; it depends altogether 
upon the user. Some people will take care of things and 
others do not. 

If a man has got your atomiser first he will not want a new 
one !—No. The average length of the life of the atomiser 
would be at least five or six years, and in many cases twice 
that. 

Mr. Duke : With regard to the fluid, that exhausts itself 
in use, of course?—Yes. 

And you charge a very large price, as it is said, 8s. an 
ounce, for the new supplies of the fluid ?—Yes, after the first 
four ounces. 

Do you find that your customers, in spite of the suggestion 
there is that there are others as good, continue to deal with 
you for the expensive article that you supply ?—They do. In 
a very few instances I have had them ask me to reduce the 
price or they would have to resort to some of these imitations. 
1 have told them to try them, and that has always been my 
answer. 

Have you found some of them have tried them !—They 
have tried them, but they have not tried them very long, 

They came back to you ?—Always came back. 

We have one or two witnesses here to deal with that 
matter. My learned friend referred to your books. Did you 
produce everything relating to your business to the defend¬ 
ants in this action !—Everything that was asked for. 

In order that they might see how your business was 
carried on ?—Yes. 

The information that my learned friend has been putting 
to you has been the information which you supplied him 
with ?—Yes. 

My learned friend asked you about a good many of the 
atomisers. Do you know that in the course of the inter¬ 
locutory proceedings with a view to this trial the defendant 
was asked to say what the atomiser was which he relied 
upon as competing with yours, and he was unable to do it ? 

Mr. Ellion Bankes : That was not right, was it; I think 
the question was not allowed ! 

Mr. Smith : It was resisted. 

Mr. Eldon Bankes: It was resisted; I mean to say we 
said it was not a relevant question. 

Mr. Duke : The substance of the matter is you have had 
no opportunity of making any test except the rough test in 
the witness box of these other atomisers, with your brother's 
atomiser ! 

Mr. Eldon Bankes : Yes, he has, Oppenheimer. 

Mr. Duke : Oppenheimer he has, but the others which my 
learned friend has produced have not been brought to your 
notice before '!- I have tried a great many different atomisers 
that have been presented as a curiosity, but I never saw one 
that I would take as a gift. 

My learned friend says, and you told him, the fact is you 
have no medical training. Have you ever, in the course of 
carrying on this business, pretended that you have had any 
medical training ?—Never. 

With regard to the questions you ask, my learned friend 
pointed out that there were questions and that there was 
only one treatment. Does the pamphlet and do the instruc¬ 
tions ttite in the clearest way that it is only one treatment ? 
■—Yes. 

That there is an inhaler and a fluid the character of which 
is decided beforehand ?—Yes. 

Do you think it is possible that anybody who had read the 
pamphlet or read the directions could suppose that there was 
any alteration in the treatment possible on your part ?—No. 

Then my learned friend asked you about the relative 
symptoms of consumption, Bright’s disease, and heart dis¬ 
ease. Have you ever suggested to anybody that this specific 
would have any effect upon a case of Bright's disease?— 
Never any beneficial effect whatever. 

Or on consumption?—No. 

Or on heart disease?—No. We always tell them it will 
not, and that is why we say it would give them no permanent 
benefit, but it may give them a trifle of relief. 

Suppose a consumptive patient who had a catarrhal con¬ 
dition of his throat and lungs : do you know what would be 
the effect of his inhaling the vapour 1 —It would be beneficial 
so far as the catarrh trouble is concerned, but it would be no 
benefit to tuberculosis or consumption. 


It would relieve the catarrhal trouble, but it would not 
relieve the permanent disease !—That is so. 

Have you ever said that it would ?—No. 

With regard to the paragraph on page 6 of the pamphlet, 
my learned friend asked you whether it was true, as I think 
your brother says : “ Asthmatics who have organic heart 
disease or weak heart action can nse the remedy with perfect 
safety. In fact, if the heart is sound when first commencing 
treatment, asthma will never be a cause in the development 
of heart disease for the reason that the specific will keep the 
asthma under perfect control.” You say that yon knew from 
experience that that was the fact ?—Yes. 

Was that limited to your own personal experience or to 
your knowledge of other persons who have used the specific ? 
—It is my own personal experience and my observation of 
the public generally. 

My learned friend cross-examined you upon the question 
of a cure. Except in the sense of preventing an impending 
attack or dispelling an attack which was actually in progress 
is there any cure of the liability to asthma?—No, there is 
none ; we never claimed it. 

But the attack you say is cured?—Y'es. 

It can be warded off when the symptoms are shown or it 
can be stopped when it is in progress 1 —Yes. 

I will not take uptime in reading it, but I think on page 11 
you call attention to that matter ?—Yes. 

Y’oa say “The treatment will give almost immediate 
relief and completely arrest the attacks, and by persevering,” 
and so on ?—Y’es. 

Then with regard to the instructions, your brother says in 
his instructions : “ If you are in the habit of using alcoholic 
stimulants, morphine, opium, or other narcotics, abandon 
their use. Smoking is also a source of irritation, particu¬ 
larly in closed rooms, and is liable to bring on an attack 
of asthma.” That is on page 7 of the instructions. My 
learned friend asked you whether you could understand any 
honest man saying that when he was going to propose the 
present specific for use in asthma. Tell me, with regard to 
that, are you able to say from your experience what the 
effect upon the asthmatic tendency is of the use of alcoholio 
stimulants?—It is a very decided injury to an asthmatic. 

It provokes ?—It provokes an attack. 

Is it the same with regard to these other matters that are 
mentioned ?—Y'es. 

Do you think there is anything dishonest in telling people 
that!—No. 

Mr. Ei.don Bankes : Morphine and opium I said. 

Mr. Duke : I will come to the others, morphine and 
opium. Do you know of your own knowledge whether the 
use of morphine, opium, and other narcotics has any influence 
in asthmatic cases ?—They injure the general health of the 
patient and render him much more liable to attacks. 

Those are your brother’s directions, but so far as you are 
concerned in the sending out of those directions do you see 
anything dishonest in it ?—I never could discover it, no. 

I think my learned friend rather suggested that you con¬ 
cealed your identity from public knowledge. Is there any 
truth in that ?—Not the least. 

And in fact is it true, as you told my learned friend in 
answer to an earlier question, that you have sent out in 
this country many thousands, four or five editions, of this 
pamphlet, upon the face of which there is a picture of your 
residence with your name and address at the foot ?—Yes. 

And a complete statement inside of the whole business ! 
—Yes. 

In fact, as you told my learned friend, you have not 
advertised in the newspaper press ?—I have not. 

I think the only other matter I need trouble you about is 
the price which you have charged for this remedy and the 
profits you have made. In the first place, have you ever 
charged the patient any more than you told him you were 
going to charge him in the particulars !—I never did. 

And, in spite of the charges, do the purchasers come on 
and repeat their orders ?—Y’es. 

With regard to your dealings with your brother, do you 
know what relation the price he charges you bears to the 
price he charges the general public ?—My understanding is 
that I pay him- 

I ask you if you know. Do you know what prices your 
brother charges the general public in the United States ?— 
Yes. I do. 

That is all I want to know. What does he charge them ?— 
He charges them 124 dollars for what I furnish for £3, but 
he has no medicine stamps or revenue stamps to put on it. 




The Lancet,] 


TUCKER r. WAKLBY AND ANOTHER. 


[Feb. 1 , 1908. 325 


And of course he has no carriage. He does not have the 
item of expense that you have, being resident in this 
country ?—Nothing like it. His net profit is much larger 
than mine. 

Your books have been referred to. Have you worked out, 
as far as you were able to, what your net profit is—what 
your percentage of profit is !—As near as I can estimate— 
it is an estimate because 1 have not kept an accurate account 
of the expenses—the net is about one-third of the gross 
receipts. 

Mr. Justice Ridley : Net profits do you mean ! —Yes, 
one-third of the gross receipts ; that is 33a per cent. 

Mr. Et.don Bankes: That is quite new. 

Mr. Duke : It follows entirely on what my learned friend 
has been cross-examining on. 

Mr. Justice Ridley : It follows, of course. 

Mr. Eldon Bankes : It does not appear in the books. 

Mr. Justice Ridley: No, he would not have taken it out 
in the books, I suppose, so it would not appear. 

Mr. Eldon Bankes: Of course, it would appear in the 
books if he chose to keep a full account of the expenses. 

Mr. Justice Ridley : If you chose to put them together it 
would. 

Mr. Eldon Bankes : Of course, if all the materials are 
there you could find out, but the materials are not all there. 

Mr. Duke: If my learned friend wants to ask a question 
I am not going to raise any objection in a case of this kind. 

Mr. Eldon Bankes : Will you ask him to give us all the | 
items of expenditure ? 

Mr. Duke: I will ask anything my friend wants to ask, 

but if my friend wants to cross-examine further- 

Mr. Eldon Bankes : l should prefer it. 

Mr. Duke: Very well. 

That is your estimate, one-tliird ?—Yes. 

With regard to the volume of that business has the volume 
of it been obtained in the manner and been the result of 
efforts which you have explained to the jury ?—Yes. 

And of the success of the specific ! —Yes. 

Further cross-examined by Mr. Eldon Bankes. —With 
regard to these profits there are no materials in your books 
enabling anybody to ascertain exactly what your net profit 
is !—There has never been any accurate account of expenses 
until about the 14th of last May ; from that date we have an 
accurate account of expenses. 

Did you give us yesterday all your items of expeditures ?— 
No, I was not asked for them ; I gave all that were asked for. 

Let me understand. There is your house rent, of course? 
—Yes. 

You live in the house ?—Yes. 

Do you debit your business with the whole house rent aDd 
rates and taxes and so forth in the estimate of 33 per cent ?— 
I have debited the business with one-fourth of the amount 
and one-fourth of the expense of keeping up the house. 

Is that in your estimate of 33 per cent. ? I understand you 
have been keeping accounts since May and now you may 
have kept them properly, but when you speak of your rough 
estimate of your net profits being 33 per cent., are you taking 
into account that you debit the business with the whole rent 
of the house ?—Never, no. 

Then I understand there are the wages of the six people 
who are employed in the house ?—Yes. 

There is the commission fer the agents ?—Yes. 

There is the cost of the materials ?—Yes. 

The atomisers and so forth ?—Yes. 

And there is the item of carriage ?—Yes. 

Is there any other item of expenditure ?—There is the item 
•f stamps : postages and medicine stamps. 

Revenue stamps. Is there any other item ?—It would all 
be included under the supplies. 

Of course, the cost of the materials and so forth ?—Yes. 
Your learned counsel suggested yesterday it would be 
right to deduct your income tax before arriving at your neb 
profit. Have you done that ?—I did not. 

So that we know the items of disbursements although they 
do not appear in full in the books ? —No, I have not kept an 
account of expenses. 

1 asked you yesterday and you told me you thought it was 
approximately correct that your gross receipts for the year 
1906 were £19,800, I think, and that the amount you paid 
your brother for the liquid and the parts of the atomiser that 
he supplied was £5,600 ?—I do not know' what the amount I 
paid him was. The books would show that exactly; yon 
tan get it to a fraction, but 1 have not footed it up. 


Further re-examined by Mr. Duke. —You tell us your 
estimate is one-third net profit?— Yes. 

Is that an estimate worked out in detail in figures, or a 
rough estimate?—It is worked out in detail as accurately as 
we could do it without keeping an accurate account of every 
item of expense. 

Have you got it worked out l— No. 1 have not got it here. 

I worked it out with one of the Revenue inspectors four 
years ago. 

You had to deal with one of the Revenue inspectors with 
reference to your income?—Yes. 

Then you made it out ?—We made it out together. 

That is how you got at your one-thind ?—Yes. 

Edward Alfred Coombs, examined by Mr. Duke. 
You are the Borough Treasurer of the Borough of Kensing¬ 
ton ?—That is so. 

You are 41 years of age, 1 think l -42 now. 

Had you for many years formerly been subject to attacks 
of asthma ?■—I had. 

Since about what time?—I cannot fix the exact date, but 
certainly upwards of 13 years, probably 15. 

Have they been severe attacks 1—Very severe until recently. 
Had^you undergone treatment for them? Yes. 

And used a variety of remedies ? —Yes, many. 

Have you been successful or not?—I found that some of 
the remedies were more or less successful for a time, but 
after a time they lost their effect entirely. I might say after 
a short time, after a few months, they lost their effect. 

Since what period have you ceased to ba subject to fre¬ 
quent severe attacks of asthma !—Within the last two years. 
Is there anything which fixes the point of time .’ —Yes. 
What is it ?—I obtained from Mr. Tucker on the 2nd or 
3rd of February, 1906, one of his atomisers on 14 days’ free 
trial, and there was a gradual improvement from that time, 
which has resulted in an almost complete cessation of severe 
attacks of the asthma. 

Has the specific continued to have a beneficial effect, if 
you have to resort to it, or not ? Most decidedly. 

It has been suggested that the use of the specific has some 
effect on the general health. What has been your condition 
as to general health since you have been using the specific? 
—My health has been much better—considerably better since 
I have used the specific. If I may add something to that, 
formerly 1 was very susceptible to taking ordinary colds, and 
they were invariably followed by severe attacks of bronchial 
asthma which confined me to my bed for anything from a 
week to a fortnight, but since that time I have managed to 
disperse colds in a few days without taking to my bed except 
on one occasion. I also find that whereas formerly I had to 
be very careful in my diet I can now eat and drink what I 
fancy without any ill-effect. 

With regard to the use of the specific were you formerly 
much subject to disturbance by asthma in the night 1 — 
Almost every night up to that time since I first bad an 
attack of asthma I was obliged to leave my bed to inhale 
something from some burning powder, or use some other 
remedy of that kind occasionally two or three times in the 
night. I think l may say always once at least. 

What has been the effect of the use of the specific in your 
case with regard to that liability ? I think that since using 
the specific on no occasion have I had to leave my bed to 
relieve an attack. The plan I follow is to keep the atomiser 
quite handy at the side of the bed, and should 1 be awakened 
in the night I just use it for possibly a minute, but I fall 
asleep again and know no more about it. 

With regard to the use of the atomiser, can you give us 
any idea, in order to deal with the question of quantity, 
how many compressions of the bulb are required to give 
you the dose of vapour which you want for your purpose ?—I 
cannot tell you what the minimum number i* that would 
produce the result, because I ara never at all careful. I use 
it just as I feel inclined to use it at the time, but I may say 
when I first began to use this my breaih was so bad that I 
could not inhale more than three compresMons of the vapour 
up each nostril at a time. I can now with ease do from 10 
to 15 in one breath, and 1 never take less than 10, I suppose. 
And you find it perfectly successful ?—P»rL cMy. 

Have you tried the use of Tucker's fluid in otl er atomisers 
or another atomiser ?—I did on one occasion trv the use of 
Tucker’s fluid in another atomiser but I found it did not 
break it up sufficiently finely. 

When it is not. broken up sufficiently finely does it have a 
beneficial result ?—No, it has rather a deleterious effect. It 

E 4 





326 The Lancett,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


seems to lodge in the nostrils and the back of the nose and 
create a slight irritation. 

Have you tried a specific produced in competition with 
Tucker's ill Tucker's atomiser ?—1 oannot say that I know 
the fluid was produced in competition with Tucker's, but I 
have tried a fluid which I have been told is supposed to 
relieve spasms of asthma. 

You have tried other fluids?—I have tried’another fluid. 

1 n Tucker's atomiser ! —Yes. 

Did it have the effect 7— As far as I can judge it had no 
effect whatever of any kind. 

Did yon get that fluid made up yourself?—No, I purchased 
it; it is a proprietary article. 

Will you give me a description of it! 

Mr. Eldon Bankes : 1 object to this. 

Mr. Justice Ridley : 1 do not see that this is material. 

Mr. Eldon Bankes : We cannot inquire whether other 
people are doing the same thing. 

Mr. Justice Ridley : We shall get into protracted inquiry 
into all sorts of things. 

Mr. Duke : I do not think so, my lord, for this reason : 
wo have reason to suppose the ingredients are the ingredients 
my learned friend says are the ingredients of Tucker's. 

Mr. Eldon Bankes : If they are they do the same wrong. 

Mr. Duke : That is an observation which is hardly worthy 
of my learned friend's position. 

Mr. Justice Ridley : That would make it material, because 
you have stated that the constituents of this medicine are so 
and so and so and so. 

Mr. Eldon Bankes: Yes. 

Mr. Justice Ridley : I really do not know what evidence 
you have on that subject, and I am speaking at random, but 
if Mr. Duke can show that a medicine made up of those 
ingredients has no effect at all I think that is material. 

Mr. Eldon Bankes: My point about that is, it has the 
effect of poisons, and whoever sells the poisons without the 
proper safeguards we rightly or wrongly should say the same 
about them. 

Mr. Duke : You would say it was fraudulent. 

Mr. Justice Ridley : You have no right to say it is fraudu¬ 
lent ; that is the difficulty in this case. 

Mr. Eldon Bankes : That, of course, is the question we 
are trying here. 

Mr. Justice Ridley : But you cannot. 

Mr. Eldon Bankes : With great submission it cannot be 
relevant to this case to deal with the question of any oilier 
preparations. 

Mr. Justice Ridley : No; I do not think it can merely as 
such, and I quite agree with you, but the difficulty I have is, 
if you have stated that certain ingredients are the ingredients 
of this stuff, and are deleterious, and he can show he has tried 
stuff made up of those ingredients and it has no effect at all, 
I do not see how it can be excluded. 

Mr. Eldon Bankes : No one says that one single spray of 
tliis stuff would have any effect. 

Mr. Justice Ridley : No, that is quite true. 

Mr. Eldon Bankes : It is the constant use of it. 

Mr. Justice Ridley : That is quite true. (To the witness) 
How often did you use this other medicine, once or more 
frequently 7—I tried it for a somewhat prolonged period in 
order to see exactly, but probably a week or a fortnight— 
oertainly not less than a week. 

Mr. Duke : Did you give it a full trial with a view to 
seeing if it would relieve your asthma ?—I did. Perhaps 1 
ought to say it was owing to my not having at that time any 
severe attacks of asthma I thought 1 would take the oppor¬ 
tunity of trying this other, but it did not relieve to any con¬ 
siderable extent the mild attacks that I did have. 

Will you look at that. I do not propose to do other than 
identify it at the moment; is that the proprietary article 
which you used ? (Same handed to the witness.)—It bears 
the same label. 

You got it as that proprietary article ?—I did. 

Mr. Duke : I should like to have that identified. 

Mr. Eldon Bankes: You can mark it. May I just look 
at it so that I may know what it is i 

Mr. Duke: 1 can tell you what it is; it is Oppenheimer 
21. Some question may arise about that. If your lordship 
would allow me 1 should like half of that taken from the 
bottle in order that I may be able to deal with It to test the 
suggested ingredients of it, and the other half to remain or 
be at the disposal of my learned friond. In order to be able 
to cross-examine 1 should have to be able to do so. 

Mr. Justice Ridley : I do not see how I can object to 
your making the use you propose to make of it. 


Mr. Duke : When it has been identified I should like to 
have half of it to see if it is correctly described to have the 
ingredients it has or not. 

Mr. Justice Ridley : I do not know whether you will be 
able to do that. I expect Mr. Bankes will object to that. 

Mr. Duke: I expect, if I am right in my hypothesis, to 
defeat his objection. 

Crntt-examined by Mr. El, don Bankes.— I understand 
you tried some other atomiser and your objection to that one 
was that it did not make a sufficiently fine spray?—That 
is so. 

Thomas Edwahd Mansfield, examined by Mr. F. E. 
Smith.—I think you are a member of the Bar ?—Yes. 

Have you been a sufferer from asthmatic trouble?—Yes, I 
have. 

For how long ?—It gradually increased up to two years ago 
for, I should think, the last 12 years. It gradually got 
worse up to two years ago. 

Were your attacks severe or not ?— Four years ago or three 
years ago they got very severe indeed. In fact, it got rather 
serious. Of course. I was using this before. 

Were your attacks of a kind to interfere with your pro¬ 
fessional work!—Very much indeed; that was the serious 
part, about it. 

While you were suffering, and until you began to use Mr. 
Tucker’s specific, as to which I will ask you in a moment, 
did you have medical advice for the treatment of your ail¬ 
ment?—Yes, certainly, and drugs too. 

Taking it generally, you have tried many remedies, I 
think ? —Yes; they were relief for the time but they were 
always objectionable. 

Did the efficacy wear off with repeated use?—I had it 
daily and it was only a relief. 

They returned as bad 7—Y'es. 

Did your attacks come on in the night time ?—Yes ; they 
always come worse then ; the moment you lie down, of 
course, it always begins. 

What would be the duration of an ordinary attack 7—A1 
night through if you have got asthma very bad. You may 
sleep for half-an-hour and then wake up again and want to 
breathe. 

When did you first begin to use Dr. Tucker’s specific ?—I 
cannot fix the date, but it is a good many years ago. I 
bought the first instrument in Holborn personally. I was 
recommended. 

Did you get it for trial first or not 7—Yes ; I had it a fort¬ 
night. 

You did not part with your money for that time ?—No; 
then I kept it. 

Mr. Justice Ridley : Yon cannot tell me when it was ?—I 
cannot. 

Mr. Eldon Bankes : The plaintiff says that he moved 
seven years ago. 

The Witness : I attended at the place personally in 
Holborn. 

Mr. Smith : It is somewhere about seven years ago; that 
is sufficient '! —Yes. 

I want you to tell my lord and the jury what has been 
the effect of using this specific and atomiser upon your 
ailment!—I could not do without it. I can now comparatively, 
because in the atmosphere I am in—not just at the moment— 
it suits me better than North Lancashire. 

You were formerly practising at the local Bar in Lancashire ? 
—Yes. 

Mr. Justice Ridley : But you can now ?—I have it with 
me always by way of preventive, because I do not have it if 
I have it with me, but if I am without it I begin to think 
about it and begin to get asthma if you get nervous. 

Mr. Smith : You always carry it with yon ?—Yes. 

Have you got it with you now ?—I have. Of course, it is 
nervousness, I suppose. If you know you have a thing that 
will give you instant relief and you have not got it with you 
and you have to do what our profession does, you get nervous 
for fear it should come on. 

How long did you use it before you got into the condition 
in which you say you can do without it ?—For the last 18 
months I have used it very little. 

You did not find the habit growing upon you 1 —I cannot 
understand anybody using it unless they want it; they are 
only too glad to be rid of it. 

Mr. Justice Ridley : It is not pleasant to inhale vapour up 
one's nose, I must say. 

Mr. Smith : Has it exercised that kind of seduction over 



The Lancet,] 


TUCKER t> WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 32 7 


you that you are not happy unless you are using it ’—No, it 
has not indeed. 

Would you say, in fact, your use of it has grown less ?— 
I never use it unless I need it, and as I say I cannot under¬ 
stand anybody using it for amusement. 

Whenever you have a spasm does it in fact give you relief ? 
—Immediately. 

Cross-examined by Mr. Bankes.—I understand that you 
have arrived at the happy state when it is just as much use 
in your pocket as in your nose ?—It is certainly very much 
better in my pocket than in my nose. 

Re-examined by Mr. Duke.—I daresay it suits both your 
comfort and your pocket to have the atomiser there than 
being kept going day and night ?—Yes, the only thing that 
rather bothers me is that it costs la. 6 d., and I have to 
pay 8s. 

Mr. Justice Ridley : But now you have got past that. 

Mrs. Fanny Stewart, examined by Mr. Duke.—A re you 
the wife of Major General Robert, Stewart ?—Yes. 

Do you live at Hove with your husband ?—Yes. 

Yonr husband, I think, is a very aged man ?—Yes ; he will 
be 83 in two months. 

He is not able to leave home now ?—No ; not in this weather. 

Was your husband for many years subject to severe attacks 
of asthma ?—Only for the last four or five years. 

During that time, was he under medical treatment 
frequently ?—Nearly always. 

Did he become a purchaser of Dr. Tucker's specific ?—Y'es ; 
two years ago last November. 

He had it on trial, I think ?—Yes; he heard of it by 
accident, but he was very, very ill at the time. 

Was he ill with asthma at the time?—Y'es ; asthma and 
bronchial catarrh, which caused incessant coughing. The 
asthma began to affect his heart. The doctor thought very 
seriously in his case. 

Y'ou say he had it on trial, but what was the effect upon 
him of the use of the specific with the atomiser?—He bad 
relief at once. Within 24 hours he was quite in a different 
state, and if I remember rightly he used it first on November 
3rd, 1905. and he wrote within a week that he would 
purchase it. 

And pay for it ?—And pay for it, certainly. 

You have told us what his condition had been up to that 
time during the pievious two or three years. What has been 
his condition since that time?.—He has gradually grown 
much stronger. 

With regard to the recurrence of attacks of asthma, has he 
had attacks such as he had before he used the specific or 
not ?—Not nearly so often, and it also affects the coughing 
very mneh. The asthma was caused in his case by the 
incessant bronchial coughing. 

Do you find in his case that the specific continues to afford 
him now the relief that it afforded him two years ago ! —Yes, 
quite the same ; it has never failed. 

Of course you personally have no interest in Mr. Tucker's 
8nccess or failure ?—No; I never heard of the specific, and I 
never heard of Mr. Tucker until one of the tradesmen came 
up to the house 

Mr. Eldon Bankes : Well, we cannot have that. I have 
no questions. 

Arthur Belfield, examined by Mr. Duke.—Y' ou are by 
profession a solicitor ?—I am. 

Do you live at 7, Kensington Square Mansions ?—Y'es. 

Are you 50 years old ?—I am. 

Were you for very many years subject to severe attaeks of 
asthma ?—I was. 

For how long I—For about 30 years I have been. 

Had it any effect with regard to your profession ?—Y’es; it 
had a very serious effect. I was compelled to leave my 
business in the country and to come to London in con¬ 
sequence. 

Did you remain subject to asthma after you came to 
London ?—I did. 

During a great part of those 30 years were you using a 
great variety of inhalations and remedies of one kind and 
another ?—I was. 

Under medical advice or not ?—No. 

Were yon treated by doctors for your asthma ?—I was. 

By few or many ?—I should think by eight or nine. 

When did you first get any relief from the recurrence of 
these severe attacks of asthma ?—That is a question that I 


really can hardly answer. Tho attacks were always with me 
more or less, and I got temporary relief from various 
inhalations. 

Did you some years ago become aware of what is called 
Tucker’s remedy—the remedy sold by Mr. Tucker, the 
plaintiff?—I did. 

Do you remember when that was ?—Y'es; it was either in 
March or April, 1900. 

Did you get it ?—I went to see Mr. Tucker. 

Mr. Justice Ridi.ey : In Ilolborn !—In Holborn. yes. 

Mr. Duke : Did you get the remedy—the apparatus and 
the liquid ?—I had it on trial first lor a fortnight. 

At the end of the fortnight did you purchase itI bought 
it, yes. 

What was the effect of the use of the vaporiser and the 
fluid l — It afforded me the most marvellous relief. 

What has been the subsequent effect with regard to your 
general state of health and with regard to your liability to 
asthma ?—The remedy has continued to give me the same, or 
almost the same, relief as it did on first using and my general 
health has improved immensely by the relief from the strain 
of tho attacks. 

Can you give me an instance with regard to the effect of 
localities upon you and the consequence of using the remedy 1 
—Yes; there are some places t.he air of which brings on 
attacks with great violence, and in which I have found that 
the relief obtainable from Tucker’s remedy is very much 
reduced, but these places are quite exceptional and of course 
I avoid them. 

But without the remedy would you be able to venture into 
those places at all ?—No 1 should t>e very sorry to. 

Mr. Justice Ridley : Tell me one or two of them !—There 
is a place on the Quantook Hills near Bridgewater that, 
have had entirely to give up visitiDg—a friend's house. 
Bournemouth is another place. 

Mr. Duke : Do you mean that if you have the protection 
of the specific you can venture into those places, but if you 
have not you cannot ?—I should he very sorry to go, even with 
it. I may add that I have used the remedy sometimes for 
several hours, I do not mean without stopping, but several 
hours during one night to keep me going. I could not have 
got through the uight without it; but still I was pretty 
miserable with it. 

You told me what your condition of general health has 
been. Will you tell me whether you have observed any 
tendency following the use of the specific to want to use it 
although you had not any asthma /—Certainly not. 

It is suggested it exercises some sort of seductive influence 
on the person who uses it so that he will not be able to get on 
without it whether he has asthma or not. Is there any 
foundation for that in your experience '—Certainly not. 

1 think you have not only used this yourself. Have you 
provided it for other persons .’—I have provided it for sundry 
poor people who were unable to pay for it, and have had it 
at reduced prices. 

Y'ou have bought it at a reduced price because you were 
giving it away ?—Mr. Tucker let me have it for £2 in those 
cases instead of £3. 

Mr. Eldon Bankes : I have no questions. 

Mr. Justice Ridley : How many witnesses are you going 
to call. Mr. Duke? 

Mr. Duke : If my friend does not challenge this evidence 
I do not want to call a lot of witnesses, but it is a serious 
question and 1 would like to call one or two to represent 
a somewhat different class. 

Mr. Eldon Bankes: I am quite prepared to accept any 
number my friend will give me that he has got here of 
witnesses who will give the same kind of evidence as this 
witness. I do not dispute that this drug may give relief, and 
in many cases with beneficial result. I am quite prepared to 
take ray statement in this general way ; if my friend will give 
me the number I will admit that they will give similar 
evidence. 

Mr. Duke : I have a very large number of persons. 

Mr. Eldon Bankes : Will you tell me the number you 
have h6re ? , ., . . , , 

Mr. Duke: I will call one or two, and if my friend does 
not cross-examine I will leave it there. 

Mr. Eldon Bankes : I should not cross-examine it they 
give the same kind of evidence. 

Mr, Duke : Very well, I will call one or two. 

James Alfred Fort, examined by Mr. F. E. Smith.—I 
; think you are an assistant master at Winchester School, 




Tub Lancet,] 


TUCKER t>. WAKLEY AND ANOTHER. 


[Fbb. 1, 1908. 329 


I believe your chest is weak ? You have weakness of the 
respiratory system?—No, I am suffering from bronchial 
catarrh. 

Since that time in 1894 when you felt the symptoms of 
asthma about you have you resorted to Tucker's specific 1— 
Yes. 

What has been the effect of it from that time until this 
whenever you have had occasion to resort to it?—It is a 
difficult question to answer. From that day to this if ever I 
have felt uncomfortable, and I have got hold of Tucker's 
atomiser, in half a minute or, we will say, one minute, I am 
quite right. 

Mr. Ei.don Bankks : I think he must have made a mistake 
about 1894. 

Mr. Dukb : No, it could be bought, although it was not 
in London. You say you bought it in 1894; where did you 
get it?—I got it from Holborn. 

Mr. Justice Ridi.ey : Are you sure of your year, because we 
have evidence that he was not in Holborn as soon as that ! 

Mr. Duke: My learned friend Mr. Bankes suggests from 
the letter you wrote about it that you are mistaken in your 
year, and it was 1899 ?—I did not sav 1899. 

Mr. Tucker says it was 1899 or 1900.—What did I say ? 

1894.—I meant 1904. 

Mr. Eldon Bankes: You are wrong again. It has not 
improved your memory. 

Mr. Justice Ridley : What was the year. We want to 
know as near as you can tell us?—I got it in 1894 to the best 
of my recollection. 

Mr. Duke : You bought it of Mr. Tucker, who is here !— 
Yes. 

He came to London in 1899, so you are mistaken. —I see. 

Mr. Justice Ridley : I thought you might have bought it 
in America ?—No, I did not; I never was there. 

Mr. Duke : Having regard to the period during which 
you used it, can you tell us whether there is any craving for 
the use of the thing if you have not any ailment which 
requires the use of it!—The only thing that could make me 
use it at all events would be the fear of an attack coming 
on, no other feeling. 

Mr. Eldon Bankes : I have no questions. 

Travers William Pic km ever, examined by Mr. Smith. 

What, is your occupation ?—None now ; I am independent. 

What were you formerly ?—A wine merchant. 

Do you mind telling us how old you are 1—51. 

Did you suffer from a liability to asthma '! —Yes. 

How long have you suffered from it ?—Since 1903. 

Was it acute, or did it become acute !—It gradually became 
worse. 

You bad, I think' severe attacks !—Yes. 

The effect of the attacks on your general health was 
bad ?—Certainly. 

Did you hear of Mr. Tucker’s asthma specific from some¬ 
one ?—Yes. 

Did you obtain it on the trial basis !—No; I bought it 
outright. 

What was the effect upon your health of its use ! -How do 
you mean ? 

When you got it first; we will go by steps !—It relieved 
me at once. 

Has the relief continued ’—Certainly. 

Has it had any injurious effect at all upon your general 
health .'—None whatever. I played in three cricket matches 
last year. 

Has it produced in yon the slightest desire to use it except 
as a preventive or a cure for an attack I—I never use it except 
I feel an attack coming on. 

It has never produced any desire in you to use it .'—None 
whatever. 

Mr. Eldon Bankes : I have no questions. 

Mr. Duke : There is this question of the suggested 
craving for cocaine or something. My learned friend has 
not cross-examined my witnesses with regard to this matter. 
I do not want to go on putting witnesses into the box. 

Mr. Justice Ridley: I take it it is not necessary for him 
to do so after he has made the suggestion which he did. 
You must take it that he disputes it. 

Mr. Ei.don Bankes: I do not suggest that any of these 
witnesses have the cocaine habit, or any desire to have it, 
and I do not dispute that out of the 25,000 my learned 
friend can call a great many who have not. 

Mr Justice Ridley : I was a little inaccurate. While not 
disputing what they say he does say it might produce and 


would be liable to produce that in others. That is the case 
you have to meet. 

Mr. Ei.don Bankes : If my friend will give me the 
number of people he has got here I will admit it. 

Mr. Duke: My learned friend must take his own course 
but if my learned friend persists in the allegation that the 
use of the atomiser produced an unwholesome craving for 
cocaine, I must go on. 

Mr. Eldon Banker : In certain cases it does. 

Mr. Justice Ridley : Have you got the people here .' 

Mr. Ei.don Bankes: No; 1 have evidence about it. 

Mr. Justice Ridi.ey : Have you got the people who use it 
and have got the craving ? 

Mr. Eldon Bankes: I have got the doctor who treated 
them. 

Mr. Duke : The people who use this inhaler .’ 

Mr. Eldon Banker : Yes. 

Mr. Duke: Then I must go on. I am sorry that my 
friend in giving particulars of his defence did not give any 
particulars of this matter. There is no suggestion of it in 
the defence, and I shall have to consider what the position 
is if my learned friend tenders the evidence. 

Mr. Justice Ridley : You must take your own course. 
Perhaps you can take them in batches. 

Arthur Stephen Lowry, examined by Mr. Duke.—A re 
you a wine merchant !—Yes. 

You live at Beckenham ?—I do. 

Were you for many years a sufferer from asthma? — 
About 50. 

Mr. Justice Ridley : How old are you ?— I am 55. 

Mr. Duke: From your childhood you have been liable to 
attacks of asthma .’—Yes. 

Had you had medical attendance for it ?—Yes, many 
doctors. 

And a great variety of remedies !—Very great. 

Did your liability to asthma continue .’—Yes, the acute¬ 
ness of the attacks decreased slightly but the frequency in¬ 
creased. 

Down to what period ?—I think six or seven years ago. 

How do you mark the time ! -That is when I got the 
Tucker's atomiser. 

Did you get it on trial —I did. 

Did you pay for it when you had had it about a week .’— 
No. I did not wait more than a day or two. 

You waited a day or two and found that the use of it was 
beneficial to you?—Yes. 1 had had my three guineas’ worth 
or three pounds’ worth in a day or two. 

Did you get it then at a time when you were actually 
suffering from an attack of asthma ? - Yes, it had been recom¬ 
mended to me by a friend, but I did not take very much 
notice then, but one day I was walking across Holborn 
Viaduct and breathing very badly and I Baw the name 
“A. Q. Tucker.” That decided me. I went in and tried it 
on the spot and had instant relief. 

So far as you were concerned, was there any fraud, did 
you consider, in your being charged £3 for it?—Not in the 
least. 

You paid what you bargained to pay for it?—Certainly. 

Was there any element of deceit which you have since 
discovered, any imposture upon you !—Not an atom. 

How could it compare as regards expense since the time 
you have had it with the period during which you had not 
got it. when you were suffering from asthma ?—My expenses 
in connexion with asthma must be infinitesimal to what 
they were before I had it. 

SpeakiDg generally, what has been your condition with 
regard to asthma since you have had the atomiser and the 
specific ? . 

Mr. Justice Ridi.ey : He says it gave him immediate 
relief. 

Mr. Duke : Very well, I will leave it at that. 

Do you find any craving for the stuff when you have not 
had the trouble ?—None whatever. 

Mr. Eldon Bankes : I have no questions. 

Francis Henry Venn, examined by Mr. Duke. —You 
are the solicitor for the plaintiff Yes. 

When did you first come into communication with the 
plaintiff .'—in 1902. 

Were you at that, time very subject to attacks of asthma 
—Yes, I was suffering severely at that time. 

What effect had they upon your condition and your 
ability to follow your profession .’ I was subject to attacks 




330 The Lancet,] 


TUCKER r. WAKLEY AND ANOTHER. 


[Feb. 1,1908. 


of asthma from about 30 years ago. In the later years the 
attacks increased in severity, in frequency, and in dura¬ 
tion. 

To what extent had that affected your ability to follow 
your profession !—It prevented me attending business regu¬ 
larly, and I had to leave business very often suddenly. 

Since you have had the Tucker specific and used it, what 
has been your condition as to asthma ’—I have been practic¬ 
ally independent of and free from asthma. I do not mean 
actually free from it, but the attacks of asthma can always 
be controlled, and they never interfere with my arrangements 
in any way. 

With regard to this suggested craving for the preparation 
do you find any craving tor it ?—Not the slightest. I do not 
use the specific as often as I should do. I could use it 
between attacks so as to prevent attacks, but I only use it 
when the attacks are actually imminent. 

With regard to your general health, how has it affected 
your general health ’ - My general health is much improved. 
My health is normal now ; I can eat, drink, and sleep. 

Dr. Thomas Clark, examined by Mr. Duke.—Y ou area 
registered medical practitioner?—I am. 

Where do you carry on your practice ?—Wandsworth 
Common. 

Have yon been subject to asthmatic attacks ?—I have. 

Did you become aware of Tucker’s specific some years ago ? 
—Eight years ago. 

Did you adept the use of it ?—I did. 

What was the effect of i,t ?—I have been kept from my 
work for three months on account of it. 

On account of what ?—On account, of the asthma. 

I am speaking of the specific. What has been the effect 
of the use of the specific since you have had the specific ?— 
The effect of it is instant relief. 

Since that time when you adopted the use of it eight years 
ago have you continued to use it!—I have. 

Have you found the same benefits - Always. 

I do not know whether you know the composition of it 
yourself or not ?—I do not. 

Do you find in your erase anything of the nature of a craving 
for the specific when you were not in danger of an attack of 
asthma ?—Not the slightest. 

It is fair to you to say that you did not see your way to 
give Mr. Tucker a proof of any evidence '!- I did not. 

You are attending here on subpoena .' Exactly. 

Cross-examined by Mr. Eldon Bankes.—A s a medical 
man perhaps you can tell me something about cocaine. Are 
you familiar with the effects of cocaine ?—We use it in 
practice, certainly. 

First of all, is it a poison ?—Y T es. 

And a poison which appears under the schedule to the 
Pharmacy Act ?—I believe it does. 

Mr. Justice Ridley : It is not in my copy as far as I can 
remember. 

Mr. Eldon Bankes: Your lordship will remember that 
the Act provides that in addition to the poisons appearing 
in the printed schedule additions may be made from time to 
time by the Privy Council by Order. 

Mr. Justice Ridley : It has been added afterwards ? 

Mr. Eldon Bankes: Yes. 

Mr. Justice Ridley : No doubt it would be classed amongst 
poisons. 

Mr. Eldon Bankf.s : Coming under the schedule to the 
Pharmacy Act do you know that the sale of it is surrounded 
by certain restrictions !- I have no means of judging that. 
We buy it from the wholesale drug houses in the usual way 
With other drugs, of course. A layman would be the one to 
give that evidence. 

You do not know, perhaps, the provisions of the Pharmacy 
Act concerning the sale of poisons ?—I know they have to 
sign a book when they receive it, but that does not apply 

us. 

The Pharmacy Act does not apply to a prescription by a 
duly qualified medical man .'—No. 

I want to kr w a litt le about cocaine. Of recent years 
have doctors fc nd that cocaine ought only to be used under 
very stringent precautions?—When injected under the skin 
it lias to be used with great precautions. 

Has it bten found that some per.-ons are extraordinarily 
susceptible to cocaine ?—Yes, when used in the manner 1 
have indicated. 

We will come to the use in a moment. Has it been found 


that in some persons it will produce the most dangerous 
symptoms although administered in minute quantities ?—All 
I know is when injected under the skin. 

You are confining your remarks at the present moment to 
when injected under the skin ?—Exactly. 

Has it been found in some persons when injected under 
the skin in minute quantities it produces the most dangerous 
symptoms ?—Exactly. 

Do you know that some doctors now, many doctors, refuse 1 
to prescribe cocaine at all ?- I was not aware of that. 

Do you know that many doctors, when cocaine is pre¬ 
scribed, indicate on their prescriptions that it is not to be 
made up again without a further order?—No, I do not. 

May I ask, do you hold any qualification, and what is 
your qualification -Iam a Licentiate of the Royal College 
of Physicians of Edinburgh and the Faculty of Physicians 
and Surgeons of Glasgow. 

Is yours a general practice at Wandsworth Common ?— 
Mine is a large general practice at Wandsworth Common. 

You have spoken of the effect of cocaine if administered 
by injection ?—I have. 

Of course, if administered by injection it is quickly 
absorbed into the system ?-—Instantaneously, of course. 

Have you considered whether a drug would be readily 
absorbed into the blood if inhaled ?—Yes, it would be 
absorbed into the blood, I have no doubt. 

And more readily absorbed into the blood if inhaled than 
if swallowed ?—I should say so. 

In addition to this peculiarity of cocaine, that many persons 
are extremely susceptible to cocaine, is it within your know¬ 
ledge that very small quantities of it produce the cocaine 
habit in patients I have never met with a case. 

Have you never had a patient with the cocaine habit 
Never. 

Do you know from your medical reading that the cocaine 
habit is very readily acquired by certain persons —I do. 

Of course, it depends upon the state of health of the 
patient and his susceptibility as to whether he or she will 
acquire it or not?—I do not think so. 

For instance, some persons would be more apt to acquire 
the cocaine habit than others ? -Yes, some are more weak- 
minded. 

And many people might take a quantity of cocaine without 
the habit, whereas the same quantity might produce it in 
another person ! Certainly, that might be so with anything. 

Do you know that the cocaine habit is more difficult to 
deal with and cure than either the alcoholic habit or the 
morphine habit ?- I have no experience of it. 

Is that the result of your reading about the cocaine habit ' 
— I have no experience of it. 

Either by reading or otherwise ? 

Mr Justice Ridley : I have never met anybody with it. 

Mr. Eldon Bankes: I am glad your lordship has not. 

Mr. Justice Ridley : Have you ? Let us see what we are 
dealing with. The alcoholic habit, I am sorry to say. is very 
familiar to us all, but I have never met anyone with the 
cocaine habit. 

Mr. Eldon Bankes : The cocaine habit is not so prevalent. 
You can only buy cocaine under stringent restrictions unless 
you get it through Mr. Tucker. Of course, alcoholism i> 
very common and the cocaine habit is not so common. 

Mr. Justice Ridley : That is what I say. Surely it must 
be infrequent. 1 thought it was chiefly to be found amongst 
the Indians of South America. 

Mr. Eldon Bankes : Because, of course, coca is obtained 
there from which cocaine comes, but I think your lordship 
will hear it is unhappily prevalent in this country. 

Mr. Justice Ridley : I suppose it is from what you say. 

Mr. Duke: There is no suggestion of it in the pleadings 
and there is no issue of it in this case, and at some time or 
other I shall have to ask your lordship’s ruling as to whether 
my friend can deal with it. 

Mr. Justice Ridley : We must get our facts first. 

Mr. Eldon Bankes (to the witness,): Is cocaine a drug 
which it is extremely unwise to administer to a person who 
has got a weak heart ?—1 should say that it depended on the 
dose that was given. 

But speaking generally is it unwise to administer cocaine 
to a person suffering from a weak heart !—I should use it in 
certain cases whether they had a weak heart or not, quite 
indiscriminately. 

Of course, you would require to examine the patient very 
carefully before you would administer cocaine at all !— 
Certainly not. 




The Lancet, ] 


TUCKER v. WAKLEY AND ANOTHER. 


[Fbb. 1, 1908. 381 


Would you administer cocaine for instance by correspond¬ 
ence ?—I might. 

Would you treat a patient by correspondence with cocaine 
although you had never had an opportunity of examining 
him ?—Cocaine is very often used for the eye. I might use 
it as drops for the eye as a prescription by correspondence. 

I ask you, Would you in your profession treat any patient 
by correspondence with cocaine for any purpose without 
having had an opportunity of examining him ?—If Tucker's 
specific contains cocaine 1 would prescribe it to anybody by 
correspondence for asthma. 

We will leave Tucker out of the way for a moment. I ask 
you generally so that I shall be able to form an opinion 
about it. Would you as a professional man- 

Mr. Justice Ridley : Surely that was a very sensible 
answer of his. If it contains cocaine he would recommend 
it because it is a remedy for asthma, that is why. 

Mr. Eldon Bankes : You say you would advise it without 
having had an opportunity of examining the patient?—I 
would in those doses. 

Without giving the patient any warning that it contained 
cocaine ?—1 should not think it necessary to give him any 
warning. 

And you notice, do you not, that, as administered by 
Mr. Tucker, there is no indication that the patient ought to 
be careful as to its use?—I have never found the necessity. 
I have recommended it in numbers of instances, and numbers 
of my patients use it. 

Do you think that before recommending it you ought to be 
•quite sure that the person is suffering from asthma?—It 
would not do him any harm. 

Do you not think it would do him any harm whatever his 
condition is ?—Undoubtedly it would not. 

Do you think if the patient for instance were suffering 
from phthisis you could safely administer this specific ?—Quite 
safely, and if he was suffering from bronchial catarrh it 
would relieve that catarrh. 

Do you give that answer without knowing what is in it, or 
accepting the suggestion that it contains cocaine and atro¬ 
pine 7—I give that answer on my knowledge of the specific 
and its action on patients. 

Have you ever had it analysed ? —I have tried to have it 
.analysed, but they were unable to give me a fairly good 
result. 

Unable to give you any result?—Yes. 

Could not they tell you whether it contained cocaine ?— 
They could not. 

I I could not have been a competent analyist, could it 2—I 
judged not. 

You sent it to somebody who could not analyse it, and he 
«aid he could not ?—Well, he was an analytical chemist. 

Supposing I were to satisfy you that it contained both 
cocaine and atropine, would you, as a professional man, pre¬ 
scribe that for anybody without examining him?—1 should, 
-decidedly, because of the small minute doses in which they 
must be, because of the effect I know it has upon myself. 

Of course, when you speak of small minute doses you 
mean the amount which is vaporised by each compression, 
or. we will say, by a dozen compressions ?—In 100 com¬ 
pressions. 

The amount, of course, which a patient absorbs into his 
system depends entirely on the extent to which he uses it?— 
Decidedly. 

Mr. Justice Ridley : Of course it does; how could it fail 
to do so ? 

The Witness : But he stops using it when he gets relief. 

Mr. Eldon Bankes : Supposing I could satisfy you that a 
patient acquired the cocaine habit by the use of Tucker’s 
specific would you then cease to prescribe it ?—I should not. 

Although I could satisfy you that a patient had acquired a 
cocaine habit ?—Although you could satisfy me that a 
dozen patients had I should still prescribe it. 

Without seeing the patient ?—I should have no hesitation 
at all if I was told he was a martyr to asthma. 

Mr. Justice Ridley : You have recommended it, I under¬ 
stand ?—Yes, in numbers of cases. 

Mr. Eldon Bankes : Let there be no mistake. You 
would continue to prescribe it without supervision even if 
you were satisfied that 20 patients had acquired the cocaine 
habit through it?—I should. 

lie-examined by Mr. Duke.—I n your experience is there 
any real risk of a person who uses this remedy acquiring any 
/pernicious habit by the use of it ?—Not the slightest. 


It has been suggested that there is a grain and a half of 
cocaine in an ounce of this fluid ?—Yes. 

In an ounce there are 480 grains, are not there ? 

Mr. Eldon Bankes: No, 440, is it not? 

Mr. Duke : I am told according to the best modern 
science it is 437£. They have advanced since I learned. 
Take 440 grains to an ounce. One and a half grains are 
suggested to be cocaine. That will be 3/880ths; it is 1£ 
over 440, 3 over 880—about 1,300th part of an ounce roughly 
will be cocaine; that is arithmetic. How long will an 
ounce last you in use? 

Mr. Justice Ridley : If the ounce lasts for six months— 
that is the evidence—you get l/300th part of an ounce in 
six months. 

Mr. Duke : How many drops are converted into vapour, 
do you think, when you press the bulb?-I should say not 
one drop, judging from the time it lasts—not one minim, I 
should say. 

You do not think the discharge of vapour on each compres¬ 
sion discharges one minim or one drop of the contents of the 
bottle ?—No, 1 do not—one minim. 

How many minims will there be in 440 grains ?—There are 
60 minims in a drachm and eight drachms to the ounce. 

So there will be 480 minims in 440 grains. Take it roughly 
a minim to a grain. At each of these discharges you discharge 
l/480th part or thereabouts of one grain of cocaine, according 
to my learned friend ?—That is a possible figure. 

The vapour which you produce fills the cavity of the lungs ? 
—Yes. 

And a great part of it is discharged from the mouth ?— 
It is. 

And the mischievous part, if it is mischievous, must be that 
which adheres to the lungs; it will not be that which is dis¬ 
charged into the air ?—I should say not. 

I suppose you cannot give me a measure in volume of the 
part of the one grain that adheres to the lung?—I could not. 

In order to find out what portion of one grain of cocaine, 
or of l/400th part of a grain of cocaine runs the risk of passing 
into the system when the patient inhales from the atomiser 
you have to work out those calculations?—It could be tested 
and found out. 

Do you think there is any occasion for testing and finding 
it out after the practical experience you have had ?—I do not. 

Your patients have used this remedy ?—They have. 

Beneficially or not ?—Very beneficially. I have one case 
of cure by it. She was in bed for three winters with bronchial 
asthma, and after she used that she gradually recovered and 
has not had an attack since. 

That patient, in your judgment, has been cured by the use 
of this remedy ?—She has. 

Dr. John Dunnell Rawlings, examined by Mr. Duke.— 
I must put the same questions to you as I did to Dr. Clark ; 
you are attending here on subpoena ?—Yes. 

And, as I understand, against your will ?—I did not want 
to come, certainly. 

So I have no proof of your evidence ?—No. 

You are a registered medical practitioner ?—Yes. 

Have you yourself been subject to asthma? - No. 

Who was it in your household who required a supply of the 
Tucker specific ?—Nobody ever has. 

Mr. Justice Ridley : Nobody in your house ?—No. 

Mr. Duke: Then who was it in your practice who required 
it ?—I do not say it was required, but I suggested to one of 
my patients that she should try it. 

How long ago was that ?—I think about a couple of months. 

Was it tried with beneficial results, or not?—I really can¬ 
not say. The patient herself thinks it did her a certain 
amount of good. Her attacks have not been severe, and they 
have always been in the night, so I have not seen them. I 
have had no opportunity of judging it myself. 

But the patient thought it did her good ?—To this extent 
that she did buy the thing, but she was not at all enthusiastic 
about it. At the end of a fortnight she was still quite 
uncertain whether she would buv it or not. 

Although she was uncertain, aid she buy it?—She did buy 
it, yes. 

And did she buy it with your approval ?—Yes. 

Had you heard that the specific might include cocaine ?— 
Yes. 

Did the lady get her ounce of specific, or whatever it was ? 
—Yes. 

And used it at her discretion ?—Yes. 

May I take it that you did not consider that there was a 



332 The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


real risk of her falling into pernicious habits by her inhaling 
this vapour 1 —No, I did not. 

Cross-examined btj Mr. Eldon Bankes. — I understand that 
yon suggested this for one of your own patients?—Yes. 

Would it, under those circumstances, be used under your 
own supervision !—I was not there, of course, when she was 
using it. 

She continues to be your patient ?—Yes, certainly. 

So that if you observed any ill effects from it in her case, 
you would be able to stop it'?—Certainly. 

Cocaine is prescribed, is it not, by doctors for certain 
purposes 'Yes. 

Is it in your opinion a very potent and dangerous drug ?—It 
is very potent, certainly, and very dangerous by improper use. 

In your opinion ought it ever to be used except under the 
most careful precautions 7—No. 

Do you think it legitimate to supply people with a specific 
containing cocaine without having ascertained exactly what 
it was from which they were suffering before it was delivered ? 
— 1 should not do so, certainly. 

Do you know that the symptoms of asthma are very often 
confused by patients with the symptoms arising from heart 
disease of from phthisis ?—Yes. 

So that a patient may think he is suffering from asthma 
and say so, although he is really suffering from heart disease 
or phthisis .'—Certainly. 

Is cocaine a drug which it is proper to administer in cases 
of heart disease or phthisis except after careful examination, 
and under supervision?—I should not administer it at all 
except under careful supervision, of course. 

Is cocaine a drug to which certain persons are extremely 
susceptible ?—Certain y 

Even administered in very small quantities has it been 
known to produce most dangerous symptoms ?—Yes. 

In your opinion is that result confined to cases where it is 
injected under the skin ?—No, it is not. 

Has it been known that the same result applies where it 
has been rubbed on people’s gums ? —Yes. 

And in whatever form it is applied to people has it pro¬ 
duced this extremely dangerous result?—That is rather 
sweeping, but certainly in more ways than one. I do not 
think it makes the least difference how it is applied as long 
as it is absorbed. 

Do you agree that cocaine, or any similar drug, would be 
more readily absorbed into the blood if inhaled than if 
swallowed ? —That would depend upon the condition of the 
stomach entirely. It would be absorbed very readily from 
an empty stomach, but not from a full one. I should say, 
applied as vapour to the lung, it would be absorbed as rapidly 
as it would be from an empty stomach—more rapidly than 
it would be from a full stomach. 

Do you think it is safe to sell a specific containing a 
considerable quantity of cocaine indiscriminately ?—Speaking 
generally, certainly not. 

Are you familiar with the cocaine habit ?—I have seen it. 

Do you, from your reading, know that it is very easily 
acquired by certain persons ?—Yes. 

And if acquired it is one of the most difficult habits to 
eradicate? -Yes, it is. 

And has the most dangerous results of any?—I do not say 
that quite, but I should put it rather on a par with morphia. 

Mr. Justice Ridley: Opium! Morphia is the active 
principle of opium. 

Mr. Justice Ridley : I know. 

Mr. Eldon Bankes : 1 ought to ask you about this. Is 
atropine also one of the poisons which is scheduled to the 
Bharmacy Act?—Yes. 

And are the effects of atropine somewhat similar to those 
of cocaine, but not so dangerous?—No, I should say they are 
quite different. One does not see chronic atropine poisoning. 
If anyone sees atropine poisoning, it is acute ; a person has 
taken a single large dose of belladonna generally. It is not 
quite the same kind of thing. 

Mr. Justice Ridley : Is atropine the same thing as bella¬ 
donna? -It is the active principle of belladonna. 

Re-examined by Mr. Smith. -1 will not follow into the 
general question at all, but with regard to the patient to 
whom you recommend the use of this specific, she took a 
fortnight, I think you told us, to try it?—Yes. 

During the fortnight that she tried it, did you think it 
necessary to be present on any one occasion when she was 
making a trial ot it ?—I could not very well because it was 
almost always in the night. 


You did not, as a fact; I will not follow you into the 
reason ?—No. 

So far as your patient was concerned she was permitted to 
form her own unassisted judgment as to whether or r.ot it 
would be beneficial or injurious to her ?—Yes. 

You saw neither danger, inconvenience, nor impropriety in 
allowing your patient to do so ?—No, 1 did not. 

Mr. Justice Ridley : Will you tell me one thing. We are 
told it would take something like six months to consume an 
ounce of this mixture—of this specific ?—Yes. 

And we are told that 1/300th part of it is cocaine ?—Yes. 

Do you think the consumption of I/300th part of an ounce of 
cocaine in six months would be likely to be prejudicial to 
anybody 7—I certainly cannot say it would not be to sus¬ 
ceptible persons. 

l/300th part of an ounce in six months. Do you mind telling 
me what that is in grains ?—That is all the cocaine there is 
in this mixture. 

How much is the quantity of cocaine? l/300th part is 
cocaine. It is about one grain, is it not ? 

l/300th part of the ounce is cocaine—1 / ounces ?—Y'es. 

In six months ?—l should not expect it to be with most 
people. 

Sir. Smith : And that is assuming, of course, my lord, 
that it is all absorbed into the system ! 

Mr. Justice Ridley : That is all there is in the ounce. 

Mr. Smith : It is all that can be absorbed by the most 
retentive constitution ? 

Mr. Justice Ridley : Yes, if you take it all into you. it 
would be one grain and a half in six months. 

Mr. Ei.don Bankes: Your lordship says six months. 
That, of course, is assuming that that particular patient took 
six months. 

Mr. Justice Ridley: lam only taking the average; it is 
quite true. 

Mr. Eldon Bankes : Of course, if the patient took six 
months to take it he would take very small quantities, but 
there is no reason why the patient should not take it all in a 
week. 

Mr. Justice Ridley : We were told how long it would take. 

Mr. Smith : Of course, if you chose, you could take it all 
in a week ? 

Mr. Ei.don Bankes: Directly you got the cocaine habit 
you would take an ounce in a week, or something like that. 

Mr. Smith : I think Mr. Bateson told us that lie took it 
frequently ? 

Mr. Eldon Bankes : Very likely he took it frequently, 
but not an ounce a week. 

Mr. Smith : I do not know whether my friend is going to 
call witnesses who took an ounce in a week. On that point, 
as it may be ot importance, will your lordship allow me to 
recall Mr. Symonds, who, as your lordship knows, is a 
member of the Bar, and he will tell us the time an ounce 
lasts ? 

Mr. Justice Ridley : If you wish to do so, I do not see 
any objection to it. I have only got the average, and I am 
not quite sure it is quite right, because I am not quite sure, 
to tell you the truth, whether Mr. Tucker said it was five 
months or six months. 

Mr. Smith : The evidence has varied. 

Mr. Eldon Bankes: In the pamphlet Mr. Tucker says it 
will last two to three months. 

Mr. Smith : Four months. 

Mr. Eldon Bankes : Whatever the figure is. 

Mr. Edward Symonds recalled. — Mr. Justice Ridley. 
How long did an ounce last you ?—An ounce lasts me from 
12 to 18 months; I think always over twelve months, and 
nearer 18 months. 

Mr. Smith : Is the explanation of the time that an ounce 
lasts you that you make infrequent use of it!—I use it con¬ 
stantly. I may use it—I cannot tie myself literally to every 
t,j me —from eight to ten times in an hour, almost through the 
24 hours. I use it constantly. 

You were a very severe sufferer indeed, I think, at one 

time ?_I got sometimes almost unconscious from it. I have 

the most horrible attacks of asthma—I used to. 

Further cross-examined by Mr. Bankes: Y*ou say you used 
it very constantly occasionally. That would be, 1 assume, 
when the attack comes on ?—No; I have used it constantly 
when there is no attack, if I had had any sort of fear that 
there might be going to be an attack, if 1 thought I might 
have got a little chill, or anything of the kind. 

For instance, does a fortnight or a month sometimes 






The Lancet,] 


TUCKER r. WAKLEY AND ANOTHER. 


[Feb. 1, 19C8. 333 


elapse without your using it at all .' Never at all ; never a 
day. I have used it this morning, and I used it last, night. 

1 understand that using it as frequently as you use it, 
which appears to be very frequently, your ounce will last 
you from 12 to 18 months ?— Yes. 

Do you notice in the memorandum Dr. Tucker says that 
the fluid will cost you 8*. an ounce, which lasts from two to 
four months ?—No, l have not read it. 

So that Dr. Tucker assumes that a person following his 
instructions will use this remedy so much more frequently 
than you do, that a person will exhaust it in from two to 
four months, whereas with you it takes from a year to 18 
months ?—I can only give you my experience. Unless I 
drank it I could not get rid of it in that time. 

Mr. Smith : You do not drink it?- No, I do not. 

Dr. William Batson, examined by Mr. Smith.- I think 
you also are here in attendance on subpoena, and you have 
given no statement to the plaintiff / -Quite so, I have not 
given any statement. 

Have you, or some of your patients, suffered from time to 
time from asthma ? 

Mr. Justice Ridley : You are a medical practitioner ? - Yes. 

Mr. Smith : Do you mind telling me what your qualifica¬ 
tion is ?—1 am a Licentiate of the College of Physicians and 
a Member of the Royal College of Surgeons. 

Have you from time to time sent for Mr. Tucker’s specific ? 
—Yes. 

Will you tell my lord and the jury for whose use you sent 
for it?- For my own. 

Have you been a sufferer from asthma ?—Yes. 

For many years ?—Yes, 50 years. 

In that time you have tried many remedies probably ?—Yes. 

What result did you find from the use of this specific and 
atomiser ?—A great benefit. 

And you have not felt the cocaine taste growing on you ?— 
No. 

Cross-examined by Mr. Eldon Rankes. —Did you know it 
contained cocaine .'—I did know it, yes; at least 1 am told 
it does. 

Did you know of that from communication with other 
doctors ?—I knew it was analysed in 1903 by an analytical 
chemist. 

And it had become more or less common knowledge in the 
profession, had it not ?—Yes, quite. 

It had become common knowledge in the profession that 
this contained cocaine .’—I think so. 

And you think that was so in 1903 /—I think that is the 
date. 

Do you recognise that cocaine is a drug which should only 
be prescribed under most careful restrictions —Yes, certainly. 

Do you defend a system under which cocaine is supplied 
indiscriminately without any examination of the patient, or 
any warning that the specific contains cocaine?—it depends | 
upon the dose. 

But under any circumstances would you justify selling 
cocaine indiscriminately, even in small quantities ?—In minute 
doses, why not ? 

Have you had any experience of the cocaine habit?—No. 

Then you have no experience as to how readily the habit is 
acquired, even by the taking of very minute doses /—No. 

Would it modify your view if you were satisfied that 
patients had acquired the cocaine habit from the use of 
Tucker ?—I should think it was impossible from my own 
experience. 

But assuming it is shown to have happened, would that 
modify your view .'—I should be most sceptical. 1 should 
think it could not possibly happen. 

Mr. Justice Ridley : You mean from this specific used as 
directed ?—Y'es ; I have used so much of it. 

Of this specific?—Yes ; I am an asthmatic. 

Personally, you mean ?—Yes. 

Mr. Eldon Bankes : But you know, do you not, that the 
susceptibility to cocaine varies enormously in different 
persons ?—Yes, like every other thing. 

Mr. Justice Ridley : How long does an ounce last you ?— 

I am afraid only three months ; sometimes less. 

Mr. Eldon Bankes : Why do you say you are afraid .' 

Mr. Justice Ridley : It shows what a bad sufferer he is. 

The Witness : The more 1 use it, the more expensive 
it is. 

Mr. Justice Ridley : Is that your reason .’ I thought you 
meant the greater the disease was. 


Re-examined by Mr. Smith. —You are familiar, I take it, 
with the ordinary recognised remedies for asthma ?—Yes. 

And 1 daresay both in your own case, and in the cases of 
other patients, you have had to try them from time to 
time ?—Yes. 

As compared with them have you derived more or less 
relief from the use of Mr. Tucker's specific?—Yes. 

You mean more from Mr. Tucker s specific ?—Yes. 

Than from any of the ordinary remedies with which you 
are professionally familiar?—Yes. 

Mr. Justice Ridley : It is the best remedy you know ?—Yes. 

Mr. Smith : You have never felt that you have been 
defrauded by paying £3 for using it ?—No. 

Mrs. Kirton Pimm, examined by Mr. Smith.— 1 think you 
have suffered from time to time from attacks of asthma ?—I 
have suffered with asthma since 1891. 

Did it cause you great inconvenience ?—Yes, I have been in 
my bedroom for a week at a time, and not able to go out. 

Your general health suffered, I think, from the attacks ?— 
I have been an entire wreck. I was quite a wreck five years 
ago. 

Did you consult doctors for relief ?—Yes, I constantly had 
the doctor in the house. 

Was he able to give you relief ?—No, not at all. 

I think you tried many remedies?—I tried everything 1 
could think of. 

About five years ago did someone bring Mr. Tucker's 
specific and atomiser to your notice?—Yes, they recom¬ 
mended it to me as having cured them between four and five 
years ago. 

On that recommendation you sent for the atomiser, and for 
some of the specific /—Yes, I wrote to Herne Hill for it. 

Did you get it on trial ? —Yes. I paid for it just before the 
fortnight. 

What w r as the immediate effect of it.’—It was a relief 
instantly. 

That is five years ago, and has the relief continued ?—Yes, 
1 have never been laid up a day since. 

We perceive you are no longer a wreck ?—No, I am not. 

But you say you have never been laid up since ?—No, not 
once since. I can work now, and I could never work before 
without bringing on asthma. 

It has really given you back the capacity for doing work ? 
Yes. 

Mr. Justice Ridley : Have you acquired the cocaine 
habit ? —No, not at all. 

Mr. Eldon Bankes: I have no questions. 

Herbert Henry Norman, examined by Mr. Smith. — 
Are you a reporter on the staff of the Southwark Recorder 
and South London Gazette ?—I was in 1906. 

And at the beginning of 1907, 1 think, too ?—Yes. 

Did you attend the inquest which was held on the deceased 
man Cushing on the 1st of January, 1907 .'- Yes. 

Did you take a shorthand note of the proceedings ? —No, 
not a shorthand note. 

But you took a note ?—I wrote the case as it went along. 

You were not reporting it sufficiently fully to make it 
worth while to take a shorthand note ? No. 

Was the paragraph headed ** Believed in Quacks” which 
appeared in the Recorder on the 5th of .January, 1907, the 
product of your pen, if I may so express it / —Yes. 

Mr. Justice Ridley : Is that the one referred to in the 
libel. 

Mr. Eldon Bankes: I have not seen that. 

Mr. Smith : No, 1 will give your lordship a copy of it. 
(To the witness) Would you mind lookiug at that to 
identify it ? (Newspaper handed to the witness). 

Mr. Justice Ridley: It is the newspaper report referred 
to in the libel ? 

Mr. Smith : No it is another one. Your lordship will see 
why I call the evidence. “ Believed in Quacks.—The circum¬ 
stances attending the death of Alfred Albert Cushing, aged 42, 
late an engineer’s labourer, living at 132, H Block, Queen's 
Buildings, Borough, were enquired into at the Southwark 
Coroner’s Court on Tuesday. The widow said her husband 
had suffered from asthma and bronchitis for 12 years and 
used to doctor himself with almost anything he was told of. 
He had no faith in doctors, saying they did him no good. 
On Saturday, 23rd ult., he was obliged to keep his bed, and 
witness called in a district nurse. The nurse sent for a 
doctor, who pronounced life extinct. Dr. G. A. Paton, of 
Marshalsea Road, who made a post-mortem examination, 




334 TheLjn:bt,] 


TUCKKR v. WAKLEY AND ANOTHER. 


[Feb. 1, 19C8. 


said death resulted from old standing and advanced consump¬ 
tion. The deceased used a spray which cost £3 3.*., and a 
fluid that cost 8*. an ounce. The Coroner : ' Some quack 
remedy.’ The widow stated that the deceased thought 
the use of the spray and liquid relieved him. The Coroner: 

‘ Do you think it hastened his death i ’ Dr. Patou : 1 I can’t 
say that it hastened his death. Many of these things are 
quite ineffective, and, therefore, harmless.' The Coroner 
referred to the advantage that quack remedies had among 
the poor and the ignorant because they bore the Govern¬ 
ment stamp. Many people, he said, took the stamp to mean 
that the quack remedies were guaranteed by the Government, 
whereas many of them contained noxious drugs that might 
cause a great deal of mischief.” 

You heard all the coroner said. I want to ask you whether 
the coroner said either that Tucker’s dealing was a fraud, or 
that the remedy was a fraud I do not remember it. 

If he had said it do you think you would have remembered 
it ? I think I should have included it in the report. 

Would it have been good copy ?—I think so ; yes, very good. 

As far as your memory goes your summary of what took 
place was accurate ?—Yes. 

Cross-examined hy Mr. El,DON Bankes: I understand you 
have no note at all of what took place ?—No, no note. 

When were you tirstasked what you recollected ?—Perhaps 
three months ago. 

Two months ago ?—Two or three. . 

This inquest took place in January, 1907 !—Yes. 

And you were asked, we will say, in October or November, 
1907 .’—Nine or ten months afterwards. 

Was there anything special to canse you to retain the 
events of this inquest in your mind ? No, nothing particular. 

I suppose in order to refresh your memory you looked at 
your newspaper ?—Yes. 

You do not find in your newspaper any reference to the 
word “ fraud ” at all. do you ?—No. 

Have you looked at any other newspaper reports 1—I have 
glanced at the Morning Advertiser. 

It is quite plain that the Morning Adiicrtiser uses the word 
“ fraud ”—I will not say in what connection ? -Yes. 

Have you any doubt that the word fraud wag used by the 
coroner ?—I am almost certain it was. 

So that your recollection now is that the coroner did use 
the word fraud ?—Yes. 

You did not include that in your report at all ?—No. 

1 think you misunderstood my learned friend a moment 
ago when you said that if he had used the word you would 
have put it in ? 

Mr. Smith : No, he did not say that. What he said was 
if he had used it either of Tucker's dealiug, or Tucker's 
medicine, he would have put it in. 

Mr. Eldon Bankes: I see. Yon think he did use the 
word “ fraud " i —Yes. 

Have you any distinct recollection of the connection in 
which he used the word ? Yes, my recollection is that he 
used the word “fraud” in connection with the putting of 
the Government stamp upon patent medicines. 

That is your recollection .’—Yes, distinctly. 

You say that without any note to remind you?—Yes. 
1 feel now that had he said that this particular remedy was 
a fraud, 1 should have used the word, and used the phrase. 

You are arguing now as to what you would have done if 
something had happened 1 Yes. 

But you have no distinct recollection ?—No distinct 
recollection. 

I suggest to you that the coroner used the works “quack ” 
and “Iraud” with reference to Dr. Tucker and his treat¬ 
ment ; but your recollection is not that !—Knowing Dr. 
Waldo- 

That is another argument ?—That is another argument, as 
you say. 

Dr. Waldo is a person in whom you place reliance ?—Yes. 

If he comes and says he did you would not dispute it I—It 
16 a question of memory, I think, in both cases. 

Mr. Eldon Bankes : That is quite a fair answer. 

Re-examined by Mr. Smith. —Just to lie quite clear, with 
regard to a well-known medicine like this, you think it 
would have been good copy if it bad been described as a 
fraud ?—Yes. 

Perhaps you do not think it would have been equally good 
copy if the Government system of putting stamps on is called 
a iraud. Is that equally good copy?—1 thought I covered 
that point without making use of the word fraud. I might 


or might not have used the word fraud, but I thought I 
covered the point. 

But in the other case it would have been a thing which 
would have struck you ?—Certainly. 

As to whether your memory was only refreshed by your 
own report, when you were shown your own report, were 
you also shown the competing reports—the other reports .' 

I believe so at the same time. 

Your memory was refreshed impartially by both !— 
Yes. 

Mr. Smith : That is the plaintiff's case. 

Mr. Eldon Bankes: May it please your lordship, 
gentlemen of the jury: In ibis case I appear with mv 
learned friend, Mr. Fraser, for the newspaper, The Lancet, 
in whose columns this article or notice has appeared which 
is complained of. You have up to this moment paid the 
greatest possible attention to this case, and I am sure vou 
will continue to do so until the end, because I expect you 
realise, and it is not necessary for me to say, that not only 
are the personal interests of the plaintiff and the defendant, 
involved in this, but it so happens that there is a great 
question of considerable public importance involved, because 
upon your verdict will largely depend the question as to 
whether the wholesale dissemination of this liquid con¬ 
taining, as I shall submit to yon, very considerable 
quantities, and dangerous quantities, of certain drugs is 
defensible or is not defensible ; and whether it is to continue 
under existing conditions or not, possibly may depend to 
some extent upon your verdict in this case. My learned 
friend has said that The Lancet newspaper is an old 
and well-established paper and a well-conducted paper, 
and he has pointed out that it is a paper which comes into 
existence for the purpose of circulating mainly, if not 
entirely, amongst the medical profession, and that it deals 
with medical questions and questions of interest to profes¬ 
sional gentlemen. You will have presently to say whether 
the language The Lancet used with reference to this 
specific was under the circumstances in excess of what they 
were justified in using; and of course, I ask you, in con¬ 
sidering that question, to bear this in mind, if I may use the 
expression it is a case of doctor talking to doctor, and there¬ 
fore of a person talking to another person upon matters 
about which both of them have a considerable amount of 
common knowledge which it is not necessary to express. 
Now it is very necessary to bear that in mind when 
you come to consider the language which was used. 
The matters which I suggest to you were common know¬ 
ledge, both to the person, the editor of the paper for 
this purpose, and the persons for whose benefit these notes 
are written, are two. First of all it was common knowledge 
what the law of this country is with reference to the sale of 
poisons. I want just to say a word to you, and it shall only 
be a word, about that. Mr. Tucker has told yon that to his 
knowledge every country by its laws in some way or another 
safeguards the public against the indiscriminate sale or use 
of poisons, and in this country those safeguards are contained 
in what is known as the Pharmacy Act; and they are very 
exact. They are of two kinds. First of all it is provided 
that nobody, unless he is a registered chemist, shall he 
allowed to sell these poisons at all. Of course, the object of 
that is that the sale of these poisons shall only be entrusted 
to a certain specially qualified class of persons, a man who 
has had a certain training, a man who has had a certain 
experience, and a man who has passed certain examinations 
before he can become registered. Therefore, that is the first 
precaution; that is the first safeguard. The other is this, 
and it depends upon the character of the poison : there are 
some poisons with regard to which it is only necessary, if 
they are sold by a chemist, to state upon the bottle or the 
box the name of the article and the word “ Poison,” with the 
name and address of the seller ; and in that class of article 
you have this protection, you have the protection that it can 
only be sold by a chemist; you have the protection that every ¬ 
body into whose hands that bottle comes shall be warned 
that it is poison, and shall be told what it is. In the other 
class (and into this class come both preparations of 
atropine and cocaine and its salts) the precautions are 
much wider and stricter. In that case the chemist may 
only sell the article if the purchaser is known to, or is 
introduced hy, some person known to the seller; there could 
be no indiscriminate sale in such a case ; it can only be sold 
by the chemist to some person known to him or to some 
person introduced by a person known to him ; and entr ies 
must be made in the Poisons Book of the date of sale, the 




Thb Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 335 


name and address of the purchaser, the name and quantity 
of the article, the purpose for which it was wanted, attested 
by signature, and it must also have the label “ Poison.” So 
you will see how careful the legislature is in safeguarding 
the public generally from the sale of these particular things 
which I shall show you in a moment are contained in this 
specific of Mr. Tucker's from indiscriminate sale. That fact 
would be known, and is known, to the medical profession 
generally, and, indeed, to most persons, and there is this 
further fact known to the medical profession, because we 
have beard now from the plaintiff's own witnesses that it was 
generally known in the medical profession, at any rate by 
the year 1903, that this particular specific contained cocaine. 
Now, gentlemen, you will bear in mind the circumstances 
under which this article was written to which 1 will have to 
call attention in a moment, and the fact that the specific 
was sold without regard to any of these precautions, 
and, indeed, without any of these precautions; and. on 
the contrary, it had upon it what, as was pointed out by 
the coroner, and, no doubt, you will understand, is often 
understood by the common people as being a mark of 
genuineness and authenticity—it had the Government 
shilling stamp. Now, what was the composition of the 
liquid which was sold in this way by Mr. Tucker 7 We have 
had it analysed and we find by analysis that the ounces 
which you may buy do not always contain the same quantity 
of ingredients, apparently. If that is so it would indicate 
that there is not very great care taken in the preparation of 
it by the people who are responsible for the preparation, 
because our analyses vary to this extent; take cocaine for 
instance; one sample which was analysed was found to 
contain about a grain and a half, or thereabouts, of cocaine, 
per ounce, but another sample which we analysed contained 
a bout 2'28 grains, or thereabouts—a considerable quantity in 
excess of what there was in the first sample; and it un¬ 
doubtedly does contain in considerable quantities cocaine 
and atropine and sodium nitrite. Now sodium nitrite is not 
a poison. Cocaine and atropine are, but the combination of 
these sold indiscriminately in this way will be proved before 
you to be, in the opinion of men standing as high in their 
profession as anyone can possibly do, to use their own words, 
-a serious danger to the public. Now, why is that so ? 

Mr. Justice Ridley : That is not what you said in the 
libel. 

Mr. Ei.don Bankes: Yes, my lord. 

Mr. Justice Ridley : It is not, Mr. Bankes. 

Mr. Eldon Bankes : What the libel says is that it is a 
fraud upon the public. 

Mr. Justice Ridley : Yes; but that is not the same thing. 

Mr. Eldon Bankes : That is a question for the jury. 

Mr. Justice Ridley: If you charge a man with fraud you 
.must, prove that he is guilty of it. That is not a question of 
public interest at all, hut it is a question of which yon must 
prove the truth. 

Mr. Eldon Bankes: Of course, my case to the jury is 
this- 

Mr. Justice Ridley : I have not any doubt at all about it 
that if you charge a man with fraud you must prove that he 
is guilty of it, or you are guilty of libel. 

Mr. Eldon Bankes: It depends what your lordship means 
by “ fraud.” 

Mr. Justice Ridley : Dishonesty. 

Mr. Eldon Bankes : I submit I am entitled to say of this 
system under which this specific is sold that it is a. fraud 
upon the public. 

Mr. Justice Ridley : That is not what you have said. 

Mr. Eldon Bankes : It is a question for the jury. 

Mr. Justice Ridlf.y : You have charged him with fraud. 

Mr. Eldon Bankes : It is a question for the jury, surely, 
as to the meaning of the libel. 

Mr. Justice Ridley : I agree ; but it seems too plain that 
that is what you have said, or 1 should not have put it so. 

Mr. Eldon Bankes: 1 am sure your lordship will not 
prejudge the question. 

Mr. Justice Ridley : It is hopeless. You have not said 
■tliat this is a serious danger to the public. Where are the 
words in the libel which say that 7 

Mr. Eldon Bankes : I am commenting upon a certain 
«tate of things. One of the things upon which I am com¬ 
menting is that this specific, containing these drugs in 
dangerous quantities, is being sold indiscriminately; that is 
the first thing. I say that it has been sold indiscriminately 
without any warning as to its character and with an 
encouragement to use it to any extent. 


Mr. Justice Ridley: That is not what you have said in 
the libel. 

Mr. Eldon Bankes : Those are the facts upon which I 
am commenting, and I respectfully submit to your lordship 
that 1 am entitled- 

Mr. Justice Ridley : I must ask the jury what they think 
about the meaning of the libel. 

Mr. Eldon Bankes: I am obliged to your lordship. 

Mr. Justice Ridley : I have great difficulty in the case, 
as I have told you, from the outset. You have not said that, 
but yon have something much worse. You charge him with 
fraud and give the reasons. There is the price of the 
article. 

Mr. Eldon Bankes : Gentlemen of the jury, I am sure 
you will realise that the question ultimatelj- is a question 
for you. Undoubtedly the word “ fraud ” has been used. It 
is a word which has many meanings, and it is a question for 
you as to the meaning in which it was used in this particular 
article. I suggest to you that this particular article, or note, 
or whatever you call it, uses the word in this sense: the 
writer is saying that this specific is a fraud upon the public ; 
the circumstances under which it is sold, the nature of the 
specific, the way in which it is advertised, what is said about 
it—all those are material matters for you to consider when 
you are asking yourselves whether this word “fraud" in 
that connexion is a word which may legitimately be used by 
persons who formed a very strong opinion upon the subject. 

Mr. Justice Ridley : You must prove it is true. 

Mr. Eldon Bankes : I have an authority about that 

Mr. Justice Ridley : So have 1, and l am speaking from it. 

Mr. Eldon Bankes : Of course, I will discuss it with 
your lordship now if your lordship wishes it. 

Mr. Justice Ridley : When you choose to. My view is 
that if you choose to charge a man with such an offence as 
fraud it is an attack upon his character, which is not a matter 
of public interest and which you must justify. 

Mr. Eldon Bankes: Of course, if your lordship rules 
that there is no justification, there is an end of the case. 

Mr. Justice Ridley : That is what I think. 

Mr. Eldon Bankes: If your lordship takes it upon 
yourself to rule it now I have nothing more to say. 

Mr. Justice Ridley : I should like to hear your argument 
about it, because that, is my view of the law. 

Mr. Eldon Bankes: Does jour lordship wish me to 
argue it. now 7 

Mr. Justice Ridley : If it comes to that, I do. I should 
like to know bow you put it. I have understood that to he 
so for a long time. I see your junior in a book which he 
lias written—a very able book—suggests that to be the fact, 
and I think 1 have an authority to that effect. 

Mr. Eldon Bankes: I should like to refer your lordship 
to an authority if you wish to hear me now. 

Mr. Justice Riiiley : If you wish to deal with it now, do. 

Mr. Eldon Bankes: I rather understood that your lord- 
ship wished me to do so now. 

Mr. Justice Ridley : I am rather subject to yon. You 
may wish to bring a body of evidence here to justify, not 
the truth of the matter, but to prove that it was a matter of 
public interest. 

Mr. Eldon Bankes : Yes, my lord. 

Mr. Justice Ridley : And that 1 conceive to be the fact; 
it is a matter of public interest if you deal with the general 
question relating to the sale of specifics which contain 
poisons. 

Mr. Ei.don Bankes : Yes, my lord. 

Mr. Justice Ridley : But the thing is as to the character 
of the person who has done it in this case. 

Mr. Eldon Bankes : I say nothing about the man’s 
character. 

Mr. Justice Ridley : Then if yon have attacked his charac¬ 
ter by charging him with fraud he is entitled to say : “1 am 
not fraudulent and you must justify it." 

Mr. Eldon Bankes : It is a question as to what the libel 
means. 

Mr. Justice Ridley: Yes. 

Mr. Eldon Bankes : It is ultimately for the jury to 
decide. 

Mr. Justice Ridley : I think I shall have to leave it to the 
jury. 

Mr. Ei.don Bankes: If your lordship pleases; and then 
perhaps it will be convenient for me to say what I have to 
say to them now. 

Mr. Justice Ridley : I do not wish to stop you, but at the 
same time 1 had better warn you that my present mind is 





336 Thb Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


that if the jury should find that this does make an imputa¬ 
tion upon the plaintiff's character, that he has been guilty of 
fraud, you must prove it to be the fact if you wish to have a 
verdict. 

Mr. Eldon Bankes: I will bear in mind what your lord- 
ship says. I do not want in the least to escape from or 
evade the point, but what I do want to put before the jury 
are certain considerations ; because, gentlemen, my case is, 
if I may summarise it—perhaps it will be the simplest way 
to summarise it after what my lord has said, and then per¬ 
haps amplify it a little bit more, if you will allow me to do 
so—what I say in substance is this, that, for a man who has 
no medical knowledge or skill at all, and who has no know¬ 
ledge of the constituents of the specific which he sends out 
broadcast, lo send out advertisements saying that the stuff 
of which he knows nothing is harmless, to send it out with¬ 
out any of the warnings with which the law says he ought to 
accompany it, and to send it out. not only without those 
warnings, but with an encouragement to use this stuff in 
unlimited quantities, and if you find that the stuff itself does 
contain poisons in dangerous quantities, if you find it is very 
likely to be taken by people who are suffering from diseases 
to whom it will be actually harmful, when you find that, 
and, on the top of it all, instead of these warnings he adopts 
a system which enables him to put upon it the Government 
stamp, carrying to many minds the indication of genuineness, 
then I say it is fair to say of that man that his system of 
trading is a fraud upon the public. That is in substance 
what 1 say this article means, and that is in substance what 
I submit the facts prove. That is, I submit, wlmt we did 
say, and that is. I submit, language which is not in excess of 
the particular occasion. Now I want this afternoon badly to 
call some of these gentlemen before you whose time is 
valuable and whom I inay not be able to call on another 
occasion, and therefore 1 want to curtail what I have got lo 
say at this moment within reasonable limits; but 1 do want 
you to bear this in mind when you are considering this 
case, and our evidence and the evidence for the plaintiff, I 
ask you to bear in mind these observations with reference to 
this particular class of medicine ; whether you call it a quack 
medicine or whether you call it a so-called quack medicine I 
do not mind ; but bear this in mind, that no man who has 
got one of these tilings to sell can ever make a success of it 
unless it contains a drug which will be beneficial to a con¬ 
siderable number of persons. He would never sell it at all 
unless it was for that. This specific contains cocaine, a most 
powerful and potent agent, which undoubtedly does operate 
to deaden the mucons membrane of a person who is suffering 
from asthma or any similar disorder ; and there is no doubt 
that if you administer cocaine to such a person, particularly, 
probably, in conjunction with atropine and these other 
matters which I have referred to, it undoubtedly does bring 
relief to him or her, because it deadens the mucons 
membrane. Therefore, of course, to a considerable number 
of persons it will be a benefit. Mr. Tucker could not have 
sold the quantities he lias sold unless it was a benefit. No 
person who has made fortunes in "selling similar remedies or 
other quack remedies could have made the money lie did 
unless the specific contained some drug which was of use 
under certain conditions ; but the danger of doing that is 
this: You send it out without knowing the particular 
disorder from which the person is suffering to whom you 
send it. You do not know the condition of his nervous 
system ; you do not know the condition of his heart; you 
do not know whether he is suffering from consumption. 
All you know is that he writes and tells you that he is 
suffering from asthma, which, as the plaintiff says, may 
be an entire misconception of his condition. Therefore, 
when you send your specific out you do not know-, and you 
have no opportunity or means of knowing, whether it is 
going to do good or harm to the particular person who 
happens to receive it. That is the danger of all these quack 
remedies ; that is the ground upon which they have from the 
beginning been attacked. Nobody suggests that they cannot 
do good and nobody suggests that in certain cases they do 
not do good, because they never succeed unless they did do 
good in certain cases ; but what is attacked and always has 
been attacked is this, that you have no right to send out 
drugs of this character without first of all a careful examina¬ 
tion which will enable you to judge whether it is a proper 
case in which to administer the drug, and, furthermore, you 
have no right to send it out, to prescribe it to a person, 
unless that person will he under your observation, and you 
will be able to see whether or not the drug is doing him harm 


or doing him good. Therefore, if that is right, you will 
follow that in this case or in any similar case it is always 
possible to call a large number of persons who have benefited 
by the specific. Just bear this in mind ; according to Mr. 
Tucker's own case he lias got or had 25,000 patients. What 
proportion of those do you think he has benefited ? I do not 
dispute for a moment that lie has benefited a considerable 
proportion. Therefore, having 25,000 patients in all 
these years, he can call a very large number of persons 
who have benefited But what about the people who 
have not benefited 7 He, of course, does not call 
those. They are not people who go parading in the street 
the fact that they have taken Tucker and suffered damage 
from it. We can only call before you persons who, in 
their professional career, have had to deal with people 
who are suffering and seriously suffering from what 1 
think some of them, at any rate, have called the Tucker 
habit. Please bear that in mind in considering this 
case. Of course, they can bring people who have benefited 
by the treatment, and of course they bring the people who 
have benefited and leave at home the people who have not 
benefited. It would seem to me childish to ask gentlemen 
who come into the box there one after the other whether 
they had any temptation to the cocaine habit. It is obvious 
they had not. It is obvious that they had never used this 
thing to excess. It is obvious that they were not susceptible 
persons, and they were selected because they were persons 
who had benefited by the treatment. 

Now let me say aword quite shortlyto amplify those points 
which I made before you a moment ago. This specific, 
instead of being sent out under the precautions enumerated 
in the Poisons Act, instead of being prescribed by persons 
who would be able to watch the effect upon the patient—am 
1 exaggerating at all when 1 say that it is sent out indis¬ 
criminately by the gallon ! It is sent out by a man who 
would have you believe that he does not know what it 
contains; sent out by a man who has told you in his 

own language that so far from warning people as to the 

amount that they should take, or the extent to which 

they should use it. he impresses people that they should 

use " it—I forget the exact expression he used, I think it 
was “We insist upon the frequent use”; sent out by a 
man who comes here and defends it in this language. 
1 say to him, “ Do you defend sending out indiscriminately 
these large quantities of liquid without ever inquiring 
what the constituents are, or what harm they will do in 
certain cases!” and his answer is “Yes.” It is sent out 
under those conditions with a statement in print that it is 
absolutely harmless, and sent out with a statement in print, 
not only that it is absolutely harmless in general, but, 
remember, specifically stating that it is harmless in cases of 
weak heart. The exact words are: “Any asthmatics who 
have organic heart disease or weak heart action can use the 
remedy with perfect safety.” 1 suggest to you that under 
those circumstances there is every justification for the 
use of strong language, every justification in the interests 
of the public for the use of strong language, and that we 
have not in the note that we issued in The Lancet of that 
date exceeded the proper limits of such language. I ask you 
one further question—to consider the bearing of the price at 
which this article is sold. I am not going into this in detail 
now because I have told you that I am very anxious to call 
my evidence, but I do want to make my position plain about 
that. Of course, a man is entitled to charge as much for a 
thing as people will give him for it, but you have to consider 
the circumstances under which that price is charged. You 
have to consider this, that this kind of advertisement appeals 
largely to the poorer classes, and appeals largely to men of 
the Cushing class—fitters and people earning weekly wages, 
to whom this sum of £3 is a very considerable item of ex¬ 
penditure. Now a man may say, “ I am justified in charging 
anything people will pay me for this thing.” That may be, if 
you are satisfied that the person making the charge has taken 
every precaution to see that before lie takes the man’s 
money it is not only going to give him temporary relief but 
that it is going to do him some substantial good and is not 
going to do him harm. Mr. Tucker, through his counsel. 
claims credit for the fact that lie allows this fortnight’s 
trial. You must guard yourselves, I submit, from being led 
astray by that. Of course, Mr. Tucker sends out a powerful 
drug which must necessarily give felief; he is quite certain 
that if he sends out this specific to persons who suffer in the 
way that asthmatic persons do, and will grasp at any remedy, 
within a fortnight they will be so gratified with the relief 






Thb Lancet,] 


TUCKER r. WAKLEY AND ANOTHER. 


[Feb. 1,1908. 337 


that they receive that they will tend him the money and he 
will be in the same position, practically, as if he had received 
it at first. It is quite true that they have that opportunity 
of testing it, but Mr. Tucker gave them the opportunity of 
testing it because he is satisfied that the drug is so potent 
and so powerful that it is bound to give them such relief that 
they are certain to send their money ; but he does not take 
any steps to satisfy himself that the specific so sent, though 
it gives temporary relief, will not do the man ultimately 
considerable injury. I say when you find these sums charged 
under those circumstances it is a legitimate ground for using 
strong language with regard to such a system. You have 
heard the details of the differences in price and you have 
probably formed your own opinion about them. You have 
heard the amount which he receives annually for the 
sale of this specific. You know what his expenses come 
to, and I shall probably have afterwards to say a 
word to you about them. But I want you to bear in 

mind what our point is with regard to that. It is not 
merely the fact that what may seem to be an exorbitant 
price is charged, but the circumstances under which it is 
charged—that it is asked of a man who has been given no 
opportunity of being examined, no opportunity of being told 
whether it is likely to do him permanent good or permanent 
harm. Mr. Tucker, you know, when he sends this out, 
goes, as I suggest to you, a great deal further than the case 
justifies, and a great deal further than he himself now is 
willing to justify. I ask you to look at these things and to 
say that when he sends these out with this specific for the 
fortnight’s cure he is content to rely upon the fact that he 
thinks the patient will get immediate relief; but he does 
represent to the patient that not only will he get immediate 
relief, but the stuff, if he uses it, will cure him. Now what 
justification is there for that ? He has sought to draw the 
distinction, and he says “I mean by ‘cure’ that it will 
relieve the attack from which you are suffering at the 
moment, but I cannot and do not suggest that it will prevent 
it ever coming on again.” If you read these instructions you 
will see that he draws the distinction between relief and 
cure. Let me read one passage. He says: “You will 
notice by the above instructions that it is necessary for the 
vapour to reach the lungs in order to arrest the attacks, heal 
the mucous surfaces, and cure the disease.” This is part of 
the system under which this specific is sold, and I ask you 
again, What do you say of a man who comes here and tells 
you that he does not profess to cure and that the stuff will 
not cure, but the stuff will relieve and because the attacks 
are relieved the patient’s general health will improve, but 
that he does not profess to cure asthma ! And what do you 
say of the system under which it goes out on trial, and 
the patient, who undoubtedly will receive immediate relief, is 
told here distinctly and definitely “ And what is more, if you 
buy this it will cure you.” And. gentlemen, it does not end 
there, because there is another expression in these instruc¬ 
tions to which I will ask your special attention. What is 
meant by this statement to the patient: “ If you are in the 
habit of using alcoholic stimulants, morphine, opium, or other 
narcotics, abandon their use.” Is it not to indicate to per¬ 
sons receiving this specific that such things are not given to 
asthmatics, and that if he will take this in substitution it i 
will benefit him ? What do you think of a person doing that 
if in fact the stuff contains, not alcoholic stimulants, mor¬ 
phine, opium, or other narcotics, but it contains cocaine and 
atropine? What can be said for a system part of the 
machinery of which is the use of this thing to induce patients 
to believe, not only the broad statement that it will not 
harm them, but the statement that *‘ these obnoxious things 
are bad for asthmatics, give them up, take my treatment in¬ 
stead ” ; whereas in fact you find that there are more power¬ 
ful and potent poisons in his mixture than these the use of 
which he says is to be avoided. There is another point I 
want to mention, and I will ask you to bear it in mind. 
What is meant by that list of questions which is sent out 
with the specific ? What is the object of that ? Is the object 
of that to lead the patient to think that he is in connexion 
with some qualified medical practitioner who will be able to 
judge from these answers whether his case is a fit one for 
this treatment l Is that the object 7 What other object can 
there be ? You will remember I put to him question after 
question, and I said, “ What do you want to know that for ; 
what good is it to you ? ” and his answer was “ It is my 
brother’s question.” I said to him, “ Were they not framed 
by your brother, who is a doctor, in order that on receipt of 
the answers he might judge whether the specific was one 


proper to be sent to that patient or not? ” and he had to admit 
it. Then why is it sent out from this villa at Herne Hill by 
people no one of whom possesses any medical knowledge at 
all, except for the purpose of inducing the patient to believe 
that he is dealing with a person who can judge by those 
answers as to whether the specific is one suited to his case? 

Now, gentlemen, those are matters entirely for you. I 
want you to pay the attention to my evidence which you 
have so kindly paid to the evidence of the other side, and I 
can tell you shortly what it consists of. I first of all shall 
call evidence to prove the analyses of this liquid in order 
that you may be in possession of the information as to what 
it contains. I then shall call, gentlemen, a large body of 
medical evidence, persons about whom it cannot be suggested 
that they come here from any indirect motive of benefiting 
the medical profession. I hesitate to give you their names 
because of course I am not always sure that at the moment 
I can get persons in this position to come here at the time 
when their evidence will be wanted ; but I feel sure that 
I shall be able to bring before you persons in the posi¬ 
tion of Sir Douglas Powell, and Sir Lauder Brunton, and 
Mr. Tilley, and many others who are at the head of the 
various branches of their profession, and who will tell you 
in substance this—that in their opinion the sending out of 
this specific indiscriminately, containing cocaine as it does, 
is a danger to the public, because cocaine is an extremely 
insidious drug, and some people are extraordinarily sus¬ 
ceptible to it, and that its use under these conditions in 
their opinion is likely to produce danger to the public. They 
will say that in their opinion the quantities, although small, 
sprayed in this way are sufficient in certain people to produce 
this cocaine habit. I shall also call one gentleman parti¬ 
cularly who has had under his treatment a number of persons 
who have suffered through the Tucker treatment. 

Mr. Smith : I do not want to take any objection, but if 
my friend is going into thi9 in detail I should ask him to 
reserve it until I can take a formal objection to the evidence. 
If my friend states to the jury the effect of it now the point 
of the objection has gone, but I mean at the proper time to 
object to this evidence. 

Mr. Eldon Bankks: I want to fight this case perfectly 
fairly, and therefore 1 will not go into any detail about it, 
but, in order to explain this to you and to prevent any mis¬ 
conception which you may be under, this witness will tell 
you—I am not going into details--that these people are 
suffering from what he calls the Tucker habit, and he will 
explain to you exactly what it is, and the effect upon the 
patient. It is not perhaps quite accurate to call it the 
cocaine habit, but it is a form of the cocaine habit, and I 
think he calls it the Tucker habit. He will tell you the 
difference, if there is any difference, between the two. I 
want to make that plain because possibly I may have not 
made the matter quite plain myself before because I did 
not quite understand what the distinction was. 

With those few preliminary observations I will now call my 
evidence. 1 have not addressed you, possibly, on some 
points upon which I ought to have, because, as I have told 
you, I am most anxious to call certain gentlemen this after¬ 
noon in order that they may be liberated, because I know 
their time is very valuable. 

Clarence Arthur Symmons, examined by Mr. Fraser. — 
I think you are a clerk in the employment of the defendant's 
solicitors, Messrs. Totter. Sandford and Kilvington ?— I am. 

Did you in pursuance of instructions from your principals 
go to Mr. Tucker’s house in Herne Hill in July, 1907 ?—Yes, 
I did. 

On the 8th July, l think it was ?—Yes, the 8th July. 

I think you saw the plaintiff, Mr. A. Q. Tucker?—I did, yes. 

What did you ask for ? I asked for two ounces of Dr. 
Tucker's specific, and he gave me a two-ounce bottle, but I 
said I would prefer two separate ounce bottles, so he took 
that back and gave me the two separate ounce bottles, and 1 
gave him the 16s. and came back. 

I want you to look at the bottles, please. (Bottle handed 
to the witness.) -That is one of them. 

It was sealed up, was it?—Yes, just like this, without the 
label on it, with a shilling stamp over it. 

Now look at the other one, please. (Handing bottle to the 
witness.) 

Mr. Smith : Is there any difference ? 

Mr. Eldon Bankes : There is no difference ; it is merely 
to identify them.—Yes, that is the other one. 

Mr. Fraser : These are the two ? —Yes. 




38 The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER, 


[Feb, 1, 1908. 


Did you take those two bottles on the same day, the 
8th July, to Mr. Yasey?—I handed itactually to Dr. Sprigge, 
but. it readied Mr. Vasey, 1 think. 

It was handed to Mr. Yasey, the analyst?—Yes. 

'That was in the same state when you handed it to him as 
when it was received ?—Exactly, with the exception that I 
had put the label on that I had purchased it. 

VVhat did you do with the second bottle?—We kept it in 
the safe, 1 think. On the 22nd November I took that to Dr. 
Willcox, at the St. Mary’s Hospital, Paddington. 

You left it there fastened up, 1 think, for him, did you 
not.'—Yes, that is so. 

Mr. Smith : 1 do not ask anything. 

Dr. Wilt.iam Henry Willciox, examined by Mr. Ei.don 
Bankhs.—I think you are a Doctor of Medicine, a Fellow of 
the Institute of Chemistry and a Fellow of a number of other 
societies '! —Yes. 

1 think that yon are the scientific analyst to the Home 
Office ?—Yes. 

On the 22nd November, 1907, did you receive at St. Mary's 
Hospital one of these two packages '! —Yes. 

Did it contain a glass bottle ?—Yes. 

Is that it which you have there ?—Yes, that is the one. 

It contained a quantity of dark coloured fluid ‘1—Yes. 

Mr. Justice Ridley: You analysed the contents; let us 
get on. There is no doubt about that, is there 1 

Mr. Smith : No, my lord. 

Mr. Justice Ridley : It is no use making such a fuss. 

The Witness: 1 analysed the contents. 

Mr. Eldon Rankes : Will you give me the result of your 
analysis ! 1 think the simplest way will be to give it in 
grains per fluid ounce ?—Yes. The bottle contained 31 cubic 
centimetres, that is a little over an ounce of liquid. It was 
a dark reddish-brown liquid, it had an aromatic smell, and it 
contained some alkaloids. 

Can you tell 11 s what the constituents of the bottle were ?— 
Y'es, 1 will go on with that. The total amount of alkaloids 
present was 3-15 grains in the fluid ounce. The alkaloids 
present were two in number, cocaine and atropine. 

Mr. Justice Ridley; How much was the cocaine?—The 
cocaine was 2 28 grains. 

And how much was the utropine?—0'87 grain. There 
was also present nitrite of soda, 15'25 grains in the fluid 
ounce ; and glycerine was present, between 20 and 30 per 
cent. I did not estimate the exact amount. 

Mr. Eldon Rankes: Between 20 and 30 per cent, by 
volume that would be ? —Yes, then there was some balsam 
present, or gum benzoin—balsam. 

Anything else?—Minute traces of mineral matters which 
were of no importance. 

Was there oily matter?—Yes, oily matter. 

And vegetable colouring matter and so forth ?—Yes. 

What were the active ingredients in the specific ?—They 
were cocaine, the atropine, and the nitrite of soda. 

Was your analysis an exhaustive analysis in the sense that 
it exhausted the active ingredients?—Yes. 

Can you tell us what the actual cost of sufficient of these 
ingredients to make an ouuce of liquid would come to ?—The 
actual cost would be about 3d. That would not include the 
cost of the time in making it up, but it is the cost of the 
ingredients. 

What is the action of these two alkaloids, cocaine and 
atropine ?—Tliey are both poisons. Shall I take cocaine first ? 

Yes, if you please.—Cocaine is a local anmsthetic ; that is, 
it takes away the sensibility of the part. 

Mr. Justice Ridley : It is what a dentist uses when he 
wants to take a tooth out ?—Yes. 

That is the English of it ?—And it is a powerful depressant 
of the heart. 

Mr. Eldon Bankes : You have finished what you have to 
say about cocaine !—Those are the main actions. I can go 
into it at great detail, if you like. 

No, we do not want great detail. Now, as to atropine ?— 
Atropine quickens the heart’s action, and it is used a great deal 
for allaying spasms, for instance the spasm of the bronchial 
tubes. It is a deliriant poison if it is taken in moderately 
large doses. 

I think that you prepared a report, did you not, in conjunc¬ 
tion with Professor Pepper, in connection with this specific ? 
—Y'es. 

Mr. Justice Ridley: Y’ou say it is a deliriant poison?—Yes, 
it prod ices delirium. 

Mr. Eldon Rankes : I will just go through the points of 


your report. There was nothing on the bottle, was there, to 
indicate that it contained a poison ?—No. 

What would be the effect to the taste of its containing 
glycerine ?—It was rather sweet to the taste. 

Mr. Justice Ridley : la that material ? 

Mr. Ei.don Rankes: Assuming the bottle to be left about 
with this sweet tasting stuff with no label upon it, do yon 
think that in itself is a source of danger?—Certainly, it 
would be dangerous. 

And why ?—It might be drank in mistake by a child, for 
example. 

With regard to true asthma do the symptoms of asthma 
closely correspond with the symptoms of otiier diseases ?— 
Yes. 

Will you mention Borne ?—In some forms of kidney disease 
the symptoms are identical ; symptoms occur which are 
identical with those of asthma. In fact the name nraimic 
asthma has been given to that condition. 

I mentioned Bright's disease ; would you include that ?— 
Bright's disease is the term which is used to cover that class of 
case. 

Mr. Tucker laughed at it., but you say that the symptoms 

of Bright’s disease-1 prefer you to use the words “ kidney 

disease,” which is the same thing really—that is, some 
cases of kidney disease have symptoms exactly identical 
with those of asthma. 1 have seen several. 

Will yon mention one or two other ailments with similar 
symptoms ?—Yes, in some of the forms of heart disease there 
are attacks of shortness of breath which only a medical man 
would distinguish from asthma. 

Is there any other ?—In lung disease, called emphysema, 
there is shortness of breath and a condition of things which 
closely resembles asthma. Some forms of bronchitis have 
svmptoms closely resembling asthma. 

I think you mentioned phthisis, did you not?—No, I did 
not; 1 have not come to that. Some cases of phthisis might 
present symptoms like those of asthma. As a rule the cases 
would not be the same, but some would undoubtedly give 
symptoms very like those of asthma. 

In your opinion, what might be the effect of giving cocaine, 
even in small quantities, to patients suffering from any one of 
these diseases which are not asthma ?—In the case of heart 
disease, cocaine would be a dangerous drag to be given at 
all. In kidney disease it ought not to be given. Shall I go 
on with the other diseases ? 

Y'es.—In cases of advanced consumption it should not be 
given. In bronchitis, in my opinion, it wonld be better not 
to give cocaine, and also in emphysema. 

Mr. Duke : I think you mentioned two or three of these 
before. 

Mr. Eldon Bankes : It is said by Mr. Tucker that the 
quantities of cocaine which are given by means of his specific 
used through the spray are so infinitesimal that they could 
not do any harm. What do you say about that?—I think 
that to people suffering from disease of the heart a small 
dose of cocaine would be harmful. 

When you say a small dose, you mean snch a dose as he 
could receive by this spray ? If it were used for a long time 
1 should think such a dose might be given. 

Apart altogether from any of these diseases which you 
have mentioned, are there certain persons extremely suscep¬ 
tible to cocaine ?—Yes. 

In your opinion is it safe to give cocaine even in this way 
indiscriminately ?—Not indiscriminately. 

Why not ?—Because if it were given to a person suffering 
from one of these diseases which I have mentioned it might 
produce harmful effects. 

But 1 am asking you now to deal with the case of a person 
who is not suffering from one of these diseases which you 
have mentioned, but who is susceptible to the influence of 
cocaine. Would it be harmful to administer this specific to 
such a person ?—I should think that it would he unwise. 

Have yon any experience of the cocaine habit?—Yes. 

Is that, in your opinion, easily produced ?—Yes. 

In your opinion would the continued use of Dr. Tucker’s 
specific be likely in some cases to produce it?—It might be. 

What is the primary action of the spray produced from 
this specific? How does it act to relieve the immediate 
attack ? 

Mr. Duke: We both mean the same thing, I suppose—the 
vapour ? We call it the vapour. 

Mr. Ei.don Bankes: Y'es. 

The Witness : The spray would come ijto contact locally 
with the bronchial tubes. 




Thh lanobt,] 


TUCKER v. WAKLBY AND ANOTHER. 


[Fan. 1,1908. 3,39 


Mr. Justice Ridley : There is not any spray. 

Mr. Duke : I suggested that the witness should describe 
what he means. 

Mr. Eldon Bankes : The vapour; we mean the same 
thing. 

Mr. Justice Ridi.ey : The spray would not come into con¬ 
tact with the bronchial tubes according to the evidence 
before me. X have not got evidence of any spray which could 
possibly get there. 1 am only dealing with the evidence. 

Mr. Ei.don Bankes : Is your lordship referring to the 
difference between vapour and spray 7 
Mr. Justice Rldlby : Yes, I think you had better use the 
word vapour. 

The Witness : I do not think “vapour” is a correct 
scientific term. A vai>our is invisible and does not contain 
solid particles. Call it a flue spray. 

If you do not object 1 shall call it vapour, because I shall 
know what I mean 7 —Yes, but scientifically a fine spray 
would be the more correct term. 

I would rather say vapour if 1 may. because I shall be able 
to keep my notes of this case correct, but 1 quite understand 
what you mean. What would happen to the vapour ?—The 
vapour would come into contact with the bronchial tubes and 
the spasm of them would be relieved by the atropine and 
cocaine present, and also the nitrite of soda would assist 
that action. 

Mr. Ei.don Bankes: In what way would they act!—By 
deadening the sensibility. The cocaine would act in that 
way and the atropine would also act in a similar way. 

So that by the use of the drugs in this way you would 
expect to get immediate relief from a paroxysm of asthma 7— 
Yes, I should expect it. 

That would be the natural result of using these powerful 
drugs?—I should expect in true asthma that the spasm would 
be relieved and relief would be given in many cases. 

In your opinion, as a concluding question, is it safe to 
distribute this specific in the way in which it is distributed 7 
—No, I do not think it is. 

Mr. Justice Ridley : That is not the point at all. 

Cron-examined, by Mr. Duke. —Do you think it is 
fraudulent to distribute it7—I should not like to express an 
opinion. 

You would want to know first whether it was honestly 
distributed, would you not, or whether anybody was inten¬ 
tionally deceived about it 7—1 should prefer not to express an 
opinion. 

You are here with your opinions about this matter. 

Mr. Justice Ridley : Is there any fraud in this matter? 

Mr. Duke : Suppose I had a bottle of this specific and an 
atomiser and an asthmatic friend whom the members of your 
rofession hud totally failed to relieve, and I handed it to 
im and said : Look here, I have heard during two or three 
days evidence which satisfies me that this will do you good ” ; 
would you say I was guilty of a fraud upon him because 
there was cocaine and atropine in it ?—No, I should not say 
you would be gailty of a fraud. 

It would be most unjust to say so, would it not 7—1 should 
say it would be unjust. 

And if that is what the defendants in this action sub¬ 
stantially have done about Mr. Tucker, what do you think of 
that; is it just or unjust? Perhaps you would rather not 
express an opinion 7—1 do not think that that is an opinion 
which I ought to express. 

If you tell me that you would rather not. I will not press it. 
Mr. Justice Ridley : Very well, leave it. 

Mr. Duke : I am going to ask you about two or three of 
these things which you have been giving us evidence about,. 
You have made an analysis 7 —Yes. 

Are you in general practice as a medical man 7— Y’es, a 
consulting practice. 

Mr. Justice Ridley : What is the rest of it 7 Will you ask 
him ; we have got three grains at present. 

Mr. Duke : I was going to ask him that. 

You have three grains out of what quantity 7 - A fluid 
ounce. 

Three grains out of 440 ?—Yes. 

Wbat are the other 437 grains 7 

Mr. Justice Ridley : We have nitrite of soda. 

Mr. Duke: Y'es, there is nitrite of soda, too. Cocaine 
was 2 ■ 28 grains and atropine 1 ■ 57.—The atropine was 0 • 87. 
What was the nitrite of soda 7—15 • 25. 

Were there any ottier specific ingredients ’—Glycerine. 
Then there was some oily matter. 


Do you know wbat it was 7—I think that tliat arose from 
some balsam which was put in. 

Do you know I —Y’es. 

Y’ou are sure 7—Y'es. 

It was oily matter which arose from balsam ; what quantity 
was there of that 7—0 ■ 87 grain ; benzoic acid, 0 49 grain ; 
then there was a trace of silica, 0 • 24 grain ; oxide of magne¬ 
sium, 0 ■ 11 grain ; the glycerine I have mentioned, and the 
rest was water. 

How much glycerine 7—20 to 30 per cent, by volume. 

Mr. Justice Ridlby : Not per grain you mean 7 -No. by 
volume. 

Mr. Duke : About 20 or 30 grains possibly would be 
glycerine 7—No, more than 20 or 30. 

Because the specific gravity would be different 7 —20 or 30 
per cent. 

I did not follow that; that is about one-fourth ?—About 
one-fourth. 

Do you think you could make this preparation ?—1 think so. 

Have you any confidence in being able to make it 7 You 
have given your analysis. Have you any confidence that vou 
could make it?—1 think that 1 could make a prejiaration 
which would have the same action. 

But are you sore that you could make this preparation ?—1 
do not say that it would be absolutely identical, but it would 
have the same physiological effect. 

Why is it that you cannot be sure that you could make a 
preparation identical with this in its constituents !—The 
colouring matter might be different and certain details. 

I will leave out colouring matters. What are the other 
matters besides colouring matter 7—If I had the same 
colouring matter anil the same ingredients as in the analysis 
the preparation would be almost exactly the same. 

Are you always able to ascertain vegetable oils with 
certainty in analysis 7—When there are small quantities 
present one cannot--- 

Cannot with certainty say what they are !—Cannot with 
certainty say exactly what they are. 

Do you think that there may be in this composition some 
small quantity of vegetable oils which you cannot with 
certainty identify 7—I do not think the vegetable oils would 
have any definite effect. 

Perhaps yon would not mind going back and answering 
my question now. Do you think there may be in this 9|iecific 
some vegetable oils in small quantities which you cannot 
with certainty identify 7—You can detect them as vegetable 
oils. 

But you cannot with certainty say what they are 7 —1 could 
not say what they are. 

That is what I call identifying them. Y’ou think that may 
be so 1—There are some there, yes. I said so—oily matter. 

That is what you call oily matter ?—Y’es. 

That is rather an uncomplimentary sort of description of 
it; it does not prepossess you with it. does it 7 It is just 
possible that the inventor of this specific might attach a 
good deal of importance to what you call the oily matter 7 
1 tasted this oily matter and examined it; it seemed to be 
quite inert. 

1 did not ask you that. It was put there on purpose 
evidently, was it not 7—Y’es, possibly. 

And it is conceivable that the inventor of this specific may 
have supposed, rightly or wrongly, that it was an important 
ingredient in the specific 7—It may have been supposed so. 

Mr. Duke ; Your lordship identified a bottle this 
morning. 

.Mr. justice Ridley : Y'es, I put the figure 1 on it. 
(Same handed to the witness.) 

Mr. Duke : Just look at that and see if you recognise it. 

Mr. Justice Ridley : When was that put in, 1 have 
forgotten 7 

Mr. Duke: It was produced by one of the witnesses who 
said he had tried a specific which he had obtained in the 
Tucker atomiser, but it was ineffective for the cure of 
asthma. 

Is that a preparation of a well-known firm of wholesale 
druggists 7—Y’es. 

Oppenheimer, Son, and Co., Limited?—Yes. 

Are the ingredients practically the ingredients which you 
say this preparation of the Tucker specific contaius 7—1 do 
not see the ingredients on the bottle. 

Are they not stated there 7—No. 

Do you know Oppenheimer's list ?—I have seen it. 

Just look at that and see if it is Oppenheimer's list which 
is in general use among people who deal in drugs and see if 



340 Thb Lanobt,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1906. 


that commodity No. 21 is there? (Book handed to the 
witness.)—Yes. 

And is what purports to be a description of it there ?—Yes. 

Oppenheimers are careful, accurate people in sending out 
these things, are they not?—Yes. 

Just tell us what No. 21 is said to consist of ?—It consists 
of atropine one-third of a grain in the ounce, cocaine hydro¬ 
chloride two grains in the ounce, a solution of hyponitrous 
acid gas to saturation, and balsamic extracts to the ounce. 

Are Oppenheimers selling that as being substantially the 
same as the preparation of an American doctor which is 
being sold in this country ?—I did not know that they were, 
but I see that it is stated there. 

Do you know any other preparation of an American doctor 
except the Dr. Tucker specific ?—There may be many others. 

Do you know of any others ?—1 do not know of any. 

That is what I asked you. 

Mr. Justice Ridley : What does it say?—Shall I read it out? 

Mr. Duke : Read it out, if you please.—“ Many inquiries 
from important medical men having reached us regarding a 
certain preparation for asthma recommended by an American 
doctor, we introduced our Neboline compound No. 21 which 
is similar in every respect to the preparation in question, and 
which from the reception accorded to it seems to meet all 
requirements.” A very fraudulent transaction, is it not ? 

M. Justice Ridley : That is by a chemist, is it not ? 

Mr. Duke : It is by the most eminent firm of wholesale 
druggists. 

Mr. Justice Ridley : There is the balsam, and there is the 
cocaine, and there is the atropine?—There is no glycerine 
there, and no nitrite of soda. 

Mr. Duke: You think they did not hit it quite as ac¬ 
curately as you have ?—I should say undoubtedly not. 

Mr. Justice Ridley : It appears to me, though I may be 
wrong, that what you place chief reliance upon is the cocaine 
and the atropine being there?—Yes. 

Mr. Justice Ridley : They are there, you know. 

Mr. Duke: Will you give me the book, please. (Same 
handed to learned counsel.) “ Many inquiries from im¬ 
portant medical men having reached us regarding a certain 
preparation for asthma recommended by an American doctor, 
we introduced our Neboline compound No. 21 which is 
similar in every respect to the preparation in question, and 
which from the reception accorded to it seems to meet all 
requirements.” Then there is this note in italics : “ Practi¬ 
cally a specific for asthma.” Then there is this further 
statement that the specific can be purchased wholesale by 
the profession of Messrs. Oppenheimer at 3*. 6d. an ounce 
without any Government stamp?—Yes; I did not see that 
there, but I have no doubt it is there. 

You will take my word for that, I am sure, as my learned 
friend will ?—Certainly. 

3s. 6 d. an ounce w hen the wholesale druggist is retailing it 
either to the medical man in the provinces or the suburbs 
who dispenses his own physic, or to the pharmaceutical 
chemist; that is so, is it not ?—Yes. 

What price do you think it would arrive at before it got 
out to the public? -It would be impossible to say. of course. 

It might reach almost anything, might it not? I want to 
know this as you understand these things ; do you think the 
conduct of the medical practitioner or the chemist who buys 
this—first of all with regard to Oppenheirner’s compound, 
you have told us that Oppenheirner’s can make this up at 
how much an onnee, did you say ?—1 have not expressed an 
opinion about Oppenheirner’s preparation, but about the 
analysis that I made. 

But there are more ingredients in yours than there are in 
Oppenheirner's, and so theirs would be cheaper than yours, 
would it not ?—No, theirs would cost rather more. 

How much—4 d. an ounce ? 1 could not say. 

bd. ?—I could » ot say. 

Let us be lavish about it and say 8 d. 

Mr. Eldon BANKES: He says he cannot say. 

Mr. Duke : He is going to say when he has worked it 
out.—There is hyponitrous acid in Oppenheirner’s—yon will 
see it is mentioned there—and that would be specially 
prepared. 

“ Hyponitrous acid gas to saturation.” Do you think it is 
just possible that Dr. Tucker introduced a solution of 
hyponitrous acid gas to saturation ?—No. 

Why not?—Because I found none. 

But you found some nitric compound, did you not?—Some 
nitrite 

You found nitrite preparations, but not the solution of 


hyponitrous acid gas to saturation?—No, I did not find 
that. 

Is that a costly commodity ? How much does it cost by 
the pound, for instance?—It is not priced in any list. It is 
rather a rare preparation, and it would take some time to 
prepare, so it would be impossible to tell you what would be 
the exact cost of it. 

Mr. Justice Ridley : Do you think that the bottle of 
Neboline is as likely in your opinion to be a cure as the other 
one; do you think it is as good a preparation as the other ? — 
No, I do not think it would be. 

Mr. Duke : Which is the one which is not as good as the 
other? You think that Oppenheirner’s is not likely to be as 
as good a preparation as Dr. Tucker’s ?—It is not the same 
preparation as Dr. Tucker’s. 

And so far as you can judge it is not as likely to be effec¬ 
tive? -I do not think it would be. 

But even Oppenheirner’s is recommended by them as prac¬ 
tically a specific for asthma, and you will agree with me, 
will you not, that what they say is, that, it is similar in every 
respect to Dr. Tucker’s—that is what they say in effect ? 

Mr. Justice Ridley: Is it a doctor’s prescription7—No, 
it is a wholesale chemist’s. 

Mr. Duke : Dr. Tucker's is a doctor’s prescription. 

Mr. Eldon Bankes : Is that so? 

Mr. Duke : Mr. Tucker was in the box yesterday and 
told you who his brother was, and that he is a well-known 
physician. 

Mr. Eldon Bankes : He invented it. 

Mr. Duke : He prescribed it; he compounded it. 

Mr. Eldon Bankes : Yes, he compounded it. 

Mr. Duke : It is the prescription of an American doctor. 

Mr. Justice Ridley : There is no difference. 

Mr. Duke (to the witness) : There are good doctors in the 
United States, are there not ?—Certainly. 

And apparently one of them has contrived to hit the thing 
for curing asthma with a specific which you say can be pro¬ 
duced more cheaply than Oppenheirner’s?—Yes. 

Mr. Justice Ridley : Do you know any specific for asthma? 
—There is no actual cure for it, so far as I know. 

That does not answer the question. Do you know any¬ 
thing which produces the same effects on asthma as have 
been proved to have resulted from the use of this specific ?— 
Certainly. 

Mr. Justice Ridley : I should like to know what it is. 

Mr. Duke : Perhaps you mean datura or stramonium. I think 
I saw a person smoking a cigarette of datura or stramonium ? 
—There are many drugs which will relieve asthma. 

Are they not all temporary in their action ?—Yes. 

And do not they lose their effect after repeated recurrence 
of asthma ?—Not necessarily. 

But do they not frequently 1 Are they not frequently kinds 
of things which lose their effect?—Sometimes they do. 

And do not many of them, if not all of them, cause very 
great discomfort and physical damage to the patient by 
I interference with his lungs?—No, certainly not. 

For instance, the inhalation of smoky vapour. Is not that 
! much more likely to hurt the patient than the inhalation of 
the vapour which is produced here ?—The inhalation of smoky 
vapour is injurious to some people. 

Seriously injurious?—It produces bad effects in many 
people ; it has done. 

And do doctors go on prescribing that kind of treatment 
nevertheless because asthma is such a terrible ailment?— 
Doctors are careful as regards prescribing these smoke 
medicines. If a doctor found that it did not suit the patient 
he would adopt some other form of treatment. 

Did you hear the evidence of the numerous witnesses who 
came here for the plaintiff this morning and said, “ We had 
been treated for years by medical men and they failed to 
relieve our asthma” ; did you hear that '! —Yes, I heard that. 

Is that not common experience with regard to the treat¬ 
ment of asthma ?—Is what common experience ? 

Is it not common experince that you find an entire failure 
to relieve the patient from the liability to constant paroxysms 
of asthma ?—No. 

Do you mean that the doctor usually does produce such 
effects as have been spoken to here this morning ?—Certainly. 

He does?—Yes. 

Then these are unfortunate instances where the doctors 
failed ?—I should say that these cases, many of them, 
had not been thoroughly treated by a doctor. They may 
have consulted a doctor once or twice, but I should say they 
had not been under a thorough course of treatment. 






344 The Lancet,] 


TUCKER v. YVAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


Mr. Justice Ridley : Yon will have to get to that point at 
last. 

Mr. Eldon Bankes : I do not in the least desire to argue 
it. It is very difficult to argue the case and take the 
evidence at the same time. 

Mr. Justice Ridley : I know ; but this evidence is quite 
useless, if my view of the case i9 correct. We shall be here 
for I do not know how long, if my view of the law is correct. 

Mr. Eldon Bankes : I am Bure your lordship will bear 
with me ; we are before the jury. 

Mr. Justice Ridley : Yes, but you see this evidence does 
not help me. 

Mr. Eldon Bankes : We are only now on re-examinatioD 
upon evidence which has already been given. 

You were asked some questions yesterday about Mr. 
Oppenheimer’s specific.—Yes. 

Would your opinion about that specific be the same as 
your opinion with regard to Mr. Tucuer’s specific if it was 
used indiscriminately in the same way ! Y'es. 

Mr. Justice Ridley : Are you aware that it says on the 
bottle that it is perfectly safe to use it ?—That implies that it 
is being used under medical supervision, I take it. 

Not at all. “ In compliance with the Sale of Poisons Act 
this preparation is labelled poison, but, nevertheless, it is 
perfectly safe if inhaled by means of the aeriser or 
vaporiser.” 

Mr. Eldon Bankes : Your lordship will also see it is 
accompanied by a statement in the list which I have not got 
a copy of. 

Mr. Justice Ridley : “ To be used as directed by the 
physician.” Ye9, but it says it is perfectly safe. 

The Witness : I do not think that is sold except to 
physicians; I do not think one of the public can buy it. 

Mr. Justice Ridley : I do not know. Y'our observation 
made me put this to you. I know it is sold with a safe label 
on it, and that is all I know. 

Mr. Eldon Bankes : My friend Mr. Duke read this out 
from the list yesterday : “ There is a further statement that 
this specific can be purchased wholesale by the profession 
from Messrs. Oppenheimer.” 

Mr. Justice Ridley : This direction is made for the person 
who uses it, is not it? 

The Witness : But the doctor would buy it. 

Mr. Justice Ridley : “ It is perfectly safe if inhaled by 
means of the aeri-er or vaporiser.” 

Mr. Eldon Bankes : And under the physician’s direction. 

Mr. Justice Ridley : That is on the other side of the 
bottle. 

Mr. Eldon Bankes : But it is on the bottle. 

Mr. Justice Ridley : But independently of the physician 
it says it is safe. 

Mr. Eldon Bankes : That is Oppenheimer’s view. 

Nevertheless, is that Oppenheimer safe if used indis¬ 
criminately?—No, certainly it is not. 

So your observation would apply equally to Oppenheimer, 
although they put that there, if it were used indiscriminately 
and not under the physician’s directions ?—Certainly. 

You were asked the question yesterday by my friend, Mr. 
Duke, about the official dose of cocaine ?—Yes. 

You said, I think, that was one-twentieth to half a grain. 
Does the fact that that is given as the official dose indicate 
that it may be safely used in cases, for instance, of heart 
disease?—No, the official do.-e implies that it is being given 
for a proper purpose under medical supervision. Cocaine 
would be a dangerous drug to give in any doss in a case of 
heart disease. 

That is merely the official dose for the administration of 
the drug in a proper case ?—Yes. 

In spite of the questions which were asked you yesterday 
by Mr. Duke, what is your opinion as to whether sufficient 
cocaine could be absorbed by the continued use of the Tucker 
atomiser to cause injurious effects upon persons suffering 
from heart disease, or kidney disease, for instance ?—I am 
quite certain that sufficient could be absorbed in those cases 
to cause serious affections. 

Mr. Justice Ridley ? I have had all this before. 

Mr. Eldon Bankes : With reference to persons suffering 
from heart disease getting relief from the use of the specific 
you were asked yesterday if a person were suffering from 
heart disease and if he were suffering from asthma and sent 
for this specific and used it would it give him relief?—Y'es. 

You answered that it would not give him relief.—It would 
not give him relief in pure heart disease or pure kidney 
disease, but if the heart disease or kidney disease were com¬ 
plicated with asthma or bronchial catarrh then it would give 


temporary relief ; but the effect of the drug, if continued for 
some days, would be very injurious to the heart. P&Wiyv 

Mr. JuBtice Ridley : We had better understand about this 
Oppenheimer bottle. It has got on the neck “ Boison ; not 
to be swallowed; must only be used with the aeriser or 
vaporiser ” ; then in the front “ to be used as directed by the 
physician,” and on the side, “ in compliance with the Sale of 
Poisons Act this preparation is labelled poison, but neverthe¬ 
less is perfectly safe if inhaled by means of the aeriser or 
vaporiser.” That is what it states on here. 

Herbert Tilley, examined by Mr. Eldon Bankes.—I 
think yon are a Fellow of the Royal College of Surgeons of 
England ?—Y'es. 

You are surgeon to the Ear and Throat department of the 
University College Hospital of London, surgeon for diseases 
of the nose and throat of King Edward VII. Hospital and 
formerly surgeon for Golden-square Throat Hospital ?—Yes. 

Have you for some time been familiar with this Tucker's 
specific ?—Yes, as used by patients. 

Have you had the opportunity of observing the effect of it 
upon patients who have come to you .’—Y'es. 

You have been made acquainted, I think, with the result 
of the analysis of this liquid —Y'es, I heard it yesterday 
afternoon. 

Y'ou are aware that it contains, amongst other things, 
cocaine and atropine ! —Y'es. 

Are you familiar with the nature and effect of those drags ? 
—Y’es, particularly with cocaine. 

Is it a drug which is used in medical practice ?—Yes. 

Is it a drug the use of which is dangerous ?—Y'es, without 
particular care. 

Will you give your reason for that statement ?—Cocaine is 
one of those drugs which has a very potent effect upon the 
region to which it is applied, when it is applied locally, or 
on the constitution when it is either absorbed or taken in 
some form of liquid or injection. There is no means of 
knowing before it is used, either by the local application or 
by its injection, whether that particular patient possesses 
what is known as an idiosyncrasy to the drug. An almost 
fractional amount in one case will produce very alarming 
symptoms, and in another case it may have no particular 
effect; but you cannot by any means tell before you 
administer whether the individual case will stand it or not, 
and therefore you must commence with very small doses, 
and you must watch its action as you go. 

Y'ou say it may be followed by alarming results ?—Y’es. 

How does the drug act to produce those results ?— 
Supposing the patient is affected by it ? Y'ou mean to say we 
will assume the patient cannot stand cocaine? 

Y'es ?—And he has given to him what to him is an overdose i 

Y’es ?—In the course ol about three to five minutes he 
would probably say : “I begin to feel so curious ; I feel faint; 
my heart is beating very fast.” You notice he is getting 
pale and getting a cold perspiration on him, and becoming 
what we should term anxious; that is to say, he is in a very 
uncomfortable mental and physical condition. That is what 
you might call a mild case of acute poisoning. 

Are some patients more susceptible to cocaine than others ’ 
—Y'es, curiously so. 

Are there certain cases of diseases in which it is extremely 
dangerous to use cocaine, for instance heart disease ?—I 
should say yes, but my experience in practice does not deal 
much with heart disease and therefore I could not speak with 
tbe same authority in that respect that I possibly might in 
others. 

In your opinion is it safe to use cocaine indiscriminately ? 
--Certainly not. 

And does that answer apply even though tbe doses may be 
extremely small?—Yes, because the dose, however small, 
may be a large dose for the individual who uses it. 

Are you familiar with the instructions which Dr. Tucker 
sends out with the specific ?—I read them. 

Do you think that those instructions are likely to lead to 
the continued use of this specific ?—Y’es. 

What is tbe effect of cocaine ? Is its action cumulative or 
not ?—I should say that its effect is cumulative rather than 
its action ; there is a distinction there. 

Is the use of this specific, in your opinion, likely to be 
injurious to patients, or to some patients, if they continue 
its use for a considerable time ?—Y’es. 

Have you yourself noticed the effect of the use of this 
specific upon patients who come to you ?-- Speaking gener¬ 
ally, yes. 

Mr. Justice Ridley : I have got all that before. 




The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1,1908. 345 


Mr. Eldon BaNkes: Well, I was going to ask you now 
wbat baa been tbe effect that you bave noticed ? 

Mr. Smith : I should like to ask your lordship, unless it 
is taken in tbe same way and substantially in the same pro¬ 
portion, whether or not this would be evidence. There is no 
dispute, of course, in many cases of persons who bave taken 
cocaine in large quantities, that they are very much injured 
by it. If he is going to speak to persons who have taken 
appreciably the same dose and the same atomiser of course I 
do not object. 

Mr. Eldon Bankes : I am speaking of atomisers, and I 
am speaking merely of the use of the Tucker specific. 

The Witnbss; I suppose 1 may not give the case where I 
am told “ I bave given it up because I bave felt it growing 
upon me.” 

Mr. Eldon Bankes : 1 want you to tell the jury what is 
your experience of the use of Tucker's specific with any 
patient or patients that have come to you— My experience 
of it is that it gives relief and that the relief leads them to 
continue taking it under circumstances which are dis¬ 
advantageous to themselves. May 1 explain that ’ I mean 
this : supposing a patient is suffering from asthma and takes 
this remedy he gets relief. The asthma may be caused by 
some condition which could easily be relieved otherwise, but 
because he gets relief the patient continues to take the 
remedy, and the time goes by when the real cause of the 
asthma could have been removed o.nce for all had he only 
known of it, but he is satisfied with the relief and he goes 
on until it is impossible to remove the real condition, thus 
making it impossible to effect a cure. 

So that the time passes by in which the patient can really 
be cured by anybody ?—Certainly. 

Is it possible for the specific itself to effect a cure ?—I 
have never known a case. 

Mr. Justice Ridley : Asthma, I believe, cannot be cured 
at all?—Yes ; it can be cured, but I have never known a 
case cured by this so-called specific. I should like to state 
that I do not say all cases of asthma can be cured, but there 
are certain cases many of which I am quite sure can be cured 
permanently. 

Mr. Eldon Bankes : Are you familiar with what is known 
as the cocaine habit ’—Quite. 

How does that affect a patient ?—Well, it is practically like 
all drug habits. Supposing we were to take an ordinary 
weak solution of cocaine, one of the commonest methods of 
using it is for the patient to obtain a small vaporiser, 
nebuliser, aeriser, or whatever term you like to give to the 
instrument, and just blow it into each nostril and draw the 
vapour through. In the course of a few moments, supposing 
they are suffering from a little obstruction or difficulty of 
breathing, all that passes off. Then tbe patient experiences 
a sensation of what is called by a French phrase the bien-itre 
—that is to say, a sense of well-being, a sense of elation. No 
task would be too great for you to overcome. You are 
capable of any amount of energy. Then after that comes 
the inevitable reaction in which you get hopelessly depressed. 
Then you go back to your remedy again, and so the thing 
goes on until the patient becomes an addicted cocainist, as 
we call it. Besides the effect it has on his mental condition 
in the weakening of the mind it will make him irritable and 
nervous, and in the chronic cases they suffer from sleepless¬ 
ness and want of appetite. I am speaking now of an 
ordinary bad habit of cocaine. 

Is it worse than all the drug habits ?—I am sure it is worse 
than the morphia habit. 

And more difficult to cure?—It is more difficult to cure 
because the patient in the morphia habit will like to get 
cured and try to help you to cure him, but the cocainist does 
not want to get rid of his habit, and will try and elude you in 
your efforts to cure him. 

Is it a habit very easily to be acquired ?—Very easy. 

And in certain patients who are extremely susceptible the 
cocaine habit is acquired by the use of small quantities ?— 
Possibly, because in the individual case the small quantity 
may have a very great effect upon him. 

In your opinion is the use of this specific for prolonged 
periods calculated to produce the cocaine habit 1—Yes, I 
think it is calculated to do so. 

I think you yourself have, have you not, written or lectured 
upon the precautions that ought to be taken with regard to 
the use of cocaine ?—In the last edition of my work on 
diseases of the nose and throat I have devoted a paragraph 
to it, in which I have laid stress on the fact that I think 
medical men ought to be very careful in allowing a prescrip¬ 
tion containing cocaine, even in small doses, to pass into 


the bands of their patient because they never do know what 
will be the outcome of it provided the patient is addicted to 
its use. 

Mr. Justice Ridley : I do not think I can take that down : 
it is the same thing over again taken out of your book. 

Mr. Eldon Bankes : Of recent years have the profession 
generally taken much greater precautions with regard to 
prescribing cocaine than was formerly the case !—Yes, espe¬ 
cially in the United States of America, where it is better 
known and its evils. 

Is that because of the increasing knowledge of the bad 
effects of the use of cocaine ?—And the knowledge that the 
public very easily attain the habit of using it. 

Has your attention been called to the case of the man 
Cushing who died of consumption ?—Yes, I read of it. 

Are you able to express any opinion as to the desirability 
or otherwise of using cocaine in cases of consumption ; would 
that come under your notice?—It would in the case of con¬ 
sumption of the throat, where one uses sufficient just to 
obtain ease before taking food sometimes, but one would 
never give it as a continual form of treatment—I mean to 
say, in the form nf a prescription. 

Mr. Justice Ridley : I do not think that would be 
material, because this is not recommended for consumption. 

Mr. Ei.don Bankes : No, but your lordship will remember 
that the origin of this statement either by the coroner or by 
us was, as your lordship will see stated in the article, it had 
been used by a man who died of consumption. 

Gross examined by Mr. F. E. Smith. —Before I pass away 
from that I want to ask a question about this drug habit. As 
far as taking cocaine is concerned, do yon say the cocaine 
habit is easily acquired ?—Yes. 

I suppose that would be the same as far as all drug habits 
were concerned ?—No, because all drugs have not that 
seductive influence which cocaine has. 

Has not morphia, for instance, got a seductive influence 1 
—Morphia has not got the Beductive influence of cocaine. 

Has not it a well-known seductive influence ?—But in 
another ten years cocaine will have a much greater reputa¬ 
tion for seductive influence. 

That is your view about it. You may be right. Tell me. 
What is the kind of dose where the cocaine habit in the 
extreme form exists that can be taken without the destruc¬ 
tion of human life ?—You mean to say, supposing a patient 
is a cocainist and is in the habit of taking large doses what 
is the largest dose ? 

Yes.—I do not know ; I believe it varies. I believe you 
can take 10 grains of it, or even 15. 

I suggest to you, before passing away from this, that a 
dose of 90 grains has been recorded over a considerable 
period ?—That is quite possible. 

I do not know whether you were present in court 
yesterday ?—Yesterday afternoon only. 

You heard the evidence that was given by the last witness ? 
—Yes. 

I mean with regard to the amount of cocaine that would 
be absorbed into the system by the use of this atomiser ?— 
Yes. 

Do you accept that evidence ?—Personally, not on all 
points, I should say. I do not think it is possible to say how 
much is absorbed ; I do not think the amount that would be 
absorbed really has anything to do with it. 

Well, I did not ask you that. 

Mr. Justice Ridley : I am sure it has something to do 
with it?—Something, but the question of the amount 
absorbed has really not so great a bearing as the symptoms 
produced by the actual amount that is administered in the 
individual case. 

Have you got to the symptoms at all ? Supposing there 
are no symptoms? 

Mr. Smith : Of course, we are considering it entirely 
without reference to the symptoms for the moment. That is 
the whole point of the question, but even this gentleman 
does not seem to appreciate it quite. 

Mr. Justice Ridley (to the witness): You must be wrong, 
because the quantity absorbed must have something to do 
with it.—Within limits, but generally speaking, it is not the 
amount absorbed but the effect which the drug has on the 
individual case. 

Mr. Smith : Does that mean you do not attach very much 
importance to the amount absorbed ?—Of course I do ; it is 
the whole point. 

If it is the whole point perhaps you will tell me with 
brevity the respects in which your view differs from that of 





546 The Lancet,J 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. X, 1908. 


the last witness7 You have indicated you do not entirely 
agree with him.—My view is this : I believe the evidence, so 
far as it went yesterday afternoon, was to this effect, that 
the amouat that came oat of the spray by the ordinary 
spray was infinitesimal, and could that amount be dele¬ 
terious. X think that is yonr point, really. 

Y'ou shall tell me, and I will accept it from you : Is your 
view that an infinitesimal quantity could be deleterious 2— 
The amount that comes out of this spray I think is 
deleterious if continued. Of course, once used it has a 
passing effect and will produce no harm, but the continued 
use will certainly produce harm, in my opinion. 

I would rather deal with the specific case and not 
generalities. You heard the specific evidence given by 
the last witness. I only want to know whether you will 
agree with it or whether there is any point you wish to 
make clear ?—If you will ask me the specific points I will 
answer them. 

I thought perhaps it would conduce to brevity if you 
could state, after listening to his evidence, whether there 
was any specific point you wished to dissent from !— l 
think if you just put to me one or two points I would 
prefer to answer them. 

You agree as regards the number of grains of cocaine per 
fluid ounce 7 -Yes. 

You accept all that?—I accent the analysis yesterday. 

You would accept the statement that it would take about 
100 compressions to exhaust a drop of the specific?—I think 
that has been ascertained ; I do not mind accepting that. 

I do not gatherthat you dissent, either, from the view that 
the exhalation must get rid of some of the minute proportion 
of the cocaine that there would be in the drug?—Possibly, 
but what remains in gives rise to very marked symptoms. 

I do not know whether you ought to say tbat. 

Mr. Justice Ridley : Really, tbat does not seem to answer 
the question ; it is simply confusing. What have we got to 
do with the symptoms ? It does not give rise to the sym¬ 
ptoms at all in some of the oases. We are dealing with 
quantities. Leave out the symptoms. 

Mr. Smith : I am going to ask you some questions about 
the symptoms in a moment, but leaving symptoms quite out 
of the question, do you agree that a considerable proportion 
of the cocaine, a very minute proportion of the cocaine 
which we know to be in a drop, is got rid of by exhalation ? 
—I should think a very small quantity. 

Perhaps Mr. Tucker will just take some of that in and 
discharge it. (The plaintiff did so.) Is not yonr view that 
a very inconsiderable proportion of cocaine is discharged ?— 
Not inconsiderable. (The plaintiff repeated the operation.) 

You would not form an unfavourable prognosis of Mr. 
Tucker’s case with those two applications?—No, I think he 
can do it yet again. 

You would not like to do it yourself ?—No, I am very 
susceptible to cocaine. 

You are not a victim to the cooaine habit?—No, thanks. 

Do you mind telling me scientifically, in that exhalation, 
whioh would appear to cover a considerable volume of 
vapour, very little of the cocaine would be discharged?— 
Because I think there is very little in that. 

Your point is really that very little would be discharged in 
the exhalation because there has been so very little in the 
exhalation 7—Yes. 

We are reaching common ground, then. 

Mr. Justice Ridley : What proportion of what is taken in 
will come out ?—I do not know at all. 

Mr. Smith : You cannot form any view ?—No. 

I will put a strong case. If it all came out, these gloomy 
views which we are encouraged to form about the cocaine 
risk we can put aside ?—If it all came out. 

You do not know how much comes out?—No. 

If you are wrong about the proportion which stays in all 
these melancholy prognostications fall to the ground Yes, 
but I think by the fact that it relieves so quiokly a good deal 
must be taken. 

You do not think it is the temporary passing through that 
would alleviate at all ?—No. 

That is your only reason for forming this view?—Whioh 
•view do you mean ? 

The only view up to the present time which you have 
Announced to me. 

Mr. Justice Ridley : Is the cocaine the only thing that 
alleviates asthma ?—I should think the atropine and possibly 
Also the nitrite of sodium. 

Mr. Smith : What proportion of those stays in ?— I do not 


know anything about the proportions that stay in and I do 
not know anything about the proportions that come out. I 
know it relieves the symptoms and has a marked effect, and 
therefore some must stay in. 

You do not know what proportion of these ingredients 
remains in the system, or whether any of them do ?—They 
must remain there, that is obvious. 

You do not know how much ?—I do not know. 

However minute they may be !—I do not know how much 
remains in or how much comes out. 

Of course, if the greater part of it is expelled it would 
considerably modify the view you have expressed ! If it is, 
but 1 think it is not. 

Your view, as I understand it, is that it is not a prudent 
thing, nor indeed a safe thing, for this to be used in this 
way without medical supervision ; is tbat so ?—1 think it is 
imprudent. 

That is as far in the direction of the unfavourable sense as 
you would feel able to go ? I should say even more; I 
should say it is very unwise for a patient to be constantly 
using a remedy of this kind. 

Mr. Justice Ridley : Suppose he used it for seven years? 
—Then I should think it seven times as unwise as if he used 
it for one year. 

Yes. I quite understand that, but what would be the effect 
upon his health in seven years ?—I think you could only tell 
by examining the individual case that had used it for the 
time. 

Mr. Smith; Of course, the learned counsel did not take 
much oppoitunity of cross-examining the witnesses on that 
point. 

Mr. Justice Ridley : We have had witnesses who have 
used it for fully that time.—I think our experience would be 
we could bring plenty of patients who had had to give it np 
because it has unset them. 

Mr. Smith : 1 am at some difficulty in dealing with this 
point. If a patient had been using it for seven years your 
view is bis case would be seven times as bad as if be had 
been using it only one year 7—I think he would be worse at 
the end of seven years than if he had used it for a much 
shorter period of time. 

Is Sir Stephen Mackenzie a man of high reputation in his 
profession?—I believe so. 

Do not you know him ?—Not personally. 

But you know his reputation ?—Yes. 

You know it is high 1 —I grant you that. 

Do you wish to make any qualification ?— No. 

None at all 7—No. 

Then without qualification his reputation is a high one ?— 
Yes. 

I suppose he is quite as capable as you are of making an 
analysis ?—Well 1 

We will not make comparisons; they are invidious. You 
have beard that Sir Stephen Mackenzie has sent more than 
once for this specific ?- 1 have not heard it. 

You heard it in evidence, not cross-examined too ?—1 had 
not heard it. 

Then assume it to be the case. 

Mr. Eldon Bankes : I did not object, but, of course, there 
is no evidence that he took it; he may have sent for it 
for analysis. 

Mr. Justice Ridley : When did you get that evidence in ? 

Mr. Eldon Bankes ; There are a good many things said 
which I did not object to. It came ont in this way: Mr. 
Duke in his opening said he was going to call people who 
used it, and, amongst others, Sir Stephen Mackenzie. There¬ 
upon he was told Sir Stephen Mackenzie was not here, and 
the thing dropped ; that was all that happened and I think 
my friend ought to confine himself to that. 

Mr. Justice Ridley : There was something else said. 

Mr. Smith ; Yes, let me remind your lordship. What 
happened was, my friend Mr. Duke inadvertently said he 
was going to call Sir Stephen Mackenzie. In point of fact 
we attempted to serve a subpoena on Sir Stephen Mackenzie 
and discovered tbat he was on the continent. We then 
tendered the evidence of the plaintiff that Sir Stephen 
Mackenzie for a period of six years had been in the babit 
from time to time of sending for this specific. We could 
have put in letters if my friend had cross-examined in any 
way. 

Mr. Eldon Banices: You could not have used the letters. 
Really, you are going beyond what you ought 

Mr. Smith : My lord will tell me whether I am. 

Mr. Justice Ridley : “Sir Stephen Mackenzie is one of 



The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1 , 1908. 347 


oar oldest patients and is still”—(looking at letter of 
October, 1907) ; that is the piece of evidence I have got. 

Mr. Smith : The letter was tendered. 

Mr. Eldon Bankes : The letter is not evidence. 

Mr. Justice Ridley : The evidence is he is one of Mr. 
Tucker’s patients. 

Mr. Smith : Assuming that to be so, that, of course, would 
astonish you greatly ?—No, it would not at all. 

I understand your view to be that nobody gets permanent 
relief or any chance of a cure from this 2—No ; I think so. 

Assuming it to be the case, would not it surprise you that 
Sir Stephen Mackenzie should use for years and order 
for years a drug that might make him a slave of the 
cocaine habit, which gives him no chance of permanent cure 
and injures his health!—I am surprised he uses it in that way. 

I thought you said you were not surprised ?—I am not 
surprised that he orders it. 

Mr. Justice Ridley : But you do not deal with it. He is 
a patient for six years, it is said. 

The Witness : Is Sir Stephen Mackenzie referring to 
himself or some patient ? 

Mr. Smith : No, to himself. 

Mr. Eldon Bankes : We do not know that. 

Mr. Justice Ridley : Yes, “ One of my oldest patients." 

Mr. Eldon Bankes : That is all he said, but it is no more 
evidence than that he supplied the stuff. 

Mr. Smith : The evidence is that he is a patient, and my 
friend did not cross-examine. 

The Witness : Because Sir Stephen Mackenzie used it 
himself it would cot influence me in thinking it was a right 
thing to do. 

You would merely think Sir Stephen Mackenzie was 
wrong 1 —I should think if he was using a drug for himself 
he knew its possibilities, and he had sense enough to know 
bow much he could use. 

But with people who have the sense to know how much 
they can use you think it is to be recommended 1—With 
great care. 

We are getting at something. This specific, if used with 
great care and among persons who understand its use, is one 
that may be used in cases of asthma?—Not by the lay 
public. I am referring to medical men. 

I guarded myself by saying “If properly recommended ” ; 
so we are at least on common ground so far, that this specific 
is a good specific for asthma if administered under medical 
advice and with medical supervision!—Yes, I think you 
might say so. 

You make the concession rather grudgingly, but you have 
no doubt about that, have you!—Well, I am on'y speaking 
for myself. I see a good deal of asthma, but 1 very rarely, 
in fact never, prescribe this remedy. 

That I can quite understand, but still you accept the view 
I put to you a moment ago ?—Generally speaking, I can 
conceive it might be done. 

As regards the witnesses who gave evidence, you know 
some 20 witnesses of the highest position, both socially and 
professionally, have been called in court. I do not know 
whether you were here 2—1 was not here. 

Assuming it to be the case that many of those witnesses 
stated that they had exhausted all the resources of your pro¬ 
fession without getting relief—you follow me !—Yes. 

And consulted all the most eminent physicians without 
getting relief, do you say such a man, if he thinks he can 
get relief by using this specific, is nnwise to do so !—Y'es. 

All the doctors had had a try at him without success.— 
Are you quite sure they all had 2 

Perhaps they had not been to you 2 —No, I was not sug¬ 
gesting that 

Assuming that they have tried competent medical advice 
for a considerable period without success, do you say to 
such a man, if he finds that Mr. Tucker’s specific gives him 
relief, he is unwise to avail himself of that relief!—I 
should take very great care to point out to him the risk he 
was running by using it constantly. 

I am sure you would, but having taken care to point out to 
him the risk be was running should you think such a man, 
having failed to get relief from the profession, was wise or 
unwise to get relief where he could find it!—I should think 
he might use the thing, but I should warn him to use it with 
the greatest discrimination. 

So do we. 

Mr. Eldon Bankes : That iB the whole point; you do not 
warn people that it is to be used with caution. You say it is 
perfectly harmless and they are to use it as much as they 
can. 


Mr. Justice Ridley: Take Mr. Symonds’ evidence. He 
was recommended the remedy by one of the leading phy¬ 
sicians of the West of England. He has got relief and hag- 
used it for seven years. 

Mr. Eldon Bankes : We do not suggest people cannot use 
it and get relief. 

Mr. Justice Ridley : You have said this is fraud. How- 
can it be fraud ? It is hopeless. 

Mr. Eldon Bankes : Your lordship uses that expression, 
but supposing there are 25.000 people to whom this is sent, 
and of those 25,000half have benefited and half have not. I 
am putting it as a supposititious case. If they say it is suit¬ 
able and it is absolutely harmless and the more you take the 
better it will be I submit that a person who holds a strong 
opinion is entitled to say that is fraud. 

Mr. Justice Ridley : I do not think he is; if he chooser 
to say a person is guilty of fraud he must prove it and justify 
it. In this case you have not done that. You have said the- 
fraud was in this man, that he was guilty of fraud. 

Mr. Eldon Bankes : No, pardon me, my lord. 

Mr. Justice Ridley : Yes, yon have. 

Mr. Eldon Bankes : That is for the jury, really. 

Mr. Justice Ridley : Y’ou have said it was fair com¬ 
ment on a matter of public interest. 

Mr. Eldon Bankes : I have the authorities that l can 
refer to in a moment. 

Mr. Justice Ridley : I know some of the authorities, and 
I daresay you know others to the contrary, but that is what* 

I mean. If you had said that this is a thing that ought nob 
to be done, that this medicine is a dangerous one which 
ought to be adminstered only under medical supervision, and 
by medical prescription, as this gentleman says, it would 
have been fair criticism on a matter of public interest 
without question, I think. No jury would have failed to- 
find it so, but if you choose to say this Mr. Tucker is guilty 
of fraud because he has sold it at such a price, because ho 
has been supplying the public with poison and robbing them, 
that is not a fair criticism on a matter of public interest. 

Ms. Eldon Bankes : If your lordship will pardon me, 1 
am fully aware of your lordship’s point. 

Mr. Justice Ridley : You said he has been guilty of fraud, 
robbery, and poison. 

Mr. Eldon Bankes: I am fully aware of jour lordship’s- 
point ; I intend to deal with it, but I ask to give my 
evidence. 

Mr. Justice Ridley : I really did not wish to discuss the 
matter at this moment. It arose in this way ; we go on with 
this point which keeps oS the libel. 

Mr. Eldon Bankes : I think if my friend had thought the 
evidence was not admissible he would have objected to it, 
but he feelB that it is relevant and I ask that it should be 
taken without objection. 

Mr. Justice Ridley : I imagine it may be relevant to the 
issue in case there be any case for the jury to support wbab 
you claim -namely, that this is a fair criticism on a matter 
of public interest. My great doubt at present is whether 
there is any evidence to go to the jury at all on your side. 

Mr. Eldon Bankhs: Your lordship I am sure will defer 
your decision upon that. 

Mr. Justice Ridley : Y’ou have not justified it and you 
ought to have done ; that is the long and the short of It. 

Mr. Smith : Were you in court while Lord Ashburnham 
was giving evidence 2—No, 1 was only here yesterday after¬ 
noon from 3 o'clock to 4 o’clock. 

His lordship said that he was recommended Tucker's 
specific by Dr. Mitchell Bruce 2—Y’es. 

I want you to tell me about Dr. Mitchell Bruce. Is he a 
competent physician 1—I am not here to express any opinion 
upon any of my professional colleagues. 

I quite see your difficulty. Y’ou would not agree with the 
advice which he gave!—I should not personally prescribe 
Tucker’s remedy for an asthmatic patient. 

Assuming that Dr. Mitchell Bruce recommended it to 
Lord Ashburnham without any arrangemaDt at all to per¬ 
sonally supervise its use your view would be that that was 
very wrong ? 

Mr. Eldon Bankes : We have not any evidence that that 
is so. 

Mr. Smith : Yes, we have. 

Mr. Eldon Bankes : Lord Ashburnham said that he was a 
patient of Dr. Bruce. He recommended it and presumably, 
therefore, if he was a patient he would continue to consult 
him while he was using it. 

Mr. Smith : As a matter of fact the only statement made 
by Lord Ashbarnham was that he was recommended to uee- 





348 Tub Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Fbb. 1, 1908. 


this by Dr. Mitchell Brace, and no question was asked by 
my learned friend at all to suggest that it was under his 
supervision. 

Mr. Justice Ridley : He was never told there was any 
cocaine or atropine in it and it is obvious there was no par¬ 
ticular care or supervision in it in his case because he did 
not know there was any poison in it. He said : “I was not 
told it contained cocaine or atropine ” ; therefore it is clear 
I should think that he was recommended to take it according 
to the instructions. Perhaps I am wrong. You see what I 
mean. I will read the whole evidence if you like. 

Mr. Smith : I should be glad if your lordship would just 
remind us. 

Mr. Justice Ridley : “ I am 67 years of age. I had 
asthmatic troubles for five or six years, violent attacks of 
breathlessness, principally in the daytime, not at night. I 
tried many treatments and on one occasion went to Mont 
d'Or and Nauheim baths. They were not much use for it. I 
consulted several doctors, and I tried all recognised remedies. 
A year ago in November I had an acute attack, and I con¬ 
sulted Dr. Mitchell Bruce of Harley-street. He gave me a 
tonic.” 

Mr. Eldon Bankes : Wonld your lordship stop there for a 
moment. This is what I relied upon, and therefore I did not 
ask any questions :—"Did you consult anyone ?—I consulted 
Dr. Mitchell Bruce of Harley-street.—Was that the first time 
you had been to see him?—No ; off and on I had seen him a 
good many years, I daresay 20 years or more perhaps ” ; so 
I took it that he was Dr. Bruce’s patient. 

Mr. Justice Ridley : Very likely he was. I have not 
taken that down, but I have no doubt it is right. 

Mr. Eldon Bankes : I understood he was a patient of the 
doctor. 

Mr. Justice Ridley : He did not state it at this moment 
because this is the evidence-in-chief. 

Mr. Eldon Bankes : I was reading the evidence-in-chief 
and that is why I interrupted. It comes just between what 
your lordship took down. You do not seem to have taken 
down that answer. 

Mr. Justice Ridley : No, I do not. 

Mr. Eldon Bankes : No doubt it did not occur to your 
lordship as being material 

Mr. Justice Ridley : May I go on ? 

Mr. Eldon Bankes : Certainly, my lord. 

Mr. Justice Ridley: "He gave me a tonic, but as to 
breathlessness could only recommend Mr. Tucker’s cure.” I 
daresay those words are shortly taken too. “ A Paris doctor 
told me of it before. I found the address out from 
Messrs. Savory and Moore, and went straight to the place. 
There I saw a lady and she showed me the atomiser. I 
bought it outright, and have used it constantly since, 
especially in London. It removes the breath troubles 
absolutely. It has not the slightest ill result, and I think I 
am distinctly better than I was a year ago. I have once had 
to buy some more liquid. Cross-examined: The attacks 
came perhaps six or seven times a day.” Then I have no 
doubt other questions were asked, but this is all I have got 
in answer. " London is a very unfavourable place. 1 do not 
use it except'when I want it. 1 gave the lady information 
about my complaint. I was not told it contained cocaine or 
atropine.” That is all I have about Lord Ashburnbam. 

Mr. Smith (to the witness) : Taking it quite shortly, your 
view is that if that advice was given and no arrangement was 
made for supervision that is extremely unwise ? 

I personally should think it was unwise. 

You will not put it higher than that; you do not agree with 
it yourself ?—I do not agree with it myself. 

But you recognise that a competent medical man might take 
a different view ?—He apparently knew Lord Ashburnham’s 
state of health very well, and whether it was possible for him 
to take this. 

Then your view is that if a doctor know his patient’s 
general state of health he might with propriety recommend 
this specific without arranging for supervision?—I do not 
think so. I think he would have to assume that the patient 
would consult him afterwards, to see whether the specific 
wa9 doing him any injury or not. I should certainly in my 
own case. 

Supposing the doctor arranged that in case the specific was 
doing injury afterwards he should come and consult him, 
you would si e no objection to it?—Less objection than other¬ 
wise, but personally, as I say, I should not use it. I mean to 
say I cannot defend what other men might do. I personally 
should not use it. 


You have heard Mr. Tucker say that he had on his books 
300 doctors of medicine ?—He might have. 

You think they are all making a mistake ?—I think they are 
unwise, and I am bound to say so. 

Do you mean unwise in the interests of the profession 1 — 
No, unwise in the interests of the patient in a great many 
cases. 

Mr. Justice Ridley: In their own cases that means?— 
Yes. 

Mr. Justice Ridley: You do not think their cumulative 
experience in actually making use of this specific is likely to 
be of no weight. Does not their cumulative experience coming 
in the shape, in many cases, of repeated orders impress you ? 
—Not very much. 

Not 300 doctors ? They are all qualified.—I daresay they 
are. 

Mr. Eldon Bankes : May I suggest that the fact that 300 
doctors have once ordered it (if it is the fact, and I am not 
disputing it) does not show that they continued to use it, or 
that they did not cease the use of it afterwards. Y’ou are 
pushing the answer farther than it will go. 

Mr. Smith : The plaintiff can give the names and addresses 
of all the doctors, and I ostentatiously invited my learned 
friend to ask for them, when, of course, the orders and 
repeated orders could have all been given. My learned 
friend, if I may venture to say so, was extremely well- 
advised not to ask for the names, and therefore they were 
not given. 

Mr. Eldon Bankes : The names would not help you. 

Mr. Smith : Perhaps the suggestion is that all these 
doctors gave one order. 

Mr. Eldon Bankes: No, it is not indeed, but I submit 
you are pressing the answer farther than it legitimately will 
go. 

Mr. Smith : I do not want to be unfair, but what it 
comes to is this. The witness says however many times 
the doctors ordered this specific it would not change his 
view. 

The Witness : Not the slightest. I have seen the evil 
effects myself of cocaine and of this remedy, and therefore 
it would not influence me whoever thought they might 
advise it. 

You have seen the evil influence of cocaine in the case of 
persons addicted to the habit, and that would not change 
your view in reference to this atomiser whatever 300 or 3000 
doctors might say ?—No, because I have seen it with this 
atomiser. 

Take, for instance, the case of Mr. Bateson. Y'ou did not 
hear Mr. Bateson give his evidence ?—No. 

He is a member of the Bar, you know ? Yes. 

He has to make extensive use of his thinking powers. I 
want to ask you about that case. That was a gentleman who 
utterly failed to gain relief from the medical faculty.—May 
I ask what the medical faculty did for him ? 

He said they administered various poisons to him. 

Mr. Justice Ridley : I think as it is short I might read 
that evidence also. 

Mr. Eldon Bankes : He said they fed him on strychnine. 

Mr. Justice Ridley : I will read what he said as far as I 
can; that is the best thing. " I am a barrister-at-law. I 
have been liable to asthmatic attacks from childhood until 
I bought Tucker’s specific about four or five years ago. I 
am now rising 42” that is what he said. "It got worse 
and constantly I could not sleep at all, but after I bought 
this I har e been able to sleep perfectly well and have had no 
trouble with asthma at all. My earliest recollection is being 
under Sir William -Tenner. 1 had recurring attacks then, 
though I daresay there was relief from time to time ’’—from 
the medical treatment that means. “ The longer I have 
used it the less I have to use it. I hardly require it at all 
now. I pay about 8s. for either 12 or 18 months which 
would be adequate certainly for 12 months. I volunteered 
my evidence. Cross-examined : I have been told it contains 
poison, but, all the doctors have fed me on poison. There is 
nothing on the bottles. I had to use it constantly when 1 
first started. Doctors have ordered me cocaine for hay fever. 
Re-examined : Sir William Jenner fed me mostly on arsenic, 
and it was suggested to me to use cocaine for hay fever.” I 
think it was he who suggested it. 

Mr. Smith : Yes, I think it was. 

Mr. Justice Ridley : “ I have Dever used care with it. I 
used it as frequently a9 I wanted it, perhaps three or four 
times in half an hour, and relief always came very quickly.” 

The Witness : It seems obvious that his diet now U 





The Lancet,] 


TUCKER v. WAKLET AND ANOTHER. 


[Feb 1, 1908. 349 


cocaine and atropine, which seems to suit him. He is being 
now fed on cocaine and atropine I take it instead of arsenic. 

Mr. Justice Ridi.ey : Do you think that is a fair answer 
really?—No, I am simply arguing because he has already 
ssid he has bepn fed on arsenic. 

Mr. Justice Ridley : He only used that phrase because it 
was put to him. 

Mr. Eldon Bankes : No, he used it playfully ; it was tot 
put to him. 

Mr. Smith : You were only speaking in play too, were you 
not ? 

The Witness : I did not mean that, of course. 

Mr. Smith : Just for a moment to get a serious explanation 
that would seem to show that you have here a case of a 
sensible professional man to whom the doctors have failed 
to give any substantial relief.—I should like to know what 
the doctors have done and what the treatment was. 

Of course there was every opportunity to ask him, and 
my learned friend very wisely did not take it. Y’ou mnst 
assume that the doctors gave him proper advice—He refers 
back a very long time to Sir William Jenner’s time when the 
treatment of asthma was not so well known as it is now. 

He did not say that he ended with Dr. Jenner’s advice, 
and it is reasonable to assume that be was given competent 
advice by qualified medical practitioners ?—Yes. 

Taking the case of a man like that - and the jury heard 
his evidence—assuming he did fail to get relief from 
qualified medical practitioners, you do not seriously suggest 
to my lord and the jury that he is unwise to use a specific 
from which he derives constant relief which has done him 
no harm up to now. That is your view, of course, if I under¬ 
stand it 1 —That he is unwise to use it 1 How often does he 
use it? 

Mr. Eldon Bankes : He used an ounce in 12 or 18 
months. 

Mr. Justice Ridley: “I used it formerly as frequently 
as I wanted it.” 

Mr. Eldon Bankes : But he said he exhausted one ounce 
in 12 or 18 mornhs; that is a very infrequent use, of course. 

Mr. Justice Ridley: “Perhaps three or four times in 
half an hour.” 

Mr. Eldon Bankes : Yes ; whenever he had an attack; 
but he only used an ounce in 12 or 18 months. 

The Witness : 1 should assume in that particular case that 
not very much harm has come of it. Whether it will in the 
course of time of course I do not know. 

That is a grudging testimonial. Would not you go further 
and say that considerable good seems to have resulted from 
it ?—He has relieved the symptoms, but apparently he is not 
cured. 

He never was cured before and he did not get relief 
before ?—He is not cured now, is he ? 

No, but he gets relief ?—But that has not cured it. You 
assume that it is a cure. 

As a matter of fact I think he did say that the asthma 
began to go. “ Since using this specific I can always sleep.” 

Mr. Justice Ridley : “ I hardly require it at all now.” 

Mr. Smith : Tue cocaine habit is making very slow pro¬ 
gress in that case, i« it not ?—Yes. 

Mr. Eldon Bankes : Do deal with it seriously. We do 
not suggest that he had the cocaine habit. 

Mr. Smith : It is so difficult to treat it seriously. 

Mr. Justice Ridley : Dr. Tilley’s evidence goes to this 
extent that it is almost necessary that everybody should 
have the cocaine habit if it is used in such quantities. 

Mr. Eldon Bankes : It is all a question of degree. I 
hoped I might save time by agreeing with my learned friend. 
I do not suggest that any appreciable harm would come to a 
man who used an ounce of this in 12 or or 18 months. It 
may be unwise, but it would give him relief I agree, and I 
agree that no appreciable barm would come to a person who 
used it in those quantities, and as long as a person con¬ 
fines himself to tho-e quantities no harm would come to him. 

Mr Justice Ridley : I do not think Dr. Tilley agrets with 
you. 

Mr. Eldon Bankes : I do not know whether he does or 

not. 

Mr. Justice Ridley : He said that it was not safe to use it 
in these doses at ad. 

The Witness : In what doses, my lord ! 

In doses such as in this specific?—I do not remember 
having said so. 

" It is not safe to nse indiscriminately, even in small 
dooes.”—Indiscriminately, yes. 


Mr. Smith : What does that complication mean ? —II 
means that a confirmed asthmatic will carry that with bin 
and use it every ten minutes or quarter of an hour or half an 
hour during the day, and my whole point is that with s 
person who used it so frequently as that and so often thif 
drug must be acting upon him deleteriously. With regard 
to a person taking it once now and again, I am not prepared 
to say that it is going to do him irreparable harm. 

Mr. Jastice Ridley : Y’ou also said this : “ I consider tbal 
this specific used for a certain amount of time is calculated 
to produce the cocaine habit.”—I think it does because 1 
have seen it. 

Mr. Smith : Do yon accept the view that an ounce used ir 
a year or 18 months could be used with impunity?—Not by 
some patients. I do cot thick some patients could use tha' 
with impunity. 

Taking the case of a patient like Mr. Bateson, who findi 
he can use it with impunity after years of experience, wh< 
gets alleviation from these attacks, and who finds he has t< 
use it less and less, do you say it is UDwise of him to use thii 
specific?—No, because if he goes on using it less and less hs 
ceases to use it at all. 

And be has the advantage of being cured ?—It will be thi 
first case I have known of a cure from it. 

One lives and learns. 

Mr. Justice Ridley : A witness was called yesterday, Mrs 
Pimm, and I do not think she has much the matter with he 
now. 

Mr. Smith : No, she iB very robust. 

Mr. Justice Ridley (to the witness) : Did you see her ? 
No, I did not. 

Mr. Smith : I suppose the appearance of external robus 
health is quite compatible with the cocaine habit. One ma; 
look very healthy and yet be addicted to cocaine, I suppose 
—In the early stages of the habit, yes 

To deal with Mr. Bateson’s case I gather that you agre 
that if the necessity for using the specific occurs less am 
less and the attacks grow fewer he was wise to use it ?—If h 
used it with discretion, yes. 

Y’ou cannot use it with more discretion than by using les 
of it, according to your view ?—No. 

Then let us have it without any qualification. Mr 
Bateson is quite right to use it?—Mr. Bateson might be. 

And yon would say as it is right for Mr Bateson to use i 
Mr. Tucker has done a service, at least to Mr. Bateson, b; 
putting it on the English market ?—At least to Mr. Bateson 

At any rate he has benefited somebody. Now let us tak 
Mrs Pimm’s case. Were you in court when Mrs. Pimm wa 
called ?—No. 

She was a lady who described herself by saying graphic 
ally that she was a perfect wreck and could not do any worl 
at the time when she was first introduced to Tucker’ 
specific. I think she uses it less, too, but my lord will tel 
me if I am wrong there. 

Mr. Justice Ridley : There is not so complete an accoun 
of her case as there is of the others and she was not cross 
examined. T think. 

Mr. Smith : No, I think she was not. 

Mr. Justice Ridley : “ I have bad asthma since 1891 an 
was quite a wreck five years ago. The doctor gave me n 
relief. 1 tried everything I could think of. Somebody r< 
commended this specific four or five years ago and I got it o 
trial and paid for it. it gave me relief instantly and 1 hav 
never been laid up since. I have never acquired the cocain 
habit.” 

Mr. Smith : There is one sentence which your lordshi 
did not take, that she always had doctors in her hons 
before. 

Mr. Justice Ridley (to the witness) : You did not see her 
—No. 

Mr. Jastice Ridley : The chief part of her evidence wa 
her appenrance, l think ? 

Mr. Smith : Yes, her robustness. 

Mr. Jastice Ridley : I never saw a more healthy-lookin 
person. 

Mr. Smith (to the witness): There again, if she had 1 

take less-?—If it will save time. I am not prepared 1 

deny that you might bring plenty of people whom it hj 
relieved and whom it will continue to relieve, but that do< 
not alter my opinion that the indiscriminate prescribing < 
ordering of that is an unwise procedure. 

You do not put it higher than that ; you simply say that 
is unwise 1 —I tbink it is a fraud. 

You think it is a fraud ?—Oh, yes. 




350 Thb Lancet,] 


TUCKER r. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


Has Mr. Tucker defrauded Mr. Bateaon, for instance?— 
'No, but he has defrauded patients whom I know because 
he has not cured them and the pamphlet bays that it pro 
duces a cure. 

This is your argument and I shall have an opportunity of 
dealing with it ? 

Mr. Justice Ridley : Does a doctor always make a cure ? 

He does not promise. 

It is very hard on the doctor i£ he is a fraud because he 
does not make a cure ?—I do not think he would promise to 
cure. 

Mr. Justice Ridlby : I think 1 have heard him do it. 

Mr. Smith : Then your view is that Mr. Tucker is a fraud ? 
—I think it is a fraudulent proceeding. I do not know that 
Mr. Tuoker himself is- 

Let us be quite clear about that before the jury. Your 
view is that this is a fraudulent proceeding, and as you have 
heard, Mr. Tucker is responsible for it, and you think be is 
taking part in a fraudulent business ?—I think it is a 
fraudulent business to send out a remedy or specific, which¬ 
ever yon like to call it, which you state will cure but which 
does not cure. 

That is your whole reason for saying so—this statement in 
the pamphlet! Have you the pamphlet there! “Specific 
for the perfect relief and cure of asthma and hay fever.” 
That is the only reason you have got for saying to the jury 
what nobody else has said so far, that this is a fraudulent 
system ? —I think it is a fraud so far as it promises what it 
does not and cannot carry out. 

And this is what you found yourself on .'—There are other 
statements in that which are not true. 

I would like to have all ths statements which would lead 
you to take the view that this is fraudulent. We are getting 
further than we have done before. This is No. 1. I will 
hand you the pamphlet. (Same handed to the witness.)— 
Perhaps I might wait for a copy in which I made some notes 
on the margin. 

Have any copy you like. (Copy handed to the witness.) 
Just refer me to the page of the pamphlet which led you to 
form the view that this is a fraud ?—Oa page 6 there is a 
statement here : “ Y'ou will notice by the above instructions 
that it is neoessary for the vapour to reach the lungs in order 
to arrest the attacks, heal the mucous surfaces, and cure the 
disease.” 

Page 6 of what ?—Of this pamphlet. 

Mr. Justice Ridley: That is not the pamphlet ; that is 
the instructions. 

Mr. Smith : Your lordship recollects the evidence that 
this was written by Dr. Tucker. 

Mr. Justice Ridley : Y’es. 

Mr. Smith : “You will notice by the above instructions 
that it is necessary for the vapour to reach the lungs in order 
to arrest the attacks, heal the mucous surfaces, and cure the 
disease.” I note that. Is there anything else ?—I do not 
agree with what is here on page- 

1 do not mind what you agree with or what you disagree 
with ; I do not care in the least. 

Mr. Justice Ridley ! What do you want to say about that 
paragraph, “You will notioe,” and so on? I thought you 
referred to that. 

Mr. Smith : Where is the dishonesty ! that is what 1 
want —I do not think it is true ; it is published aB a fact. 

Y'ou have given me one statement, or two statements, that 
is all.—Here is a point in which this vapour is supposed to 
heal the mucous surfaces. So far as I know, there is no 
wound there or anything which yon can consider is abso¬ 
lutely anything that you can heal in the sense of healing a 
mucous surface by blowing in this specific, this oil. 

Y'ou think he is wrong !—I think ho is wrong. 

And your suggestion to the jury is that it is a fraudu¬ 
lent, statement!—I think it is a fraudulent statement. 

Is there anything else?—On page 7 of this larger book, 
■the top paragraph, it says, “We now offer to suffering 
humanity the result of 20 years’ experience which has 
-finally worked out a cure for asthma and hay fever, as well 
as all other catarrhal diseases of the air passages." That is 
absolutely untrue. 

Y'ou say it is absolutely untrue?—Quite. 

So that even if witnesses come forward to say that they 
can always cure attacks of asthma by the use of that it 
does not influence you at all?—“As well as all other 
catarrhal diseases.” 1 say that that is an nntrue statement. 

I want to have all those passages on which you found 
yourself. Are there any more .'—There are the last five 


lines on page 8 You will see it is stated: “We reverse 
the order of things and think we can prove that the 
catarrhal affection is the primary cause of the spasm and 
not the effect.” That 1 do not think is true. 

That is fraudulent, is it ?—I think it is a fraud to publish 
it as fact and lead people who cannot understand. 

It is not a thing as to which there can be any honest 
difference of opinion ? I do not think that. 

Are you sure?—Yes, I think 1 can bring plenty of evidence 
to prove it. 

You are charging dishonesty ?—Yes. 

You do not do that on hypotheses. 1 suppose ?—No. 

You are sure that this is such an error as to be incompatible 
with aDj thtory of honesty at all?—1 think to put it on that 
broad basis and to send this out stating it as a fact is taking 
advantage of their credulity, which is otherwise a fraud. 

1 quite understand your general view but I am now asking 
you lor the specific grounds upon which you base that. Do 
you mind dealing with those first and you can afterwards get 
back to general grounds. Are there any more passages ?— 
This is on page 6, the second paragraph: “Asthmatics who 
have organic heart disease or weak heart can nse the remedy 
with perfect safety.” 

Your view is that they cannot !—My view is that they 
cannot 

Mr. Justice Ridley : Is that yoor personal experience ? 

No ; it is not my personal experience, because my line of 
work of recent years nas not led me to treat heart d sease. 

Mr. Smith : And although it is not personal experience you 
savit is a fraud ; you state that ! 

I think the statement will be borne out by other witnesses. 

Did you hear one or two witnesses who were called 
yesterday, members of the medical profession ! Were you 
bere ?—1 was here from 3 to 4 o'clock. 

Were you here wheD Dr. Clark was called ?—No. 

He was a fully qualified medical practitioner ?—Yes. 

Do you know that he said he suffered himself from asthma 
and that eight years ago he obtained Tucker's specific, that 
he got instant relief and has used it continuously ever since 
with benefit and has never found the slightest craving for it? 
—He personally might have done so. 

You would agree that so far as he was concerned it was a 
remedy !—I have told you already that 1 have agreed that 
many people might use this under supervision. He being a 
medical man might know the symptoms. 

It might be used with great advantage.—He may nse it 
with advantage, yes. Bo might you use morphia with great 
advantage. 

But the evidence is not that people have used morphia with 
great advantage ; 1 am dealiug with asthma —Excuse me, 
one of the most potent and easiest methods of relieving a 
violent spasm of asthma is the iojection of a small dose of 
morphia. 

Mr. Justice Ridley: He also said this: “I have recom¬ 
mended it in a number of instances and it will do nobody 
any harm.”—I cannot agree with that siaiement. 

If another medical man says that, though you do not agree 
with it, it is rather strong to say that is a fraud. I suppose 
you will say that is fraud ?—No ; it is personal experience. 

I suppose this is this gentleman's personal experience too. 
I want to know where we are. This pamphlet is founded 
upon the personal experience of Dr. Tucker. Therefore one 
is the same as the other, except that one is given upon oath 
and the other is not. It is rather strong to say that this is 
fraud. 

Mr. Eldon Bankes : Your lordship will remember that 
Mr. Tucker said here over and over again he did not claim 
that this specific cured asthma. 

Mr. Justice Ridley : Yes; I know be did, and I do not 
think it is true to say that he did claim it. 

Mr. Eldon Bankes : There, again, that is a matter of 
opinion. A person may fairly form the opinion that he did 
claim it. This gentleman formed the opinion that where 
he says on page 8 of these instructions, “If necessary 
repeat the third time and by thus persevering with the treat¬ 
ment the disease can be perfectly controlled and finally 
cured," he was drawing the distinction as I submit between 
relief and core. 

Mr. Justice Ridlby : You have to read the whole pamphlet 
together. 

Mr. Eldon Bankes : Certainly. 

Mr. Justice Ridley : 1 think reading pages 6 and 7 
together you will see that he does not claim a cure for the 
asthma in the sense in which this gentleman thinks he does. 





Thu Lancet, 1 


TUCKER r. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 351 


Mr. Eldon Bankes : We say so. We may be right or we 
may be wroDg, but if we formed the opinion that he is 
claiming a cure in the full sense, we are justified in saying 
that a person is committing a fraud on the pablic if he 
sends out a medicine with that statement when he himself 
knows that it will not cure. 

Mr. Justice Ridley : But that is entirely a travesty of the 
evidence in this case. 

Mr. Eldon Bankbs : X am sorry I do not assist; X thought 
I might save time. 

Mr. Justice Ridley : Yon do not help me at all in this 
case. I am trying to keep to the evidence and I will not be 
taken from it. (To the witness) : You say it is a fraud 
because you disagree with him ; nothing more or less I do 
not, pardon me, my lord. May I express again what 1 
believe? I think it is a fraud for a person to send out any 
drug or medicine of any kind and to lead people by a 
pamphlet such as this to believe that they can be cured 
when he himself allows that he cannot cure and does not 
cure. 

He does not say that in the pamphlet at all —[ think the 
plaint IT gave evidence here that he agreed they did not cure 
and did not pretend to. 

Mr. Smith : And you would say in the same way that it 
was fraud even if he could cure each successive attack of 
asthma f—I do not follow you. 

I should have thought it was very simple. —To you, 
perhaps. 

Even if it is a fact that he can cure each successive attack 
of asthma although he cannot remove the liability to asthma 
you would say it is a fraud ?—My point is that in using the 
word “cure” here I assume he uses it iu the sense that the 
public would accept it—that is to say, an absolute cure of 
the disease. 

You do not follow me in the least. There are two things ; 
ODe is to cure all liability to asthma and the other is to cure 
specific attacks as they develop in the person liable to 
asthma. Do you appreciate that distinction ?—Yes. 

Supposing it to be the case that Mr. Tucker can in fact 
cure specific attacks of asthma, although he cannot guarantee 
that there will not be a recurrence, do you still tell the jury 
that he is fraudulent ?—How do you speak of a " cure ” and 
in the next breath say “ recurrence”? If you “cure” a 
cancer and it returns- 

Have you ever heard of such a thing as curing a cold ? 

Mr. Justice Ridley : Are you aware that this pamphlet 
was not sent out ?—I was not aware of that. 

This thing is not sent out with the instructions at all ; you 
seem to treat it as though it were. 

Mr. Eldon Bankes : I think it is sent out. 

Mr. Justice Ridley : No, not until it is asked for. 

Mr. Eldon Bankes : His answer was that he sent out the 
pamphlet to anybody who made any inquiry. 

Mr. Justice Ridley : Yes. 

Mr. Eldon Bankes : Of course, thepsrons who make the 
inquiries are the pertons who afterwards inquire for the 
treatment. 

Mr. Smith : You can imagine, I suppose, curing a cold 
being perfectly consistent with the person whose cold is 
cured having another in six months or three months ?— 
Speaking of a cold, yes ; tut I think the term “cure” is 
not what the public would take it to be in that case. 

You shall have the opportunity of explaining it in a 
moment, bnt so far as the reasonableness ot using the term 
is concerned you wculd agree that a man may say he can 
cure a cold and yet the man may have another in six 
months 1— I quite agree. 

Why cannot a man say with equal reasonableness. “ I cure 
and relieve a specific attack of asthma, although I cannot 
prevent the man who is constitutionally liable to asthma 
getting future attacks ? -Because in one of these pamphlets 
he says, “Not only relieve, but cure,” indicating some 
difference between the two. 

Will you point it out ?—It is here somewhere. I cannot tell 
you the page, but we read it just now. 

Mr. Justice Ridi.ey: It Is just after the long paragraph 
which you have not read which describes the operation of the 
thing. He says : “ We now offer to suffering humanity the 
result of 20 years’ experience, which has finally worked out 
a cure for asthma and hay fever as well as all other catarrhal 
diseases of the air passages.” 

Mr. Smith : Is it possible that you do not see a much 
more reasonable cxplarat’on of using the word “relieve ” and 
“ cure ”—No. 


Let me see if I can suggest it to you, although I have not 
the advantage of your scientific experience. Does it not 
suggest to you that to "relieve” an attack may be to 
assuage it and to make it less severe, and that a farther 
Btsge in the alleviation is the “cure" of that specific 
attack '.’ Does not that seem to you a perfectly reasonable 
distinction ?—I am bound to say that if a man told me I had 
cancer and he would cure it I should understand by the 
term “ cure " that I need not look for a recurrence. 

Is your serious suggestion to the jury that the case of 
cancer is more analogous to the case of asthma than a cold 
in which you agreed to my description ?—No ; I think I 
agree with you there that a cold is more analogous than 
the case of cancer. 

Do not let us complicate it by illustrations that do not 
apply at all. A cold being more analogous to asthma you 
will agree that if it be the fact that Mr. Tucker can 
cure specific attacks of asthma—you follow me?—Yes.— 
You do not object to the use of the word “cure” so 
guarded ?—Yes, I do. I think you ought to say “ relieve ” 
specific attacks. 

It comes to this, that even if Mr. Tucker can cure specific 
attacks of asthma you object to him telling the public so ?— 
No, I do not. 

Then you do not object to his telling the public that he 
can cure specifio attacks of asthma ?—I do, because he 
cannot. 

You will not follow the hypothesis. I based my question 
upon a hypothesis. Assuming it to be the fact that the 
various witnesses who have spoken of it are right in saying 
that specific attacks of asthma can be cured by this, you 
would Dot object to Mr. Tucker saying that he could cure 
them .’—I should, certainly, publishing it in this particular 
form. 

You do not assist me by telling me what the words are.— It is 
simply the use of the words and the application of common- 
sense to the ordinary English language. If a man says to 
me, “I can relieve your attack of asthma, " I understand 
what he means, but if he Bays, “ I can cure it by this treat¬ 
ment,” I go away with the idea that he has done something, 
and that I need not look for a recurrence. I cannot explain 
it better than that. 

You cannot understand Dr. Thomas Clark saying that 
though it contained cocaine and atropine it is in such small 
quantities that it has no ill-effect, even though he has such a 
lot of it in his system ? You would say he is wrong and you 
are right on the broad principle of common sense.—I should 
say lie might come across esses where that small amount of 
cocaine might produce damage to the patient, or so shroud 
the symptoms that the patient could not get proper relief. 

Although you have no personal experience of it you prefer 
your opinion to his ?—Because many patients who have been 
using it have applied to me and have said- 

We cannot have what they said to you. 

Mr. Eldon Bankes : You asked the question. 

Mr. Smith : I have not asked that question, and Dr. 
Tilley knows I have not. 

You know Oppenheimer’s mixture. I suppose ?—Yes. 

Have you seen this in the book published by Oppenheimer: 
“Many inquiries from important medical men having reached 
us regarding a certain preparation for asthma recommended 
by an American doctor, we introduced our Neboline com¬ 
pound, No. 21, which is similar in every respect to the pre¬ 
paration in question and which from the reception accorded 
to it seems to meet all requirements." Then there is this 
note in italics: “Practically a specific for asthma.” Have 
you seen that note?—I see it now. 

You have not seen it before ?—I may have seen it a year or 
two ago. 

Is that another fraud ?—Does it promise to cure asthma 
here ? 

No, but it is just the same thing —He does not say it is a 
specific for the cure of asthma. 

You think it means a specific for the aggravation of asthma ? 
—No ; possibly for the relief of it. 

Mr. Justice Ridley : Are you honestly giving that 
evidence 7—I think so. 

Mr. Smith : Do you think that is a good distinction i 
Practically a specific for the relief of asthma. I do not fee 
why we should allow- 

If it had b:cn a specific for the cure of asthma you would 
ray. of course, that was fraudulent ?—I should have thought 
it was distinctly a fraud, absolutely. 

| They are very respectable people, are they not ?—Yes. 



352 The Lancet,] 


TUCKER r. WAKLEY AND ANOTHER. 


fFBB. 1, 1908. 


Mr. Justice Ridley : You may say it is “ a specific for 
asthma,” but it is not a fraud.—It is a specific for the relief 
of the asthmatic seizure, but not for the cure of asthma. 

He does not say that. He says “A specific for asthma.”— 
Therefore I take it we are allowed to regard it as we like and 
have our own opinion. 

I do not follow you. I think a “specific” is something 
which cures and so does everybody else, I should think. 

Mr. Smith : Do you really put it as a scientific proposition 
to the jury that when a firm of wholesale chemists describe a 
mixture as a specific for asthma the common-sense meaning 
(as you are so fond of common-sense) to put upon that 
is not that it is going to cure asthma? Is that your suggestion 
to the jury ?—I do not say what they mean by that at all. I 
do not know what they mean by that. I should suggest that 
they know enough of asthma to know that this is not going to 
cure it but only to relieve it. 

What I am asking is, whether, when we are told that this 
is in every respect similar to the preparation in question, 
with the knowledge, mind you, that we claim to cure attacks 

“In every respect similar to the preparation in ques¬ 
tion,” and is “ practically a specific for asthma,” do you say 
to the jury that this does not mean that they claim to cure 
it. I do not know what they mean to claim. I do not 
think it does. 

But if they did mean that it is fraudulent ? 

Mr. Justice Ridley : Will you let me see the book. (Same 
handed to his lordship). A specific is a cure I should think. 

Mr. Smith : I should have thought so. 

Re-examined by Mr. Eldon Bankes. —With regard to 
Oppenheimer's list, is that the list of well-known wholesale 
chemists which is published for dissemination amongst 
medical men and chemists ?—Yes. 

And you understand their statement to mean that it is a 
specific for the relief of asthma ?—I cannot believe that a 
firm of that reputation could wish medical men to believe 
that they can cure asthma. 

I want to know if they used the word as meaning 
“cure” would your opinion of them be the same as of Dr. 
Tucker? I am bound to say I should consider it a fraud. 

There is no distinction in your mind whether it is Oppen- 
heiiner or Tncker ? —Not a bit. 

If he advertises this stuff as a cure ?—If a man tells me he 
can cure a disease, and he only relieves it, I consider it is— 
it is my way of looking at it, I use the term fraud ; you may 
say misrepresentation ; I do not care what you call it, I call 
it a fraud. 

Before giving an opinion had you carefully read these 
instructions of Mr. Tucker and these cither doctors ? —Yes. 

And rightly or wrongly did you come to the conclusion 
that he drew a distinction between relieving the attacks and 
curing the disease ?— No, my impression is that the public 
reading that—the ordinary public—would take it that they 
have got something in that which is going to cure. 

And it is upon that that you form the opinion which you 
express ?—Yes. 

Mr. Justice Ridley : In the pamphlet. 

Mr. Eldon Bankes : And the instructions. The instruc¬ 
tions are equally specific. Your lordship will see there is a 
distinction ; I am not saying whether it is right or whether 
it is wrong. 

Now a very few questions about the many things which 
you have been asked about. You were asked how much 
cocaine a confirmed cocainist could absorb ?—Yes. 

My friend referred to some statement in some book 
showing that a cocainist could absorb 90 grains?—Yes. 

Does the frequent use of this drug or any other drug 
enable a person to take very much larger doses the longer 
they take it !—Yes, enormously. The simplest instance, of 
course, is morphia. A patient will be perhaps quite brought 
under the influence of morphia by one-sixth or a quarter of 
a grain the first time he uses it. but if he becomes addicted 
to it be could take five, 10, or 15 grains a day. 

Can a person with the confirmed morphia habit or a con¬ 
firmed cocainist, or a confirmed alcoholist take quantities 
with impunity which would kill any ordinary person ?—Yes, 
certainly. 

I mean with whisky or anything else ?—Yes. 

You are asked about the quantity of this vapour which 
would be absorbed by the compressions of this inhaler, 
having regard to the fact that a good deal is blown out. 
It is suggested to you that there may be a mere passing 
through of this vapour. Supposing there was anything in 
the nature of a mere passing through, would it have any 


effect at all upon the person in relieving his symptoms ?— 
No ; some must be absorbed. 

And is that obvious from the fact that the asthma is 
relieved ?—Yes. 

Of course, the exact quantity that is absorbed it is im¬ 
possible to say ?—Quite impossible. 

Obviously some would be expelled, and obviously some 
would remain ?—Quite. 

You have been asked questions about various persons who 
have been called as witnesses, and I understand you to say 
it is unwise for anybody to take this specific without super¬ 
vision ?—Yes. 

But is it quite possible that certain persons may take small 
quantities of it without doing themselves any harm at all ?— 
Qaite. 

And, of course, it may relieve them greatly ?—Yes. 

The necessary effect of using cocaine in this way must be 
to relieve the symptoms—the immediate paroxysm of 
asthma?—The cocaine, the atropine, and the other con¬ 
stituent, nitrite of soda. 

They will necessarily get relief because of the action of 
these very potent drugs ?—Yes, probably. 

And in your opinion it is quite conceivable that a great 
many people may use it in small quantities for a long time 
and get relief without any obvious harm ?—Y r es. a certain 
number might. 

And, of course, taking the case of a doctor who was using 
it, he presumably would be a man who would be aware of the 
danger of using it in an improper manner ?—Yes. 

Mr. Eldon Bankes : I wanted to call some other gentle¬ 
men very much, but Dr. Waldo, the coroner, I must call 
because he has an inquest this afternoon, and 1 must call 
him out of order. 

Mr. Justice Ridley : Very well. 

Dr. Frederick Joseph Waldo, examined by Mr. Eldon 
Bankes —I believe you are a Doctor of Medicine of the 
University of Cambridge ? —Y’es. 

Mr. Justice Ridley: And one of the coroners for the City 7 
—I am coroner lor the City of London and for the borough 
of Bouthwark. 

Mr. Eldon Bankes : I think you did on the 1st of July, 
1907, hold an inquest upon the body of a man named 
Cushing ?—Yes. 

Prior to that time had it come to your notice or knowledge 
as to what Dr. Tucker's specific consisted of or contained 1 — 
Yes. 

What had you heard about it ?—I had seen- 

Mr. Duke: I object to what he had heard. We cannot 
have evidence of what he had heard. 

Mr. Justice Ridley: The fact that he knew of it is ad¬ 
missible. 

Mr. Duke : Yes, that in another matter. 

Mr. Justice Ridley : We cannot have what he had heard 
unless he got it from Tucker himself. 

Mr. Eldon Bankes (to the witness) : Had you heard any¬ 
thing of what it contained ? 

Mr. Duke : I object. 

The Witness : Yes, I had heard that it contained atropine 
and cocaine. 

Mr. Eldon Bankes : My friend objects to it and if he 
does not choose to ask, very well. 

Mr. Justice Ridley : It is only admissible if this came 
from information by Dr. Tucker. 

Mr. Eldon Bankes : I submit not, but at this 6tage I will 
not press it. 

You had heard of this specifio?—I had heard of his cure. 

Mr. Justice Ridley : And of its contents ?—Yes. 

Mr. Eldon Bankes : Was evidence given before you at 
that inquest ?—It was. 

And amongst other witnesses was there a witness, Dr. 
Paton ?—Yes, he was the gentleman who was present after 
the death of the patient and he gave evidence and on my 
order he made a post-mortem examination of the body. 

Before you did he give evidence as to what was the 
cause of death ?—He did. 

What did he say ?—He said that the immediate cause of 
death was failure of the respiration and heart failure, due to 
advanced pulmonary tubercular disease, which is in plain 
English consumption of the lungs. 

Long-standing consumption ?—Long-standing consumption 
of the lungs. The actual words he used were what I first 
gave—respiratory failure and heart failure, due to long¬ 
standing pulmonary tubercular disease. 

During the inquest was anything said about Dr. Tucker’s 





The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908 . 353 


specific?—Yes. What was said about that?—The instruc¬ 
tions were handed to me with an illustration of Dr. Tuckers 
atomiser. 

Is that the paper, or a similar paper (handing document 
to the witness) ?—It is a long time ago, over a year ago, but 
so far as I can remember there was a similar paper with a 
picture- 

I think this is the actual one but I am not sure. (Document 
handed to the witness). Perhaps you will recognise it?—I 
distinctly recognise this one with “ Dr. Tucker's asthma 
specific" upon it, with the words ‘‘asthma, hay fever, 
bronchitis, catarrh," with a picture of the apparatus, and 
with the address, “ Onaway, Half Moon-lane, Herne Hill, 
8.E. All correspondence should be addressed to A. Q. 
Tucker, General Manager.” 

Is that the document handed to you or a similar one ?—It 
is a long time sines I have seen it. 

To the best of your recollection I mean ?— 1 To the best of 
my recollection. 

Mr. Justice Ridley : Had it the name and address ! 

Mr. Eldon Bankes : Had it a picture of a man nsing the 
atomiser 1 —I would not be positive about that, because 1 
have not seen it for so many months; lam sura about the 
Hont one. It was a paper, so far as 1 can remember, 
similar. 

Mr. Justice Ridley : I have the paper signed by Cashing, 
or at least the paper filled up by Cashing, if it is any good at 
all. Perhaps it would assist you to look at that. (Handing 
same to the witness.)—I have not seen this paper as filled 
in. 

Mr. Eldon Bankes : He did not have the questions ; it 
was the instructions. 

To the best of your belief it was that or something similar ? 
—Yes. 

Was anything said about the deceased man having used 
this ?—Yes ; it was said that ha had used it for some time, 
both the atomiser and the fluid used with it. Evidence was 
given also as regards the price paid. 

Do you remember what was said about the price ?—It was 
said that the price paid was 3 guineas for the atomiser and 
8s. an ounce for the fluid. I have since heard that £3 was 
the right price. 

I am speaking now of the evidence before you 7—That was 
the evidence, 3 guineas for the atomiser and 8». an ounce for 
the fluid. 

When you heard that evidence did you make any observa¬ 
tion yourself about this thing 7—I did. 

What was it you said ?—In reference to the atomiser and 
the fluid—that is the treatment—I said that I considered 
it was a quack remedy, and I also said that it was a fraud. 

That is what you said in open court at the inquest?—I 
did. 

I am not saying for a moment whether you were right or 
wrong in what you said or thought, but did you think it was 
a matter which required- 

Mr. Duke : I object to what the coroner thought. What 
he said is evidence, of course. 

Mr. Justice Ridley: What ha said must be evidence in 
this case, because it is material to the issue. 

Mr. Eldon Bankes : Very well, I will deal with that. 

Mr. Justice Ridley: But I do not think that what he 
thinks is evidence. 

The Witness : I will give my reasons, my lord, for using 
those two words. 

Mr. Eldon Bankes : I think you did not give any reasons 
in court, did you? I want all you said, as far as you 
remember, in open court about it.—I cannot remember at 
this lapse of time—it is over a year ago—whether I gave my 
reasons. I know what was in my mind at the time. 

Of course, I cannot have it unless you expressed it, but 
you have told us, in fact, what you said in open court.—Yes. 

Cross-examined by Mr. Duke. —Did you send, or cause 
your clerk to Bend to The Lancet office a newspaper report 
of the inquest!—I did. 

I call for it. Did you send it because it is an accurate 
account of what had taken place?—I sent it to the editor 
of The Lancet to do what he liked with it, because I con¬ 
sidered it a matter of interest to the profession and to the 
readers generally of The Lancet. 

Now, would you mind answering my question : Did you 
send it as an accurate report of what had taken place.—I 
did. 

WiU you look at it 7 (Handing same to the witness.) 


Mr. Justice Ridley: Is that the one you showed Norman 
yesterday ? 

Mr. Eldon Bankes : No, this is not the one which was 
shown to the reporter. This is the Morning Advertiser. 

Mr. Duke : This is the one which was sent; I do not 
care which it is ; I do not think it is the Morning Advertiser. 

Mr. Eldon Bankes : Yes, it is a cutting from the Morning 
Advertiser. 

Mr. Duke : 1 am not sure about that. 

Mr. Justice Ridley (to the witness) : What do you say 
about it 7—This is the one I sent. 

Is it an accurate report ?- As far as it goes. Of course, 
this is a very short report. 

Mr. Duke : But at that time it struck you as an accurate 
report of what yon said so far as it was material. Now let 
me read it : “Proprietary Medicines. In the course of an 
inquest held at Southwark yesterday ”—that is how it ran, 
and then I suppose it was your clerk who wrote in the words 
“ by Dr. Waldo.”—No, those are my words. 

You wrote them in ?—Yes, I wrote those. 

“ In the course of an inquest held at Southwark yesterday,” 
and then you wrote in “by Dr. Waldo,” “on the body of 
Alfred Albert Cushing, aged 42, a labourer lately living in 
Queen’s Buildings, Southwark, who died of consumption last 
Friday, the widow said her husband never cared to have a 
doctor as he thought doctors did no good. He doctored 
himself, she said, and any medicine he was told of he would 
bur He was taken ill on Dec. 22nd and never rallied. 
It Wo. s stated that the deceased used an inhaler which cost 
3 guineas and the spray 8<. an ounce. The instrument was 
an American invention, and the deceased bought it from a 
gentleman in London. (The Coroner): It is a quack remedy. 
People reap fortunes from proprietary articles. Is that 
right 7—(Dr. Paton, a witness): 1 do not think so.—(The 
Coroner): The Government do not guarantee proprietary 
medicines, but the people think they do. The sooner the 
Government do away with it the better. They get thousands 
a year from the system.—(Dr. Paton) : Most of these things 
are harmless.—(The Coroner) : But it is a fraud.” Is that 
what took place ?—Yes ; as far as it goes. 

Mr. Justice Ridley : Was the fraud in the Government 
stamp ? —I did not make use of the term “fraud” as applied 
to the stamp; it was applied clearly to the cure—Dr. 
Tucker’s so-called cure for asthma and bronchitis and other 
affections. 

Mr. Duke: Did you keep copies of any other reports 7— 
No ; I have not. 

Just look at this and see if you saw that in the newspaper 
(handing cutting to the witness).—I do not remember ever 
having seen this. I may have seen it, but of coarse it is a 
long time ago now ; it is over a year. 

But it is a report of that inquest, is it not?—Yes; 
apparently. 

There the reporter evidently understood you as saying that 
the system of stamping these things with Government stamps 
was a fraud—Yes, I see what you mean; it says “The 
system is a fraud.” That differs from the one which I sent 
to The Lancet. 

That pats upon the other the meaning which L suggest it 
actually bore.—Which is incorrect. 

Let us see how that may be.—That is not correct. 

We shall have to look at the document for ourselves. 
The one I first gave you was the one which you sent to 
The Lancet as being a correct account of what had taken 
place ?—Yes, it was. 

When did you communicate with The Lancet again 
about this matter 7 —The Lancet wrote to me, so far as 
I can remember, askiDg me for papers that were banded up 
in court. 

That was after this action was brought, was it not ?—I 
cannot say that. I think it was before. I instructed my 
clerk to send them. My clerk would really know more about 
that than I; I did not myself send them. 

When did you see The Lancet people or their solicitors 
about this matter and give them some further information as 
to what you are alleged to have said at the inquest ?—I 
believe that was subsequently to the action. 

So I suppose it was.—I was asked by The Lancet to 
give information, but I could not tell you the date. 

I have the pleading before it was amended, which had 
been delivered on the 9th July and it was redelivered as 
amended on the 21st November. Was it some time between 
the 9th July and the 2lst November of list year?—It might 
have been ; I really could not remember. 



354 The Lancet, ] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


Was it then that for the first time you told The Lancet 
people or their representative that yon hadbaid “ Gentlemen, 
the remedy is a fraud”?—If I did tell them so, it must have 
been the first time. Of course, I had sent this paper with 
this document. 

That is immaterial to the question which I am asking you. 
It appears by the pleadings which are before the Court that 
at some time between the 9th July and the 21st November 
the defendants decided to allege that you had said, “Gentle¬ 
men, the remedy is a fraud.” Did they so decide, as far as 
yon are aware, upon a statement which you then made to 
them ?- I could not say ; I do not know. 

Did you see them or their solicitor ?—Their solicitor saw me. 

Was that some time in the summer or autumn of last year? 
—Y*es, it might have been then, but I really cannot remember 
the date. 

Did yon and he read over the newspaper extract together.— 
Yes, I believe it was produced. 

Was there any discussion between you about it and about 
the possible view that what you appeared by the newspaper 
report to have attacked was the Government system, whereas 
the defendants had charged a personal fraud against Mr. 
Tucker ? Was there tome discussion between you about 
that ?—I cannot remember that. 

I wish you would charge your memory about that. You 
did discuss the newspaper report, did you not ?-j—'Yes, I can 
remember that being produced. 

Did you alf o discuss the fact that The Lancet had charged 
the plaintiff with personal fraud ?—I think it is very pr . -ble 
that on that occasion—as I say, I cannot remember details— 
I probably might have said that it was a fraud, but I intended 
the word "fraud "as against the so-called Tucker remedy, 
and not as against the use of the Government stamps 

So that, although the newspaper might have led a reader 
to suppose you bad been attacking the Government system, 
when the discussion took place and The Lancet were being 
challenged with having accused the plaintiff of personal 
fraud you said you thought it was a fraud.—Yes ; that I 
used the word “fraud” as against the Tucker cure and not 
as against the use of the Government stamp. 

So the reporter of the other paper of which yon have an 
extract before you was quite mistaken in supposing that you 
were attacking the Government system?—Yes, he was 
entirely wrong. 

And Mr. Norman, the local reporter who was here in the 
box yesterday, was quite wrong about it, too. 

Mr. Er.noN Bankes : Have you got his report ? 

Mr. Duke : 1 have not his report of the evidence. 

The Witness: I have not heard any report of the 
evidence. 

Mr. Eldon Bankes : I have had three reports and they 
all disagree. 

Mr. Duke : This is what be said : “ The coroner never to 
my recollection said that Tucker’s dealing or remedy was a 
fraud. 1 should have recollected it ; it would have been 
good copy.” 

Mr. justice Rl i it.KY: He said he had no distinct 
recollection. 

Mr. Eldon Bankes : His report does not say anything 
about fraud. 

Mr. Duke : He says : “ I should have reported the fact if 
the words had been used about Tucker." 

You, of course, sitting in your court as coroner are 
privileged to attack people’s character without hearing 
them 1 —It is my duty as a coroner if I think occasion occurs 
to give expression to that view to the gentlemen of the 
jury. 

I follow what you say, that you regard yourself as having 
a duty?—I do most certainly. 

With regard to persons who are not before you?—If the 
occasion warrants, certainly. 

If you think so ?—Yes. 

You know that you are privileged in whatever language 
you use in what you regard as the exercise of that duty ?— 
I believe I am. I swore when I was first coroner that I 
would do my duty to the public, and l consider that is my 
duty. 

I daresay you also know that a newspaper does not occupy 
the same position ?—No, I presume they have not the same 
privilege that the coroner would have. 

They have not that immunity. 

Mr. Justice Ridley : I hope not, indeed. (To the witness.) 
You are not liable at all; you are quite right.—I believe 
any judge is not liable, my lord. 


No, not at all.—A coroner is a judge of record. 

Mr. Justice Ridley : I think you are perfectly right. 

Mr. Duke : Do you not know in the ordinary course that 
before you are going to condemn a man you call him up and 
say : “ I am going to criticise your conduct; what have you 
to say about it ? ” Do you know that ?—In this case I was 
quire satisfied- 

Never mind this case. Do you know that—that in an 
ordinary case before a judge is going to condemn a man, ae 
you say, for fraud he has him before him and tells him and 
hears what he has to say ? Do you know that ?—Y’es, if there 
is occasion for it. 

But in your court you did Dot consider it necessary —No, 
I did not : I was quite satisfied with the evidence before me. 

Had you ever analysed this specific?—No, I never have, 
but I knew what was in it according to the books- 

Wo will see about that. Had yon ever received an analysis 
of it ?—I had a qualitative analysis of it. 

Was it a qualitative analysis which so far as constituents 
were concerned shows Rome such constituents as are spoken 
of in the evidence here 1 —Yes, both atropine and cocaine. 

That yon had seen and that you believed ! —Yes, I knew 
well about that some time before. 

That is, that you had become aware of it as a doctor ?— 
Yes, or as a coroner. 

I will ask you which it was ?—I happen to be a medical 
coroner—both ways. 

I am quite aware that you are a medical coroner. Do you 
suggest to the jury that in any inquest which you had ever 
conducted any evidence was ever given about this specific 
until this case of Oushing ?—Yes, the widow told me that 
her husband- 

Mr. Eldon Bankes : He misunderstands the question. 

Mr. Duke: Let me put my question again to you. Do 
you suggest that at any inquest you ever conducted except 
the Cushing inquest any evidence was given about this 
specific ?—No, I cannot remember that any was. 

Mr. Justice Ridley : It is your knowledge as a doctor 
then ?—Yes. 

Mr. Duke : Had you known anybody who had ever used 
this specific ?—At that time I caDnot say that I had. 

That is all I asked you. With regard to Oppenheimer’s 
list did you know that Oppenheimer had produced and put 
upon the market an asthma specific in imitation of this 
specific?—I had never heard so until I heard so in this 
court. 

But did you know that some eminent English drug firm 
had produced and put upon the market an asthma specific 
in imitation of Dr. Tucker s asthma specific?—No; 1 never 
kDew such was the case until I heard it in this court, 

You know it now ?—Yes ; I do. 

Does it surprise you at all ?—No; I cannot say it 
surprises me. 

You regard it, I take it, as quite a proper thing that 
Oppenheimer’s should produce this specific and sell it whole¬ 
sale at 3s. 6 d. an ounce and describe it as an asthma specific, 
and say that it produced the effects which the American 
specific produces ? You regard that as a natural thing ?—I 
have never said so. 

Do you ?—No ; I do not if, as you say, it is described as a 
specific. I take “specific ” in the English meaning—I mean 
very much the same as “ cure." 

Quite ?—If they say they profess to cure and to cure 
indiscriminately, and throw this broadcast about to all those 
who take it without beiog seen by a medical man or under 
the supervision of a medical man, then I should say it is 
very wroDg. 

Mr. Justice Ridley : Is it a fraud?—I should say it was 
fraudulent. 

Mr. Duke : Leaving out all those aggravating circum¬ 
stances which you have mentioned, do you mind dealing with 
the plain statement of Oppenheimer that this is a specific 
for asthma ? Do you want to say that that is fraudulent 
too?—I say so if they profess to cure asthma. In my opinion 
real spasmodic asthma is an incurable disease and I should 
say it is distinctly fraudulent—that is unless, of course, under 
medical supervision. I do not know what those people do— 
whether they sell it to medical men or how it is dispensed. 

Then the person who would be licensed to say that he 
applied a specific for asthma must be a medical man ?—I 
thiDk it should be given under the supervision of a medical 
man certainly, otherwise it would be most dangerous to the 
public. 

If a medical man has ever described it as a specific for 






The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908 . 3 55 


asthma then in his case yon would not describe It as a fraud ? 
—I should describe it certainly in Tuoker's case as a fraud 
most distinctly. 

Never mind Tucker’s case. I understand your view with 
regard to Tucker although I have not asked you. Do you 
know what the question was which I asked you ?—I under¬ 
stood you to say if this were dispensed by a properly qualified 
medical man. 

As a specific for asthma?—I should say it was distinctly 
wrong if he described it as a cure. 

Would you say if it was given by a medical man as a 
specific for asthma that that was a fraud on his part ?—I 
should say it was. 

Why ?- Because asthma is an incurable disease in my 
opinion. 

But suppose he took the view that he was able to repel 
the attack whenever it threatened, would you still say— 
That is another thing altogether. 

Would you say still that it was a fraud on his part? — 
No ; I would not if under his supervision and he did not 
profess to cure the disease. Certainly that would not be a 
fraud in my opinion. 

The whole substance of the matter with regard to a trans¬ 
action of this kind, fraud or no fraud, is one of the honesty 
of the person who is acting, is it not ?—Yes. 

As to Tucker’s honesty, I understand you to say that you 
formed the worst possible opinion ?—I have certainly formed 
a bad opinion. 

That is what I gathered, but I wanted it clear from you. 
HaviDg formed the worst possible opinion of Mr. Tucker, 
what you told The Lancet has induced them to take the 
responsibility of expressing that worst possible opinion. 
That is so, is it not?—They could do wbat they liked. I 
sent them the catting. 

Is that not what has happened ? -Yes. 

Mr. Justice Ridi.ey : Why did you send it to them at all ? 
—Because I considered it a matter of scientific interest for 
The Lancet to do as they liked with, botli for the medical 
readers and general readers. 

You sent it to a newspaper so that they might publish 
something about it?—Yes; I think that medical students 
and medical men should know about these remedies and 
secret remedies because the patients very often consult 
medical men, and 1 think it is only right that they should be 
able to give proper answers to questions which may be put 
by the patients. 

Mr. Duke : All I asked you was whether The Lancet 
had come up in yonr judgment to a complete expression of 
your view of the fraudulent conduct of Mr. Tucker?—I 
have read what they said in their article. They simply 
repeated what I said—that it was fraudulent—and agreed 
with me. 

You have no donbt that the issue which The Lancet raised 
about it was whether Tucker was personally guilty of 
fraudulent conduct ? You have no doubt about that ?- Ido 
not know what The Lancet thinks about it. 

That is what you thought about it?—I thought it was 
fraudulent, certainly. 

On Tncker’s part. That is what you wanted them to think 
about it, was it not ?—I did not express any- 

Was it your intention that they should think that?—I 
Bimply left it with the Editor of The Lancet to do what he 
liked with. 

Are you satisfied that they have taken the view which you 
*ay you took ?—Of course the view I took that it was 
fraudulent and a quack remedy they certainly have taken, 
but I say nothing about the comment they made and the 
rest of it. 

Tell me which is the part that you are not going to 
countenance.—I have read all of it ; I have read it through. 

Mr. Justice Ridley : Do you mean about the advertise¬ 
ments ?—Y'es. 

The plaintiff has never advertised at all.—No, the plaintiff 
never advertised. 

Mr. Duke: Just look at this and see which is the part 
which you think goes beyond what even yon intended. 

Mr. Eldon Bankes : He did not eay that. 

Mr. Duke (to the witness): Never mind Mr. Bankes; 
look at the document, please.—They mention my name aB the 
Coroner: “rightly stigmatisid this mode of dealing’’— 
meaning the plaintiffs—“as a fraud.” I quite agree with 
that. 

1 quite understand. Which is the part you do not agree 
with ?—I do not say I do not agree with any part of it but I 
am not responsible for what The Lancet may have said. 


But you do not draw any distinction. -Do you want me to 
say whether I consider that fair comment ? 

No, 1 do not want your opinion about fair comment.— 
Because I can say that. 

Mr. Justice Ridley : The jury will have to say that if 
there is any case for them, but yon say it was fraudulent 
because be said it was a cure. Yes. but I could give my 
further rearons. 

That is the reason you give us at present .’ 

Mr. Eldon Bankes :.No, he did not say that with sub¬ 
mission. My reason for saying it was this, that l consider 
that true or spasmodic asthma is an incurable disease and 
cannot be cured by drugs although 1 do most certainly agree 
that it may be alleviated and relieved ; but with regard to 
bronchitis, bronchitis is merely, in my opinion, a symptom of 
many distinct diseases. It is a sjmptom of gout; it U a 
symptom of heart disease. 

Mr. Duke: Could we stop there?—No one remedy caD 
cure all these forms of bronchitis. 

Mr. Justice Ridley : You are not asked all that, as you 
know very well. 

Mr. Duke: There is only one other thing which I am 
going to ask you and that is this : have you ever tried to cure 
asthma or to relieve asthma with Tucker's specific ? —No, I 
never have. 

So that yon have no personal experience in an asthma case 
of whether it will either relieve or cure .’—Not with this 
particular cure. 

Not with Tucker’s cure? —No—or specific; it is the same 
thing. 

Re examined by Mr. Eldon Bankes.—Y ou have been 
asked and you have stated that you are a medical coroner. 
Do you practise at all as a doctor ? -No, I do not. I give 
my whole time to my duties as coroner. 

Mr. Justice Ridley : He has medical knowledge. 

Mr. Eldon Bankes : Yes ; you have medical knowledge 
because you hold the high qualification of Dcctorof Medicine 
at Cambridge University .’ I do. 

But you do not any more practise ?—No, I do not at present. 
I have practised in the past. 

You have no interest in The Lancet newspaper, I need 
hardly say ?- I have no interest whatever. 

You sent that newspaper account to The Lancet ?—I did. 

Two different newspaper accounts have been put in of this 
inquest and there i6 a third, all differing, but at the time you 
sent it did you notice particularly as to whether or not it 
used the word “ fraud ” correctly in the newspaptr report— 
at the time you sent it ?— I did. 

I mean at the time you sent it.—Yes ; I read it and looked 
through it carefully, 

Does it correctly reproduce what you said with reference to 
the fraud—I mean the newspaper report ?—It does. 

Just look at it again. 

Mr. Duke: He has said that it does. You cannot cross- 
examine him. 

Mr Eldon Bankes : I understood him to say it did not. 

The Witness : It says, “ But it is a fraud” ; that refers as 
I read it to the treatment—Tucker’s so-called cure for asthma 
and other complaints. 

Mr. Justice Ridley: It does not necessarily follow ; but I 
am sure we shall all take the witness's evidence as reliable. 
It would not necessarily follow from the report itself because 
it might be thought to have something to do with the price ; 
it might be “ thousands a year from the system,” and also it 
might have regard to the stamp. 

Mr. Eldon Bankes : You read the report as though it 
indicated that you had used the word “ fraud ” with refer¬ 
ence to the system. You read the report in that way?—I 
read it as referring to the treatmeot. 

And in that sense you say you think it was accurate ? —Yes. 

And therefore you sent it to The Lancet ?—Yes. 

You are now asked about what you said to The Lancet at 
subsequent dates. Did you see the solicitor with reference 
to your evidence in this action?—I did. He called upon me. 

Did you then tell him what had actually happened !—Yes, 
I did. 

Did you in substance report the evidence which you have 
given here to-day ?—I did. 

Sir Richard Douglas Powell, examined by Mr. Eldon 
Bankes.—I need hardly ask you about your qualifications ; 
you are the very well-known physician?—I am. 

Have you been asked to consider the matters arising in 
this case ?—Yes, I have. 


356 The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Fbb. 1, 1908. 


Have you had submitted to you the instructions which 
Dr. Tucker sends out and the pamphlet explaining the treat¬ 
ment ?—Y'es, I know them generally. 

Have you also had submitted to you the analysis of the 
mixture ?—I have. 

Do you find that the analysis shows that the liquid contains 
cocaine and atropine and sodium nitrite?—Yes. 

Are you familiar with the nature and effect of those drugs ? 
—Yes, I am. 

Are they known drugs in medical science ?—Very well 
known, yes. 

Take, for instance, cocaine. What is the nature and effect 
of cocaine ?—It has a localised effect upon any membrane or 
absorbent surface to which it is applied and it has a general 
effect. 

Is its effect cumulative ?—The effects are cumulative, yes. 

Is it in its nature a dangerous drug ?—Yes; it is a 
dangerous drug—that is, a very small dose may be fatal. 

In certain diseases is it a drug which it is not proper to 
use t—Yes ; it would only be used for very few diseases. 

May I take the case, for instance, of heart disease ?—It 
would have to be used with very great caution. It would be 
very rarely used in heart disease. 

Take kidney disease.—It would be rather a dangerous 
remedy in kidney disease. 

And take consumption—phthisis. That is the third one 
which has been mentioned —It would only be used in con¬ 
sumption as a local application for the throat affection. 

Do all those three diseases—heart'disease, kidney disease, 
and some forms of consumption—present symptoms some¬ 
times which are very difficult to distinguish from the 
symptoms of asthma ?—I do not think there should be any 
difficulty. 

I do not mean for a doctor.—I do not think a doctor 
should find any difficulty. 

Would a patient very often mistake them ?—It is quite 
possible ; yes. 

Do you find in your practice that sometimes asthma is 
associated with heart disease or associated with kidney 
disease or associated with consumption in the same patients ? 
-—The symptoms of asthma are so associated sometimes. 

In your opinion is it safe to sell any specific containing 
cocaine indiscriminately ?—I should say it was unsafe. 

Have you read Mr. Tucker's instructions to patients how to 
use his specific 1—Yes. 

Have you noticed that there is no warning that is is to be 
used with caution ?—I noticed that particularly. 

Is asthma a very distressing complaint?—Very dis¬ 
tressing. 

And if a patient found something which would relieve the 
attacks, he would be very likely to use whatever it was very 
frequently, would he not ?—I should say so. 

Having regard to those conditions, do you think that the 
continued use of this specific in certain cases is likely to be 
injurious ?—Yes, I think so. 

In what way would it produce injury ?—It would produce 
injury to the nervous sy.-tem and weaken the heart function. 

Are you familiar with the cocaine habit ?—I have seen a 
case or two of it; I am not very familiar with it. 

With regard to cocaine, I think one witness has used the 
expression that it is a seductive habit?—Yes. 

Is it a habit easily acquired ?—Yes. 

Does it differ with different patients ? Are some patients 
more susceptible than others ?—Yes. 

And some patients take safely quantities which to other 
people would be extremely unsafe ?—I should say so. 

Do you say that with regard to symptoms likely to be pro¬ 
duced ?—People vary very much in their sensitiveness to the 
drug, and they vary very much in their disposition to take 
drugs like cocaine and morphia, and so on. 

Do you think the frequent and repeated use of this specific 
over a long period is likely to produce the cocaine habit ? 

Mr. Duke : That is a very leading question. 

Mr. Eldon Bankes : But I must put it. 

Mr. Justice Ridley : He says he has only seen a case or 
two. 

Mr. Eldon Bankes : Can you form an opinion from your 
general experience ?—Certainly. In any particular person 
inclined to habits of that kind it would be likely to produce 
the cocaine habit. 

Cross-examined by Mr. Duke.—Y ou were called in to this 
case, t suppo.-e, m :rely as an eminent medical man after this 
action had been instituted 7 —I presume so. 


Mr. Justice Ridley : Is that so ? 

Mr. Duke : You say you presume so. What I mean is, 
bad you heard anything of this matter until after the action ! 
—No. 

We have not seen the author of this publication. Do you 
know who the man was who wrote the statements complained 
of ?—I have no knowledge of it at all. 

I think what you have told us has been chiefly with regard 
to cocaine. Is it the fact that consumptive people may 
suffer from asthma, or not ?—It is not impossible fora con¬ 
sumptive patient to have asthma. 

You say it is not impossible ?—It is not very common in 
fact. 

It is a great deal more trying and distressing for a con¬ 
sumptive patient to have asthma than it is in the case of a 
person who was free from phthisis ?—I cannot say about that. 

You have no opinion about that ?—Asthma is a very painful 
affection in whomsoever it occurs. 

I should have thought it would be much more painful and 
distressing in the case of a person who bad a deadly disease ! 
—They are not very commonly combined. 

Iu the case of heart disease, have you found asthma com¬ 
bined with heart disease ?—Not through asthma as a rule, 
except that the heart, towards the end of the asthmatic 
illness, gets disabled and in that way complicates the asthma. 

Is not one effect of asthma to steadily affect the action of 
the heart?—The effect of asthma is to weaken the action of 
the heart. 

If you found a person whose health was steadily 
degenerating from asthma who by any sort of remedy was 
relieved from severe attacks of asthma and thereupon 
experienced a good recovery of general health, that would 
indicate, would it not, that the heart was getting stronger ?— 
That is rather a complex question. Will you put it again ? 

Mr. Justice Ridley : I think what counsel means is this : 
If you relieve the asthma would you relieve the heart ?—The 
remedy used for the asthma deterioriates the heart. 

Mr. Duke : Suppose you found a person getting ill as 
regards general health, and the asthma relieved and the 
person getting better, does not that show an improved condi¬ 
tion of the heart ?—It shows an improved condition of the 
asthma and a relieved condition of the heart. 

Mr. Justice Ridley : We have had evidence of that about 
General Stewart. 

Mr. Duke : And by General Lane. 

Mr. Justice Ridley : Yes. 

Mr. Duke : Will you tell me whether the symptoms of 
asthma, which, as I understand,]are simulated by some of the 
disea-es you have mentioned, are relieved by any treatment 
of asthma?—It is very possible that any spasmodic might 
relieve such symptoms. 

i rather gathered that that is a different view from what 
Dr. Willcox gave us yesterday j but that is your view ?— 
Yes. 

It would relieve what I call simulated symptoms of asthma 
arising from organic disease !—It may be relieved by any 
spasmodics. 

Had you yourself become aware of this remedy ?—Oh, yes. 

Mr. Justice Ridley : When did you become aware of it 7 
—In the course of my practice I have met with patients who 
have used Tucker's cure. 

Mr. Duke: Have they gone on using it?—Some of them 
have. 

You did not think it necessary peremptorily to stop them, 
or anything of that kind? —I have felt it sometimes 
necessary to stop the nse ; in other cases I have given 
very serious cautions as to the excessive use of the remedy. 

At any rate, patients of your own have gone on using the 
specific ?—I have no doubt; I do not know. 

We have had a Mr. Pickmeyer here yesterday who had 
been a patient of yours.— 1 have no recollection of his name, 
it is very possible. 

Mr. Travers Pickmeyer ?—i may have seen Mr. Travers 
Pickmeyer. I see so many patients that I cannot re¬ 
collect. 

I quite follow ; but it may recall it to your mind if I 
say that this was a gentleman who was sent to Mont d'Or.— 
I have sent a good many people to Mont d'Or. 

Asthmatic people ?—Yes. 

Mr. Pickmeyer was sent to Mont d'Or; he came back from 
Mont d Or not benefited, and then was referred back to 
advice at Harrogate. He told us yesterday that he failed 
to get any sort of relief from the medical treatment be bad 
had ? — Yes. 





The Lancet,] 


TUCKEB v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 357 


1 am not pnttiag that as a teftection at all upon medical 
treatment, you understand ?—Yes. 

Mr. Justice Ridley : Pickmeyer did not go to Harrogate. 
One witness did. He was a wine merchant. One witness 
was ordered to Nauheim and another gentleman went to 
Mont d’Or. I think that was Lord Ashburnham. 

Mr. Duke: Yes, my lord ; I was not in court when his 
evidence was given. 

Mr. Justice Ridi.ey: It was Lord Ashburnham who went 
to Mont d'Or. 

Mr. Duke : Undoubtedly ; but Mont d'Or is a place where 
asthmatic people are sent, and Nauheim is another place. 

But you do not remember Mr. Pickmeyer’s case specifically ? 
I cannot. 

In a great number of cases it is notorious that asthma 
quite resists medical treatment?—It is a very obstinate com¬ 
plaint, yes. 

And I do not gather from your evidence that you at any 
rate would think it improper that a medical man should 
prescribe either cocaine or atropine or a fluid which should 
be compounded of those ingredients for the treatment of his 
own patients if he thought fit’— If he thought fit certainly 
he would have the right. 

Mr. Justice Ridi.ey : Do you know of a better specific than 
this for asthma ?—There are a great many specifics, my 
lord. 

Do you know a better one!—They all contain much the 
same thing. 

As this one ?—I do not think many of them contain 
cocaine, but they nearly all contain atropine or belladonna. 

Is it within your knowledge that those other specifics 
having once been begun fail in their operation after they 
have been used for some time ’—Patients get accustomed to 
them all and they have to use them more and more fre¬ 
quently and sooner or later they Buffer from the ubb of the 
remedy. That is my experience. 

It is the fact, as we have heard, and it is correct that they 
are similar, you say, but without cocaine’—They are all 
more or less secret remedies and 1 cannot answer for the 
composition of any of them. I only know from their effects 
upon people I have seen that they do contain similar 
remedies of the belladonna class. I cannot be sure about 
the cocaine. That is a much more subtle drug. 

But “ contain similar remedies ” would be right, and they 
all begin to fall in their operation and have to be used in 
larger quantities ?—They have to be used in increasing 
quantities because the patient acquires a habit of using 
them. 

I understand that you cannot compare them with this one. 
that is, with this particular specific of Mr. Tucker as to their 
effeotual or ineffectual use?—In some cases I have known 
one remedy to give more relief than another. They vary in 
that way. 

Have yon been in court during the whole of the hearing or 
have you come in this morning ?—I have been in court for 
the last two hours. 

But you were not here yesterday ?—I was not here 
yesterday. 

We had several gentlemen here yesterday, some of whom 
at any rate said that they had such freedom from attack now 
that, carrying the specific with them, they did not find the 
necessity to use it?—Y'es. 

That does not show a tendency to increasing user, does 
it ?—I did not hear the evidence and I cannot say. 

I am asking you to assume for the moment that I am 
giving it to you accurately. If yon assume that the witnesses 
who have been here had suffered grievously from asthma and 
bad come to such a condition since they used the specific 
that they had practically discontinued the use of it, although 
they kept it by them, that would not show a tendency to 
increasing user, would it?—You cannot take individual 
cases. 

But we must take individual cases’—I am afraid you 
cannot. 

Do you mean that we ought to have the whole of our 
25,000 users here ?—I am only speaking of those cases where 
relief has been given by using anti-spasmodic remedies, 
which are the most powerful remedies in our Pharmacopoeia 
and are extensively used by medical men. 

And have not acquired a tendency to increased use ?—I 
have no evidence of that. 

But it must enter into the consideration of the conclusion 
scientifically, must it not?—I am afraid my opinion was 
given on cases I have known to the contiary. Y'ou asked me 
for my opinion. 


I am cross-examining on your opinion and you gave it to 

me ’—Yes. 

Y r ou told us you had this pamphlet. I wish you would 
take a copy. It is said that this is put about to suggest that 
this thing produced an absolute core. Take page 17 of this 
pamphlet, where the testimonials begin. I am not going to 
take more than three or four of them, but I must call your 
attention to that. Have you got it ?— I have. 

Take paragraph 3 in the first: “ Y'our specific, whether it 
cures or not, is simply marvellous in the prompt relief it 
affords take the next at the fourth line.—Yes. 

“ I caDnot of course say I am cured of asthma; but for 
the past five months, in which I have used your instrument, 
I have had greater freedom from attacks, and, what is of 
great importance, a ready and effective means of relief 
which has never failed me.” Now take the next page, the 
second line: “I have used the remedy for nearly nine 
months, and though I am not in any way cured, during that 
time I have been in no way bothered with asthma.” I am 
not going through the whole of them. I have taken the first 
three testimonials. Are not those representations to the 
people to whom this book is addressed that there are people 
at any rate who will find themselves cured by the use 
of this remedy?—Yes; they are using the most powerful 
remedies in the Pharmacopoeia, and I do not see why they 
should not be benefited by them. 

Further examined by Mr. Eldon Bankes —My learned 
friend’s cross-examination has enabled me to ask questions 
which I could not have asked before, but which I am de¬ 
sirous to ask now. Yours is, I think, a consulting practice ?— 
Y'es. 

Have you had a number of patients come to you who have 
been taking this Tucker's specific ?—I have seen a good 
number altogether. 

My lord has asked you a question about these asthma 
remedies generally and their effect and you have told him 
that patients get accustomed to them and have to take 
gradually more and more and finally get into the habit of 
taking them. From your personal experience is there any 
difference in the cases you have had before you between 
patients taking other kinds of remedies and patients taking 
Turker's remedies in that regard i —No; 1 could not say there 
is any difference. 

You have said in answer to my learned friend that you 
have felt it sometimes necessary ta stop the use of Tucker’s 
specific altogether and in other cases to say that it should be 
used with extreme caution ?—Y'es. 

What cases have they been in which you have ordered it 
to be stopped ?—In a certain number of these cases patients 
fly to the remedy with great facility. They use it too much 
and they get weak and irritable hearts in consequence. It 
affects them through the heart. That is my experience. 

In your practice have you found cases of patients actually 
beiDg injuriously affected by the too frequent use of this 
liquid?—I have in some cases to advise them to stop the 
remedy and in others to use it with very great caution. 

And is that because of the actual injurious effects upon 
Chose particular patients which you have found this remedy 
has been causing?- It is like all other powerful remedies of 
the class. People are apt to take it too frequently and to 
get injured by the use of it. The remedy gives them relief ; 
they fly to it on very slight appearances of the symptoms and 
they acquire a habit, such as the morphia or the opium 
habit. That is how I look at it. 

And the acquisition of that habit is accompanied by 
injurious results to them, and you Bay chiefly to their hearts? 
— It spoils their hearts. 

Have you found any of the cases in which you have ordered 
it to be stopped that they have stopped it ? Sometimes 1 have 
not seen the patient again. They consult me and go. They 
take my advice or leave it as they like. 

Y'ou have said in answer to my learned friend that asthma 
tends to weaken the heart ?—Yes. 

What is the operation of the cocaine with reference to the 
heart ’—ft is a decided depressor of the heart. 

If you use a remedy which tends to depress the heart if you 
are suffering from asthma which itself tends to weaken the 
heart is that a good thing for you !—Of course, the first effect 
of any remedy, and I take it the active agent in Tucker’s 
remedy as I understand it (because I have only just learned 
the composition of it) is atropine and the first effect of this 
drug iB to diminish the 6pasm, and inasmuch as it relieves 
the spasm it relieves the pressure on the heart, but as the 
patients go on using the drug over and over again without 





358 The Lancet,] 


TUCKER v. YVAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


any directions or cautions as to how frequently it may be 
used with safety they overdo it and they suffer, and they 
suffer particularly with regard to their hearts. Their hearts 
will naturally tend to become overstrained towards the end 
of the disease and become more easily affected by the 
strain. 

Further orots examined hy Mr. Duke. —Will you tell me 
when was the first time any person who had used the Tucker 
specific came to you ’ I am afraid I could not tell you that ; 
it would be some years ago. 

When was the last time ?—I daresay it may be within a 
few weeks or a few months. 

Do you know one or the other?—No ; 1 could not tell you. 

Have you any positive recollection of seeing any person 
who has used the Tucker specific during the last 12 months ? 
—Yes, I think I have. 

Is it one or more ?—I think I have had several. 

Have you any distinct recollection of any during the last 
12 months ?—Well, I saw a patient about ten days ago and I 
Baw a patient, it may be, three weeks ago. 

Both of whom had used the Tucker specific?- Yes. 

Are both of them still using it ?—One of them had 
relinquished the remedy because she found it did not do her 
any good and she flew to some other specific. She had used 
Tucker and relinquished it. 

Because she found it had not done her any good?—She had 
used different remedies at different times. 

She did not go on with Tucker ?—I think not. 

She did not find it so overwhelmingly successful that she 
went on with it ?—Quite so. 

In the other case, did you permit that patient to go on 
using it 1—I cannot say in that particular case. I certainly 
was aware that the patient was using the drug and I said, 
“ You must use it with caution.” 

That is your recollection ; that you were aware the patient 
was using the Tucker specific and you said," You must use it 
with caution ” ?—Use it with caution. 

Have you any recollection of any other case which you can 
state to the jury except those two oases of use among your 
patients of the Tucker specific ? Yes, I have. 

Will you give me the case before that 7- It was a case a 
few months ago I saw who had been using Tucker very con¬ 
siderably and got into the way of using it too much and her 
husband consulted a throat specialist about the case and by 
his advice she had relinquished the drug, and she was the 
better for it. 

Was she suffering from asthma ?—She was suffering from 
asthma. 

Apparently she had no difficulty in giving it up ?—I 
cannot tell you. I think she had great difficulty in giving it up. 

But she did relinquish it .'—She had the courage to 
relinquish it. 

Do you know anything as to the moral circumstances, 
whether there was courage or effort ? She found it did not 
suit her?—Her husband found it did not suit her, consulted 
a specialist, and induced her to relinquish it. 

Have you seen other cases of the same kind?—Yes, from 
time to time. 

Further re examined hy Mr. Eldon Bankes.— When you 
say this lady’s husband found it did not suit, how do you 
mean, that the specific did not suit her or that she was using 
it to an extreme ?—She was using it to excess. 

And it was in consequence of that that she was taken to 
the doctor? -I cannot say. She was taken to the doctor and 
he found she was using this remedy too much and induced 
her to relinquish it. 

Sir Lauder Brunton, examined hy Mr. Hugh Fraser.— 
You are a Doctor of Medicine and a Doctor of Science, and I 
think you are a Doctor of Laws of Edinburgh University, an 
Honorary Doctor of Laws of Aberdeen, a Fellow of the Royal 
College of Physicians, a Fellow of the Royal Society, and a 
Fellow and Member of various other societies, and the author 
of numerous medical works ?—Y es. 

Has the chief 6tudy of your life been the action of drugs 
and their application as remedies of disease ?—Y es. 

You are familiar, of course, with the nature of cocaine ?— 
I am. 

Will yon just state shortly the nature and effect of cocaine 
as a drug ? 

Mr. Duke: I have not asked that question in cross- 
examination about the nature and effect of cocaine. I do not 


want to stop my learned friend from giving evidence about 
the nature and effect of cocaine, but I think it would 
shorten it. 

Mr. Eldon Bankes : It is very difficult to ask the exact 
question, but if you do not object to it we will not prolong 
the examination. 

Mr. Duke : I only wished that the evidence should not be 
prolonged. 

Mr. Eldon Bankes : We shall not prolong it. 

Mr. Justice Ridley: It is only a question of degree. I 
believe that it is recognised that cocaine is in the list of 
poisons, but poisons range over the whole Pharmacopoeia; 
nearly everything is a poison if you take enough of it. ^ 

Mr. Fraser : Is the effect of cocaine as a drug cumulative 
or not; what do you say about that ?—That depends upon 
the meaning you take to the word “cumulative.” If you 
mean by “cumulative” that the drug accumulates in the 
system I say No, but if you mean that the effects produced 
by the drug are cumulative I say Y es. The drug passes out, 
but the effects that it produces during its application remain 
behind. Shall I explain that a little more fully ? 

Please - -Cocaine is a substance that only medical men as 
a rule are acquainted with, but everyone knows the effect of 
alcohol. A man drinkBA glass of whisky ; the whisky passes 
out but the effect of the whisky remains, and if he goes 
on nipping, nipping whisky after whisky all day long, 
although the whisky has passed out of him, the effect 
remains with that man. The same is the effeot of cocaine. 
Small doses of cocaine per te pass out, but the effect they 
produce remains. 

Do you say it iB a proper drug to administer, even in small 
quantities, without caution ?—No. 

Do you say that it is proper to administer it at all except 
under medical advice and medical supervision ?—It is unsafe. 

I should therefore say it is improper. 

Will you tell me, please, why you say it is unsafe?— 
Because the effect of cocaine differs so much in different 
individuals that one man may take a large dose of it and it 
may produce no effect, and another man may take a very 
small dose of it and produce a great and unexpected effect. 
It is the same way, really, with alcohol. One glass of whisky 
may make a man drunk, and another man may take a dozen 
whiskies in the course of the day and they will produce no 
apparent effect. It is just the same with cocaine. 

Would it have to be UBed with great caution if anybody 
were suffering from heart disease ?—It should be used with 
caution in all cases, and especially in the case of heart 
disease. 

Or in the case of kidney disease !—There also it should 
used with caution. 

Or in the case of consumption?—In all those cases, the 
reason being that cocaine has a certain tendency to weaken, 
the heart, and in all those diseases that is a condition to be 
avoided. 

May a person suffering from any one of those diseases 
have asthmatic symptoms which he, the patient himself, 
might simply think indicated asthma and nothing else ?— 
Yes. 

I think you have bad submitted to you the analysis of 
Tucker's specific, and 1 think also you have seen the instruc¬ 
tions issued with the specific ?—Y'es. 

Do you say that taking the specific in accordance with 
those instructions is a safe thing to do or not?— For a large 
number of people it would be quite safe, but there are 
certain persons who would be particularly susceptible to 
cocaine, and for those it would be unsafe. If I may revert 
again to my illustration of alcohol as a well-known eng, 
there are millions of people who take alcohol all their lives 
long, and in large quantities, and are not a bit the worse, but 
there are certain persons to whom alcohol is a poison, and a 
very small quantity is enough to do them serious damage 
and to briDg on the alcoholic habit; bo it is with cocaine. 

Are you familiar with what is known as the cocaine habit T 
—Familiar in so far as f have had to acquaint myself with 
the observations of o hers in order to lecture upon it at 
St. Bartholomew's Hospital ; 1 am not acquainted with it 
personally. 

Mr. Justice Ridley - : Y'ou have not met anyone who had 
it ?—I have met one man who, I believe, had it, but it was 
only after bis death that I learnt about it. 1 did not know 
of it during his life. 

Mr. Fraser : Would this Tucker’s specific cure asthma 
or not ? 

Mr. Duke : 1 object to evidence in chief Upon this matter. 





The Lancet,] 


TUCKER v. IVAKLEY AND ANOTHER. 


[Feb. 1, 1908. 35 


There is do sort of suggestion in the p eadirgs atout this 
question ot the cure of asthma. 

Mr. Eldon Bankes : Very well, if you object, Mr. Duke, 
we will not press it. 

Croas-eicamined by Mr. Duke.—I gather that you regard 
cocaine as very much on the same footing as alcohol ?—I do 
in regard to action, not in regard to dose. 

Of course, a man might want half a pint of stout, but he 
would not want half a pint of cocaine. I have not asked 
any other witness about this. Cocaine is the product of a 
plant called the coca plant, is it not ?—Yes. 

It has been known lor generations that the native of some 
'of the States of South America chew the coca plant because 
of the sustaining influence its products have upon the 
system ?—Precisely as people here take a glass of whisky. 

They chew the coca plant because of its sustaining 
iulluence upon the system ?—Because it makes them 
insensible to fatigue. 

It is quite a national habit among those people in South 
America, is notit'!—Just as much as whisky is in Scotland. 

Now you are bringing things to their proper proportion. 
Those natives in South America do not die of it ?—And the 
natives of Scotland have a way of living, or many of them, 
in spite of the whisky. 

Mr. Justice Ridley : Are you a Scotchman !—I am. 

Mr. Duke : They are a very tough, robust race, the Scotch¬ 
men, in spite of their whisky-. Those tribes in South 
America who have discovered the virtues of the coca plant 
have the credit of being exceptionally tough, robust people 1 
—I am not aware that they have, 

As a matter of reading do not you know that attention 
was called to the coca plant by the discovery of the great 
strains and fatigues that the tribes could bear who used it 1 — 
I have not understood your question rightly; I did not hear 
it rightly ; but the reason, I quite agree, for which they use 
the coca plant is because they could undergo fatigue with¬ 
out feeling it. But exactly in the same way a man will go 
on doing extraordinary exertions with alcohol in various 
forms, but that does not say that alcohol thereby is prevent¬ 
ing fatigue ; it prevents him from feeling it. 

Do not let us try alcohol in this case. Some of us take it 
with our lunch and we do not want to be disheartened. Does 
it come to this, that alcohol may be abused and cocaine may 
be abused ?—It does. 

With regard to the cocaine, take l/20,000th part of a grain 
diluted in a volume of vapour, which would fill the lungs ; 
would you, as a scientific man, speak of that as a poison ?— 
Yes, it is a poison. 

You would, really I You would say that a man who re¬ 
ceived into his lungs, diluted with a volume of vapour which 
filled the lungs, l/20,000th part of a grain of cocaine was 
undergoing poisoning !—It depends upon-- 

I wish you would tell me.—Well, I should say yes ; and 
may I elaborate that by saying this : I do not care about the 
question of dose, because dose is not an amount. A dose is 
something that acts upon the individual, and the influence 
upon one individual will not be the same upon another. 
As an instance of how far an infinitestinal dose, a mere snilf, 
will act upon one, take nitrite. We know that in Tucker's 
cure there is nitrite of sodium. I shall take another 
nitrite, which is volatile. Take the nitrite of amyl ; if 
anyone cares to test it by one sniff they would soon find 
that an infinitesimal dose will produce the most marked effect. 

Mr. Justice Ridley : And undoubtedly, I suppose, if you 
could get a snilf of prussic acid you will die ?—Well, 1 do not 
know. 

There are some poisons which are fatal in whatever quantity 
you take them ?—No, my lord; it is a question of dose in 
every one, even with hydrocyanic acid. 

Bnt with the smell !—If you get enough smell of hydro¬ 
cyanic acid you may get enough into the lungs to kill a man. 

Mr. Justice Ridley : Then all these poisons are a question 
of degree ? 

Mr. Duke : I should have thought so. I want to bring it 
down to the question of degree. Anyhow, you have told us 
a man inhaling in a volume of vapour that fills his lungs 
l/20,000th part of a grain of cocaine is undergoing poisoning. 
None of the 25,COO people who have used these things seem 
to have been poisoned by this. How would you explain that? 

_You can briog from this country not only 25,000 but, I 

should say, 5,000,000 of men who have been taking the 
poison alcohol all their lives and who have not undergone 
poisoning. 

Very well, I will accept it, and now let us pass on. You 


lave given me an instance of l/20,C0Cth part of a grain. 
What is the smallest dose of cocaine recognised in the 
faculties of medicine as producing any medicinal effect - 
That I cannot tell you, for this reason, that there are no 
definite experiments to ascertain the maximum dose. 

It is stated in Squire's Pharmacopoeia. The question of 
doses depends not merely on the amount taken but upon the 
way it is takeD. The dose that is stated in the Pharmacopoeia 
I think is about one-twentieth to one-half, but that is 
intended as a rule to be something taken by the mouth. 
Any Ihing taken by the lungs acts much more quickly, but I 
believe that we should ascertain the truth much more simply 
by getting rid of the question of dose entirely, and if any 
gentleman of the jury wishes to ascertain what one single 
whiff of a nitrite is like, and I say again there are nitrites 
which are one of the constituents of this cure, let him just 
take the stopper out of this bottle and take one whiff ; that 
will convince him there is a definite action to be got from an 
infinitesimal dose. 

I will bring you back from your nitrites to the matter I was 
asking you about. You know that the smallest dose of 
cocaine that is mentioned in Squire’s Pharmacopoeia as being 
capable of producing any medicinal effect is one-twentieth of 
a grain taken directly into the stomach ?—I beg your 
pardon, that is your minimum dose, but that is an entirely 
different thing. 

Is not that minimum dose the smallest quantity that can 
be expected to produce any medicinal effect ?—No. 

Then why is it the minimum dose ?—Because it is the 
minimum usual dose for the average of mankind, but there 
are exceptions in whom that minimum dose may produce 
very unexpected and unpleasant results. 

In one million, according to your judgment, how. many of 
those exceptional persons are there ?—I have no statistics to 
go on, and such statistics do not exist; therefore I cannot 
answer the question. 

In your experience how many persons do yon know would 
be affected medicinally by one-twentieth part of a grain of 
cocaine ?—I have not known one, because I do not prescribe 
cocaine internally. 

Mr. Justice Ridley : But have you known instances ?—No. 
If I am asked, Have 1 known an instance, I can tell you of 
one where a hypodermic injection of an ordinary quantity 
of some preparation of cocaine into the gum produced com¬ 
plete paralysis of the respiration lasting for 12 hours, so that 
artificial respiration had to be kept up. 

Mr. Duke : Surgical operations are prone to suffer from 
accidents of that kind, are not they ?—One does not usually 
consider the extraction of a tooth as a surgical operation. 

It so happened that there was something abnormal, and the 
result of a somewhat simple operation was paralysis of 
the jaw?—No, nothing of the sort. The injection of 
cocaine took place before the extraction of the tooth ; 
it was put into the gum in order to render the gum 
anesthetic and free from pain from the extraction. 
The tooth was not extracted, but the patient, a healthy man, 
was at once thrown into such a condition of collapse that he 
had to be laid on the floor aDd artificial respiration had to be 
kept up for 12 hours, he koowiog all the time that if they 
ceased to keep up that artificial respiration he would die, yet 
he being perfectly unable to move hand or foot. 

Have doctors gone on using cocaine for the operation of 
tooth-drawing?—They have. 

Although the tooth can be drawn without any alleviative 
at all, and in the case of poor people in the country districts 
commonly is drawn In that way ?—It is so. 

Is not that a fair test of the real danger there is, even from 
such a matter as the injection of pure cocaine into the jaw ? 
—I should say not. 

Then will you reconcile the practice of the doctors in that 
plain manner with the terrifying evidence which is presented 
here of the possibilities of the use of cocaine !— The reason 
is simply this, as I have said before, that some men are 
particularly susceptible to the action of cocaine. You cannot 
tell beforehand what thoee men are, and the number of these 
exceptions is small. People will go on taking the risk 
rather than face the certainty of pain in the extraction of 
the tooth. 

And do the doctors take the risk, although they know it 
exists?—Dentists take the risk for one reason. 

Mr. Justice Ridley: Because it is small?—Yes; and, 
moreover, these cases are not made known. 

Mr. Duke : But the dentists know them ?—They do not 
know all of them. 

But they know of some of them ?- -They know of some of 




360 The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


them, but it is not to the credit of the dentist to publish 
these cases, and so many more of these cases exist than are 
published, so that the other dentists do not know the risk 
to the full extent. 

Mr. Justice Ridley : I think we had better get back to the 
point. 

Mr. Duke : Had not yon better recommend the dentists to 
The Lancet, do not you think ? 

Re-examined by Mr. Eldon Bankes —Even in modern 
practice the use of cocaine in dentistry is not followed to the 
extent it was ? I do not think so. 

Mr. Duke : That is a leading question. 

Mr. Eldon Bankes : You have been asked about the 
natives of America chewing the coca plant —Yes. 

Is cocaine the concentrated extract of the coca plant 1— 
It is the active principle, yes. 

And of course it would be in a very different degree of 
strength from what it would be if the leaf was chewed ?— 
It is. 

Henry Alexander Francis, examin'd by Mr. Eldon 
Bankes. —You carry on your profession at 2, HeDrietta- 
street, Cavendish-square !—Yes. 

Mr. Justice Ridley: What are you?—A Bachelor of 
Medicine and Snrgery, Cambridge. 

Mr. Eldon Bankes : I think you have full Cambridge 
qualifications and are a Member of the Royal College of 
Burgeons and a Licentiate of the R >yal College of Physicians, 
London ?—Yes. 

I think for some considerable time you have devoted your 
attention largely to the treatment of asthmatic cases?—Yes, 
about 11 years. 

And a very large number of people have consulted you with 
reference to asthma 1—Yes. 

And amongst those patients have you bad a considerable 
number who have been using the Tucker treatment ?—I have 
a large number. 

Before T come to your actnal experience with those 
patients I want to ask you generally about this specific. 
You know of what it consists, do you 7—I have heard analyses 
and I have heard it in court here. 

Have you heard of analyses of it before you came into 
court?—Roughly, yes. I have seen printed formulae which 
are reputed to be the analyses ; I never took much interest 
in them. 

What do you think are the active constituents of this 
specific?—From what I have heard and what I have seen, I 
should say chiefly cocaine, atropine, and hyponitrous acid— 
the nitrite element in the form of sodium nitrite. I did not 
know it was sodium nitrite. 

Mr. Justice Ridley : We do not want all these over again. 

Mr. Eldon Bankes : I will ask you genera ly, Do you 
agree with what has been said by the medical witnesses you 
have heard with reference to the action of cocaine ?—Yes. 

So I need not go though it in detail. In your opinion is 
cocaine a dangerous drug to use except under very careful 
supervision ?—Very. 

Do you think that the use of this Tucker specific with the 
instructions that accompany it is likely to cause injury in 
certain cases ?—I do. 

What would be the nature and kind of injury you would 
expect to find having regard to these constituents of the 
specific?—I could deal better with the injury that I have 
found than the theoretical injury. 

From your experience what do you find is the injury to 
patients from the use of this specific ? 

Mr. Smith : I should like to refer to the pleadings on 
that. I do not know how far my learned friend proposes to 
go on this line of question. We are now coming to par¬ 
ticular observations made. If we had had warning on the 
defence that any issue of that kind was going to be raised it 
would have been perfectly easy for us to have had hundreds 
of people here who have used it instead of a limited number. 
It is a new case altogether against me. 

Mr. Eldon Bankes : It is evidence of our statement that 
these drugs are dangerous. I do not mind whether I give it 
as the result of the doctor’s actual experience or whether I 
ask generally what bis view Is in regard to it. 

Mr. Justice Ridley : Evidence of your statement that they 
are dangerous ? 

Mr. Eldon Bankes : Yes. 

Mr. Smith : That is in the amended defence, it was not in 
the original defence. The only statement relevant to that 


point is : “The constituents of the said specific are cocaine 
and atropine.” That is the original defence, and added to that 
is "which poisons are dangerous if used without medical 
advice.” In a plea of fair comment surely if the case to be 
set up by the defence was going to be that the use of this 
specific had in fact produced deleterious consequences to 
persons who made use of it, we ought to have been given 
some warning so that we might have dealt with that in our 
own case or made arrangements to deal with it. As my 
learned leader reminds me I do not recollect any cross- 
examination of the plaintiff adequate to suggest that that is 
the line to be adopted by the defendant. 

Mr. Eldon Banks : I suggested to him it was extremely 
injurious to the patient’s heart and very improper to use it 
in cases of heart trouble. 

Mr. Duke : This is a very material matter. It is sought 
now, as I understand, to give evidence of some specific 
instance. 

Mr. Eldon B inks : No, not of specific instances at all. 

Mr. Duke : Well, even worse than that, to make a general 
statement that certain persons within or without the know¬ 
ledge of the witness have been injured by the use of this 
specific. There is no possibility of effectively cross-examining 
to it, and there is no possibility of rebutting it. There is 
no knowledge as to who the persons are so that they could 
have bean Been, or it could be ascertained whether they 
had used the specific or not, and we have not had the 
opportunity, 

Mr. Justice Ridley : You do not call anyone who was 
injured by it. 

Mr. Eldon Bankes : I do net call any one of this gentle¬ 
man's patients. 

Mr. Justice I id .ey : Then I think I must say it is very 
objectionable eeidence, but 1 think I must admit it. 

Mr. Dokb : But how am I to deal with it ? 

Mr. Justice Ridley : I do not know indeed, but I think 
we must take it. I think it is a very objectionable form. 
I think particulars should have been given of this. You 
charge the man with fraud, but this is not the way to prove 
fraud. 

Mr. Duke: It is said that the plaintiff could be charged 
with fraud for certain things. Now it is proposed to give 
evidence that certain persons, with or without his knowledge, 
have or have not used the specific. 

Mr. Justice Ridley : I think I must take the evidence, but 
I think it is very objectionable. 

Mr. Duke : I submit it is inadmissible. Here is a plain 
issue of fraud, and this is evidence which is not relevant to 
any of the questions raised. 

Mr. Justice Ridley : I think I must receive it for what it 
is worth. 

Mr. Eldon Bankes : I propose to put the question in a 
form in which I think my learned friend ought not to object. 

I ask you as a medical man whether or not the use of this 
specific is likely to be dangerous ?—Certainly. 

I ask you to explain what, in your opinion, you mean by 
dangerous, and how it affects patients or is likely to affect 
patients ?—The chief effect observed is on the heart. Cer¬ 
tainly you would say that the patient when he has further 
attacks of asthma is much more likely to have heart com¬ 
plication and heart embarrassment than he would have bad 
previous to his using Tucker. Another thing is when they 
have used it for a great many years so that they have had an 
accumulation of the remedy the nervous system generally 
becomes much affected and the muscular system also later 
on, but I think that the most important observation is the 
weakening effect on the heart. 

l-i that what you would expect to find from the frequent 
and repeated use of this liquid containing the constituent 
which we now know it to contain ?—It is exactly. 

Have you in your experience observed that that is the 
effect of it ? 

Mr. Duke: You understand that you are asking these 
questions at your own risk. 

Mr. Eldon Bankes : Certainly. 

The Witness : That is quite a common experience. 

Is asthma a very distressing complaint ?—Very. 

Is this specific one that is likely to relieve the attacks of 
asthma ?—I have never seen anything that will relieve a 
mild attack of asthma so readily. 

Aod to what do you attribute that?—1 attribute it to the 
specific. Until recently I have not really thought whether 
it was atropine or the cocaine, or the nitrite of soda. I 
think it is all three, especially as the imitations do not seem 




The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 361 


to do it when the; leave out the cocaine, or one of the 
others—the; do not seem to be so effective. It is the cocaine 
of the three I should say. 

Mr. Justice Ridley : Is that a new idea to apply the three 
drugs 1—The action of each of the drugs is very similar on 
the circulation. 

Mr. Justice Ridley : I wish you would answer the 
question. 

Mr. Eldon Bankes : My lord asked if it was a new 
combination of those three drugs. 

Mr. Justice Ridley : Have you ever known anybody to do 
it before?—Not to my knowledge, but there are certain 
remedies which are supposed to be exactly the same. 

I did not ask any such question. 1 wanted to know, as you 
know well, if this was a new invention or prescription. You 
did not know it before, is the answer ; then it was new.—I 
am sorry I do not gather your question even now. 

Mr. Eldon Bankes : Given the fact that it produces 
immediate relief in this way, in your opinion is a patient very 
likely to make frequent use of this inhaler 1 —Yes. 

Is it a very frequent use of the inhaler which leads to the 
result which you have spoken of to the jury ?—In my opinion 
it is the frequent use. 

Mr. Justice Ridley : We have had all that before. We 
know about the action of cocaine. 

Mr. Eldon Bankes : I believe for some time you have 
realised the daDger of using cocaine in connexion with 
asthma ? 

Mr. Duke : Does it matter whether he has or not? It is 
quite immaterial to the issue in this action whether this 
gentleman has realised it or not. 

Mr. Eldon Bankes: 1 was going to ask another question 
npon that. 

Mr. Justice Ridley : The question here is fraud and 
nothing else, as I have said over and over again. 

Cross-examined by Mr. Duke.—Y ou have said that certain 
symptoms were what you would expect to find from the 
frequent use of Tucker’s specific and that it is common 
experience that those symptoms follow its use ?—Yes. 

Will you write down the name of the person in whose 
case you say to your knowledge that last happened ?—Will 
you tell me the symptoms again ? 

I want the name and address of the person in whose case 
you say this consequence you have been speaking of last 
happened ? 

Mr. Eldon Bankes : Of course, it is not for publication? 

Mr. Duke : Of course not. 

Tne Witness : I should have to refer to my notebook for 
the address. I can give you his name. 

Mr. Eldon Bankes : Do you want the address ? 

Mr. Duke : I probably shall, because I am going to see 
whether there was any such person. 

The Witness : I believe the number is 29. I can tell you 
by referring to my case book. 

I am not suggesting that there will not be any person of 
the name you mention, but X am going to inquire about it. 
(The Witness wrote the name and handed same to counsel.) 
Will you also give the date ? It is the last person you saw 
about this matter. Tell me when you saw him first as nearly 
as you can, and when you saw him last. It is the last 
patient in whom it is said these distressing symptoms had 
arisen.—I shall require my notebook to tell you when I 
saw him first and when I saw him last. 

Tell me about—The one I am thinking of was on Friday 
in the week before last. 

Y'ou have the name here ?—Yes ; that is speaking from 
memory as to the date I saw him last. 

When do yon suggest that the gentleman you have named 
here had used this specific 1—He used it up to the time he 
came to see me first. 

How long was that ?—He had been using it for five years, 
speaking from memory. If you had given me notice I could 
have brought my notebook here. As far as I know he had 
been using it for seven years and for five years it had no ill- 
effects. in the last two years he was getting worse and he 
came to see me. I told him I understood he was using it 
too frequently and I advised him very strongly to reduce the 
number of times at which he used it, because I believe if you 
use it not more than twice in the 24 hours it will do you no 
harm. He took my advice more strictly than I meant and 
has stopped it altogether; I believe from that moment he 
has not used it. 

Y'ou mean he has ceased it altogether ?—I believe he has 


ceased to use it. I told him it was injurious to use it too 
much and I think he has stopped it. 

He was a man who bad used this specific for five or seven 
years without becoming in any way dependent on it I—In his 
particular case not at the last. 

Do you mean there was some great effort required ?—Y’es, 
very great effort. 

Did the great effort arise from the fact that he had 
recurrent paroxysms of asthma ?—No, I do not thiDk so ; it 
was necessary tor him to stop using Tucker. 

Does he still suffer from asthma !—He still suffers from 
asthma. 

How long has he been a sufferer from asthma ?—I do not 
know. 1 can tell you if I have my notebook. 

Where is your notebook ?— It is at my rooms. 

You have not got it here .'—No. 

You knew you were coming here to make this attack 7 

Mr. Eldon Bankes : Is that a fair thing to put to 
medical man ? 

Mr. Duke: Certainly it is an attack. You regard it as an 
attack, do not you I—I regard it as a danger to certain 
patients. 

Mr. Eldon Bankes : The question is, Do you consider 
your evidence an attack ? 

Mr. Justice Ridley : It is an attack made upon Mr. 
Tucker ; he is charged with fraud. 

Mr. Eldon Bankes : If a witDeBs comes and gives evi¬ 
dence on Bubpcena surely it is not fair to say it is an attack. 

Mr. Duke : 1 take it you have given the defendants’ 
solicitors a proof of your evidence ?—Not with regard to this 
particular case. 

But you have given them a proof of everything you thought 
material ?—Yes. 

You did not think it material to give them a proof of this 
matter you have mentioned ? —I thiDk you will find I said 
that in certain cases it had had a distinctly harmful effect. 

Did you know you were coming here to help to support a 
charge of fraud against Mr. Tucker ?—I knew what was said 
in the libel. 

I wish you would tell me. You did know you were coming 
here to help to support a charge of fraud against Mr. Tucker ? 
—If it is a charge of fraud. I came here to give evidence 
from my experience of Tucker on behalf of The Lancet. 

Did you regard it as a charge of fraud 1 —I did not think of 
it one way rr the other. 

Did you know that the action was broaght by Mr. Tucker 

because he had been charged by The Lancet with fraud ?_ 

I was not aware of that till I arrived here. 

But you know it now ?—Yes. 

And you are here to give evidence in support of the people 
who made the charge ? —To say that a remedy such as Tucker 
is harmless when, as I consider, with the exception of one or 
two drugs, it is the most dangerous remedy you can obtain, I 
should say it was a deception. 

Were you here to hear the evidence of numerous people 

who said it was not only harmless but most beneficial ?_I 

did not hear it, but I can quite believe it; I think numbers 
would say it is most beneficial. 

Have you administered it yourself or not ?—What do you 
mean by “administered”? 

Recommended it.—In a very great many cases I have told 
patients that they can use it—not those who have never used 
it before, because I think it is one of the most daDgerous 
remedies, to begin with, you can find, but those who are 
using it 1 dc tell them they can use it, as far as I can see with 
absolute safety, so long as they do not use it more than 
twice, or at most more than three times in 24 hoars. I have 
told case after case the same thing. 

Then patients of yours with your approval are using this 
deadly preparation two or three times in the course of 24 
hours ?—Yes. 

Mr. Justice Ridley : How many sniffs each time?_I 

always tell them, instead of following the directions to take 
as much as they can get into their chest each time, that they 
must be content with as little as they can do with, and with 
one or at the most two sprays will have as much effect as a 
great many, and patients tell me they find it is practically 
what I say. 

Mr. Duke : They are to use it so as to procure the imme¬ 
diate relief from asthma, and that is what you tell them to 
do ? If it can be done in two or three inhalations to leave it 
at that, but if it required more ?—To leave it altogether. 

That is not what you said ?—I tell them if they cannot be 
content with two or three applications in 24 hours, using it 




362 The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


two or three times at the most instead of blowing themselves 
up with it, that they had better desist from using the 
remedy entirely. 

I am asking you as to the two or three times, not blowing 
themselves up with it. Do you leave them upon each 
occasion of inhalation, that is of the two or three times a 
day, to inhale until the attack is relieved or until the 
paroxysm is relieved ?—tf they cannot get relief from two or 
three inhalations they must not go on and fill themselves up 
with it. 

Do not you know that it is exceedingly difficult to many 
people to inhale at all. that ordinarily it is a difficult thing 
to inhale effectively ?—Well, they require a little practice. 

I come back now to the gentleman you spoke of.—I think 
I can tell you his previous address. 

He seems to be a gentleman who received the treatment in 
July, 1900, and the balance of his supply of fluid in 
January, 1901 ; is that the gentleman ?—Very probably. 

Do you know his initials 7—I rather fancy it is C., or C.E 

Do you know where he had been living before ?—He had 
been in St. Andrews. 

Then we may take it it is the same person ?—It is the same 
man, I think. 

We may take it from you that this is a gentleman whom 
you advised not to use the inhaler more than two or three 
times a day. When was that ? 

Mr. Justice Ridley : It was last week, was it not?—No; 
some three or four months ago. 

Mr. Duke : He told you that for five years he used the 
inhaler and derived undoubted benefit from it. 

Mr. Justice Ridley : That is three or four months ago?— 
I believe so; I cannot remember exactly. It was three or 
four months ago I saw him first. 

Mr. Duke : He told you that for five years he had used the 
inhaler and derived undoubted benefit from it ?—As far as I 
remember. What makes me fix the five years is because in 
the history of the man’s case he told me that two years ago 
he had been very strongly urged by a doctor to desist from 
using this remedy, because the time would come when he 
would be sorry, and it would break him up. 

What is his time of life ?—I suppose he is 50, perhaps 
older—55. 

What is he suffertng from ?—Asthma. 

Anything else ?—Practically nothing else. 

Any trouble of the heart ?—He has had very great heart 
symptoms. 

For many years ?—I could not tell you that without my 
book. 

Has he suffered from heart symptoms all the time ?— 
Certainly latterly, the last few years. 

But I am asking you now ?-I cannot tell you without 
seeing the man again. 

How many times did you see him ?—I suppose I have seen 
him roughly six to ten times so far. 

When you came to advise him with regard to the specific 
knowing that he had heart symptoms you advised him to 
use it not more than two or three times a day ?—May I 
explain ? 

Is that the fact ?—Yes. 

Yet you say this is a thing which he ought not to have 
used at all; is that so ?—Not as you put it. 

But you say it is a thing he ought not to have used at all ?— 
He would be better without using it at all and I told the man 
several times he made a mistake to stop using it suddenly 
because he went into a very serious condition as a result of 
lacking the immediate stimulating effect of the use of it. 

He was worse after he left off using it ?—For the time 
being. 

For how long ?—Nearly ten days or a fortnight I suppose. 

After that did you find some substitute for him ?—I found 
a remedy. 

What remedy did you give him ?—I treated him in my own 
method of treating him. 

Is that a method of burning the nose ?—It has to do with 
burning the nose and general health and diet. 

Having used the inhaler beneficially for years, and being 
put off it, and being the worse for it I suppose he had his 
nose burnt 7—You put it in that way, but that is not quite 
correct. 

That is accurate, is it not ?—No. 

He had used it in the early years with benefit ?—He had 
used it in the early years with benefit, but when he came to 
•me he was in a very serious condition indeed, I considered, 
from the use of the remedy and the return of the asthma 


which be had very seriously. The man has not any heart 
disease, but he has heart weakness which is the result 
partly of the asthma, and which has been aggravated, in my 
opinion, by the use of the Tucker. 

Does not that depend entirely on whether the Tucker 
counteracted the effect of the asthma?—But it did not, 
that is the point. By the time he came to me it had little or 
no effect upon him. Yet he could not stop using it as I have 
found in several cases.- 

But you found that he did stop using it?—After I had 
urged him. 

He had not had his nose burnt until he stopped using it ?— 
Well, not until I burnt it. 

You stopped him using the Tucker, and burnt his nose 
instead ?—Yes. 

He examined by Mr. Eldon Bankes.—M y friend wishes 
to make a joke of this case, but at the time the gentleman 
came to you wa9 he in a serious state of health ?—Yes, he 
was in a serious state of health. 

Did you ascertain how frequently he was using the specific 
when he came to you 7—Practically using it constantly. 

What do you mean by constantly ?—20, 30, or 40 times a 
day. I am speaking not of the exact number of times in 
thit particular case, but I imagine from what he told me he 
used it from 20 to 30 times a day. 

Is that a condition in which a patient might very likely 
get, in your opinion, if he was using this stuff without 
warning ?—Yes. 

You told him that he had better stop it and use it only 
two or three times a day; but you say he stopped it alto¬ 
gether ?—Yes. I had intended he should use it two or three 
times a day ; that was to break him of it. My intention was 
to Btop it as I had with other patients. 

When he dropped it, you Eay he got into a very serious 
condition indeed. What is that due to ? I put it down 
chiefly to nervous exhaustion and heart trouble that he 
suffered from more than the asthma when he stopped the 
remedy. I put that down to the lack or want of the stimu¬ 
lating effect, the immediate stimulating effect of the drugs 
which he had been using. 

Is that the condition of things you find in a patient 
suffering from any habit of this kind ?—Exactly. 

If you stop it immediately there is a temporary collapse ?— 
This man went into a very similar corresponding condition to 
a chronic alcoholic case ; if you stop his liquor altogether 
he is quite likely to go into a state of delirium tremens, 
and stopping this man’s Tucker in that way had a similar 
effect. 

Augustus Joseph Pepper, examined by Mr. Hugh 
Fraser.— Y r ou reside at 13. Wimpole-street, Cavendish- 
square! I think you are a Master of Surgery, London, a 
Bachelor of Medicine, a Fellow of the Royal College of 
Surgeons, England, and surgeon to St. Mary’s Hospital? — 
Yes. 

1 think you have had submitted to you the analysis of 
Tucker's specific prepared by Dr. Willcox ?—Yes. 

And you have seen the instructions and the pamphlet ?— 
Yes. 

Y’ou are familiar with the nature of these drugs, cocaine, 
atropine, and so on ?—Yes. 

Wbat is the action of cocaine?—Locally an amcsthetic; 
internally a heart depressant. 

Is it a drug that can be properly used even in small doses 
except under medical advice?—No. 

Is it a drug which requires to be used with the greatest 
care even in small doses in the case of a person suffering 
from heart disease 7—Certainly. 

Or if a person is suffering from kidney disease ?—Cer¬ 
tainly. 

Or from consumption ?—Yes. 

Is it not the case that if a person is suffering from any one 
of these diseases which I have mentioned he may have 
asthmatic symptoms?—Certainly; we speak of them as 
cardiac asthma and renal asthma. 

And the ordinary layman who is ignorant of things medical 
might very well think he was merely suffering from asthma ? 
—Certainly ; I should say in nine cases out of ten where the 
ordinary public think they are suffering from asthma they 
have no true asthma at all ; it is merely a symptom of 
another disease, a more general disease. 

Y'ou are familiar with the analysis of this specific ?— 
Yes. 



Thb Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 363 


In jour opinion, would the use of it be likely to be 
dangerous ?—Certainly, if used indiscriminately. 

Mr. Justice Ridley : That is what he has already said. 

Mr. Fraser : I have not asked him the question with 
regard to the specific. 

Mr. Justice Ridley : It conlfi not be used without proper 
medical advice. 

Mr. Fraser: That 1 b in regard to cocaine. I did not ask 
with regard to this specific. Will jou just state shortly the 
reasons why, if it was sold to the public indiscriminately, it 
would be likely to be dangerous ?—In the first place they 
would be inhaling it in many cases where they think they 
have true asthma and where the asthma is only a sjmptom 
of a far more dangerous condition. Very often it is a symptom 
dependent on organic heart disease or of advanced kidney 
disease. 

In those cases what would be the effect?—The effect would 
be much more pronounced upon the general constitutional con¬ 
dition of the patient than if it was purely a case of asthma. 

Would the effects be Injurious or not ?—Much more in¬ 
jurious. 

Orost-txamintd by Mr. Duke.— I suppose you have not 
administered, or caused to be administered, this specific to 
any of your patients ?—No. 

You know that a large number of specialists do give this 
specific to their patients for asthma ?—No, I do not. 

Is not it well known to be the most effective remedial 
agent for asthma there is?—Not to my knowledge. 

Do not you know that ?—No. 

Wbat do you suppose led Oppenheimers to introduce an 
imitation of this specific and to describe it as a specific for 
asthma if the thing was not being called for by the medical 
profession ?—I do not say it has not been called for ; prob¬ 
ably it has, but you are asking my experience and knowledge 
and I tell you I have not any. 

Have you any doubt at all that it has been largely called 
for by the medical profession !—I have not sufficient experi¬ 
ence to form an opinion upon it. I have no doubt it has been 
very largely used. 

I am not asking about largely used. I am asking about its 
extensive user by the medical profession. You have no doubt 
it has been ?—I have said just the contrary ; I have not suffi¬ 
cient knowledge to form an opinion. 

Do you know one way or the other ?—No. 

Do you know you come here to help to support a charge of 
fraud against Mr. Tucker ?—I know I come here to speak the 
truth and to give my opinion of the action of these drugs. 

I did not ask you that.—I do not think it is a question for 
me to answer in regard to the fraud. 

Did you know that the charge against which Mr. Tucker 
came to defend himself was a charge of fraud ?—Certainly. 

Did you come here to help to maintain that charge of 
fraud ?—Yes, in the belief that it was a charge of fraud and 
that it was a fraud. 

That is wbat I asked for and that is a candid answer. 
Will you tell me whether you would charge a man with fraud 
who believed this to be the best remedial agent there is and 
who sold it in that belief ?—In the conditions in which it is 
sold, certainly. 

Whether he believed it or not !—Certainly. 

However innocent he might be of any intention to mislead, 
you would think it was proper to charge him with fraud ?—I 
could not acquit him of intention at all. 

Although the regulations are written by a member of your 
own profession ?—The description of the action of the 
drug I should say : I am not speaking of the regulations 
so much. 

And the description of the action of the drug is written by 
a member of your own profession. 

Mr. Justice Ridley : It seems to me it is perfectly right 
as to the description of the action of the drug. Why do you 
say It is wrong?—I say it is a distinct falsehood. 

It has been proved to be the truth. Do you mean the 
healing of the mucous surface 1 —Certainly. 

But it does —It does not. 

Well, I do not know about that - As a matter of fact it is 
jnst the opposite. Cocaine applied locally diminishes the 
healing process, and very frequently surgically 1 have not 
used cocaine because it frequently delays the healing process. 

I am not speaking of cocaine; X am speaking of this 
specific. It certainly removes and causes the attacks to cease. 
I suppose that is because the mucous surface is benefited ?— 
The word is “healing” the mucous surfaces. There is no 


interpretation applicable to that other than that the mucous 
surface is broken ; so it cannot be healed. 

No ; not at all.—It is so, my lord. 

Mr. Duke : Take the case of a patient suffering from a 
violent paroxysm of asthma. Does that affect the mucous 
surface ?—It causes it to be congested. 

Mr. Justice Ridley : One witness said that before. I must 
say it never would occur to me that it meant a cut or a 
break in the surface in that sense. 

Mr. Duke : Everybody knows what is suggested. 

Mr. Justice Ridi.ky : You can speak of healing a disease. 

The Witness : It is not a question of healing a disease. 
Stated here, it is healing a surface. 

Mr. Justice Ridley : I will not argue about it with you; 
it is for the jury to deal with. 

Mr. Duke : Does asthma affect the mucons surfaces ? 

Mr. Justice Ridley : Because he uses the word “ healing,” 
which you do not think applicable, it is a fraud ; is that it ?— 
The learned counsel put the question to me on the question 
of healing ; I say it is not true. 

Mr. Duke: Fraudulent mis-statement; that is your view 
about it ?—If it is written by a medical maD, as you tell me, 
he must know that the mucous surface is not broken. 

Mr. Justice Ridley : You recognise no value in what I 
am putting to you, that the word “ heal ” may be used 
without a wound?—Not in connexion with those words; it 
is healing a surface. 

Suppose there is an inflammatory condition of the surface 
cannot you speak of healing that ! Surely you can ?—That 
is not the sense in which it is understood by a medical man ; 
I cannot say any more. 

You do not seem to understand, or you will not.—Pardon 
me, I do. 

Be careful, Mr. Pepper.—I am perfectly careful. 

Mr. Duke : Take the case of a man suffering from a 
violent paroxysm of asthma, does that affect the mucous, 
surface, the mucous membrane?—It causes congestion. 

Is that an unwholesome condition ?—Y'es. 

Does the relief of the attack of asthma remove that un¬ 
wholesome condition ?—Yes, by removing the spasm. 

Is not that a healing of that unwholesome condition ?— 
But it is unlikely- 

I wish you would answer the question ?—Yes. 

It is a healing of that unwholesome condition ?—For so 
long as it lasts. The action of the drug is to diminish the 
spasms and the atropine causes a contraction of the blood 
vessels, but there is an inevitable relaxation afterwards, 
and therefore it is only a temporary relief of the con¬ 
gestion. 

Do you mean that when the asthma has been relieved by 
the specific as soon as the effect of the specific has passed 
away the asthma recurs ?—No, I do not. 

I did not suppose you did. Do not you know that the 
attack of asthma may be relieved by the specific and pass 
away completely, and that there may be no recurrence of it 
for months ?—It is quite possible. 

Then why do you say that there is only a temporary 
healing of that unwholesome condition ?—Because it is the 
fact. 

Mr. Justice Ridley : But temporary or not, it is a 
healing. 

Mr. Duke : It is a temporary condition, is not it ?—The 
congestion is a temporary one due to the spasm. 

I quite follow. It is not a condition in which there is an 
abrasion or a laceration ?—No. 

it is a congested condition which needs to be removed ?— 
Yes. 

And everybody who knows anything about asthma knows 
that that is so, does not he .'—I cannot vouch for anyone. 

But do not you think that any intelligent person who had 
suffered from asthma or who had seen a victim of asthma in 
a paroxysm would know quite well that there was some 
internal cause which was spasmodic in its action?— 
Certainly. 

And which was not a case either of laceration or abrading 
the surface of the organs ? Are you speaking of the opinion 
of a medical man ? 

I am speaking of any intelligent person who knew anything 
about the matter ?—Yes ; if he knew anything about the 
matter. 

Do not you think there are people in the world besides 
medical men who]may have a little common knowledge about 
asthma?—Very common, 1 should think it would be. 

And, unfortunately, asthma is very common ?—Yes. 




364 The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908 


And, unfortunately, the failure of the medical profession to 
relieve it iB very common, is not it ?—I daresay. 

Reexamined, by Mr. Eldon Bankes. —You were asked a 
question which 1 could not ask. Y'ou were asked whether 
anybody could honestly speak of dealing with this system as 
a fraud ?—Yes. 

Before giving your answer had you carefully read these 
instructions and considered the nature of the specific and its 
possible effect ?—Certainly. 

Have yon personally any feeling against Mr. Tucker at all? 
—Not at all. 

Did you only come to the conclusion which you expressed 
to Mr. Duke after considering those materials 1 —I did. 

Whether it is right or wrong you still honestly hold that 
view ’—I do, certainly. 

In your opinion is the indiscriminate sale of this specific 
liable to cause real serious mischief and injury to the persons 
who buy it?—Certainly, I think it is pernicious and vicious. 

And fraudulent ? And fraudulent. 

Arthur Robertson Cushny, examined by Mr. Eldon 
Bankes. —I think you are a Fellow of the Royal Society, an 
M.D. of Aberdeen, Professor of the University College, 
London, and late Professor of Materia Medica and Thera¬ 
peutics of the University of Michigan ?—Y'es. 

I think you have made a special study of poisons, have you 
not ?—Yes. 

I do not want to go through the whole thing, but I want 
to ask you generally, do you agree with the opinion that has 
been expressed by Sir Douglas Powell about cocaine I Did 
you hear him give his evidence ?—I heard Sir Douglas give 
bis evidence. I agree in the general features. 

In your opinion is it a dangerous drug to sell without 
careful precaution ’—Certainly. 

One point I want to ask you about, and that is this : With 
regard to absorption into the blood of a poison if it 1 b 
administered in the form of a spray, is that a form in which 
the poison is rapidly absorbed ?-Yes, most rapidly of all 
forms. 

If you administered cocaine in that form it would absorb 
more rapidly than if it was swallowed ?—Very much more so. 

Would it absorb more rapidly than if it was injected? 
—Yes. 

So that really it is the most rapid form known of absorb¬ 
ing a poison —Y'es, except the intravenous method which is 
hardly used in man. 

Have you considered the question as to whether or not the 
continuous and frequent use of this specific is likely to cause 
injury to patients ?—I think it is likely to promote the 
cocaine habit. 

Is that extremely injurious to the patient ?—Y'es, extremely 
injurious. 

Crott examined by Mr. Duke. —How do you explain it that 
numbers of your medical brethren use these very same 
drugs for the very same purpose ?—1 think these drugs might 
be used, if watched, without particular objection. 

A man who has got asthma does not want to go to a doctor 
every time he gets a recurrence of an attack or the symptoms 
of an attack, does he ?—No. 

Then his doctor will give him some remedy which he can 
use, will not he?—Yes. 

He will give him either something he can inhale the 
fumes of upon burning or something he can inhale in a 
vapour or something of that kind ? I should not advise any 
doctor to prescribe cocaine. 

I am speaking of what your medical brethren do, not 
what you would advise them to do. 

Mr. Justice Ridley: Y’ou would not advise anyone to 
prescribe it ?—I would not prescribe cocaine in this way. 

Mr. Duke : Do not you know that they do prescribe 
cocaine ?—They do, because the dangers of cocaine are not 
properly appreciated. 

Really, it is a mistake on the part of the doctors who pre¬ 
scribe cocaine; is that it?—I think it is a mistake in any 
doctor to prescribe cocaine to be used internally in this way. 

Y'ou would not go so far as to say he was guilty of fraudu¬ 
lent representation by prescribing cocaine?—I should not 
say he was guilty of any representation at all. 

Mr. Justice Ridley : Do you practise yourself ?—No. 

Mr. Duke : I gathered he did not, because he was intro¬ 
duced as a professor. 

You say it iB injudicious to administer cocaine at all, in 


your judgment; but, on the other hand, not really fraudulent, 
you think ?—The administration is not fraudulent. 

But it is said on Mr. Tucker’s part to be fraudulent; it is 
Bald that for him to say this will cure or relieve asthma is 
fraudulent, bnt for a doctor to give it to his patient as a 
thing which will relieve asthma is not fraudulent. Where is 
the difference?—! do not think the doctor makes any repre¬ 
sentation that it is going to cure. 

He provides it as a thing which is good for an asthmatic 
patient, does not he ?—I think he might, but no doctor 
promises to cure. 

There are some things which a doctor will promise to cure, 
are not there ! 

Mr. Justice Ridley : I have been promised many a time. 

Mr. Eldon Bankes : But your lordship’s ailments are 
very trifling. 

Mr. Justice Ridley : Surely the doctor sometimes says to 
you that you will soon be all right. 

Mr. Duke: If the doctor says to you “You will be all 
right in a day or two,” that is promising a cure, is not it?— 
Yes. 

That is one of the things a doctor is privileged in doing 
without being charged with fraud. 

Mr. Justice Ridley : It would depend on what the jury 
think of these instructions. I do not think they have said 
it. Y'ou must read it all together. 

Mr. Duke : It has been suggested that they do, and they 
will have to be read later. Have you any doubt at all that 
large numbers of medical men and large numbers oE 
specialists in asthma at the present time are using and pre¬ 
scribing a specific of just the same character as that which 
Dr. Tucker of the United States discovered ?—I really could 
not say whether anyone is prescribing for asthma a sub¬ 
stance containing all the constituents of the Tucker cure. 

Not all the constituents, but as near as they can get it. 
Do not you know medical men are prescribing what they 
believe to be an effective substitute for Tucker ?—I am not 
aware of the fact. 

Why do you suppose it is that Oppenheimers are offering 
to the prescribing doctor and to the dispensing chemist a 
composition which is said to be an effective substitute ?—I 
was not aware that Oppenheimer had done so until I came 
to the court. 

But when you find it is so, is not it perfectly obvious that 
the thing is in large use in the medical profession ?—In use, 
I admit. 

Do you think Oppenheimers would take the trouble to 
advertise a thing of this kind in their list of drugs and give 
their preparation of it and recommend it specially unless it is 
a thing which is called for to a great extent ?—Called for, I 
may admit, but not to any great extent, possibly. 

But they say so upon the face of that document. Just let 
me read it to you : “ Many inquiries from important medical 
men have reached us regarding a certain preparation for 
asthma recommended by an American doctor. We introduce 
our Neboline compound which is similar in every respect and 
which from the reception accorded to it seems to meet all 
requirements, practically a specific for asthma.” Is not it 
obvious upon that that medical men are largely using or 
seeking to use Dr. Tucker's remedy ? I really cannot answer 
the question at all. 

Would you mind applying your mind to it ? Oppenheimer’s 
are one of the largest firms of wholesale druggists, are not 
they ?—Yes. 

Are the people whom they usually supply the doctor who 
dispenses his own medicines and the dispensing chemist ?—- 
I suppose so. 

Can you give any other explanation for that statement in 
their catalogue except the explanation I suggest to yon, that 
medical men in large numbers are calling for this specific 
and that it is being found effective ?—I can admit that the 
advertisement seems to me to mean that something of the 
kind is being called for. As to the numbers of medical men 
I should reverse my statement. 

Mr. Justice Ridley : I find here a number of compounds ; 
there are 21, I think, and 7 have got cocaine in them out of 
the 21 in different quantities in Oppenheimer’s list. 1 am 
not going into the particular quantities because it would be 
too loog, but it seems to be generally used.—I am very glad 
I am not responsible for Oppenheimer's list. 

Mr. Duke : Do you think Oppenheimer’s are putting up 
medicines which are not being called for by the medical 
profession ?—I scarcely suppose so. 

1 gather that wonld be so if it is the fact that the medical 



The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1,1908 . 365 


profession are using ani recommending a specific in imita¬ 
tion of Tucker’s specific as a specific for asthma. Do not 
you think it is a scandalous thing that Ur. Tucker should be 
charged with fraud for selling that specific ?—1 am not pre¬ 
pared to express an opinion as regards the moaning of fraud 
from the legal point of view. 

Mr. Duke : Very well, that is the only answer you can 
give me. 

Mr. Justice Ridley : What you mean to say is what you 
have said, which is quite intelligible to me. 

Mr. Ei DON Bankes : It is no good objecting to my learned 
friend because he persists in putting this question to the 
witnesses, but I think the jury by this time understand that 
it is a question for them, and I suppose they will not be 
affected by these questions. 

Mr. Justice Ridley : It is a great pity we have ever got 
such a question at all. If the people had actually written 
wbat they have said in court there would not be much bother 
about it, but fancy people writing this. Either they do 
not mean it or they do not know what it means. These 
things which they have written are not a part of this 
gentleman’s evidence and not a part of most of the evidence 
relating to your case, which is, that it is dangerous to 
circulate cocaine without medical supervision. That is quite 
a different point. 

Re-examined by Mr. Eldon Bankes. —You have been 
asked what other doctors do about cocaine. 

Mr. Justice Ridley : One can accept that with great 
respect and refrain from expressing any divergence of 
opinion. 

Mr. Eldon Bankes : I understand you to say that no 
doctor should prescribe cocaine. 

Mr. Justice Ridley : He goes a little further and says no 
cocaine at all. 

The Witness : No cocaine internally. 

Mr. Eldon Bankes : In yonr experience has there been 
great alteration in the view of the medical profession with 
regard to the use of cocaine quite recently ?—Very great, 
particularly in the United States, where the cocaine habit 
has been specially developed. 

And do you find also in England, to some extent but not 
to the same extent, an alteration of feeling?—I think so, 
yes. 

Mr. Samuel Archibald Vasey, examined by Mr. Eldon 
Bankes —You are a Fellow of the Chemical Society, a 
Fellow of the Institute of Chemistry, a Member of the 
Society of Public Analysts and an analytical chemist, and I 
think you have bad 20 years’ experience .' -Yes, that is so. 

You now direct the work of The Lancet laboratory?— 
Yes, that is so. 

And you act as general consulting chemist to the pro¬ 
prietors of that paper l —Yes. 

Have you analysed different samples of Dr. Tucker's 
liquid ?—I have. 

Y'ou could recognise the bottles ! Do you wish me to 
identify them, Mr. Duke ! 

Mr. Duke : No, I shall take the witness's evidence ; it is 
merely a matter of form. 

Mr. Eldon Bankes : How many analyses have you made ? 
—In all, two. 

Mr. Justice Ridley : Two bottles ? 

Mr. Eldon Bankes : I only want the approximate dates 
of the analyses.—The first one was examined on July 4th, 
1907. 

I think that was a small quantity of liquid remaining in a 
bottle and the other was of a full bottle ?—Yes, that is so. 

What was the date of the second analysis ?—July 8th, 
1907. 

Was the second analysis rather fuller than the first because 
you had more liquid to deal with ?—That is so. 

Mr. Justice Ridley : Can you give us the analyses ? 

Mr. Eldon Bankes : Yts, I can. It is only to show the 
variation. 

Did you find the same active constituents in each case ?— 
Yes, I did. 

You found cocaine in each, did you ?—Yes 
In the first one how many grains per fluid ounce ?—Of 
cocaine, 1‘03. 

In the fust one !—In the first one. 

And in the second one?—1'47. 

Did you find atropine ?—Yes. 
in the first how much?—O'52. 


And in the second one ?—0'66. 

Did yon find sodinm nitrite in each ? Yes, in the first one 
16'00 grains and in the second 24 46 grains. 

Mr. Justice Ridley : Are these all in grains which you are 
giving ? —Grains per fluid ounce. 

Mr. Eldon Bankes : I think you found considerable 
quantities of glycerine in each ?—Yes. 

And oily matter ! —Y r es. 

I think there was nothing else which it is material to 
mention, was there ?—No, I think not. 

Mr. Justice Ridley : In the other analysis which we have 
been dealing with there was 2'28. 

Mr. Eldon Bankes : Yes, your lordship will see there are 
great variations between the different bottles of liquid. 

Mr. Justice Ridley : That is more than double the first 
sample taken here ? 

Mr. Eldon Bankes: Y'es. 

Mr. Justice Ridley : And the figures that you have been 
dealing with are twice too much ? 

Mr. Eldon Bankes : Not twice too much bat it shows the 
great difference between the two samples. 

Mr. Justice Ridley : On the other hand the atropine was 
more ? 

Mr. Eldon Bankes : Yes. 

I think you also made some investigations with regard to 
the atomiser ?—Yes, I have. 

Will you please hand in the four which you have dealt 
with ? I think for the purposes of this case it is quite suffi¬ 
cient for me to deal with fonr. There is Mr. Tucker’s own 
atomiser, there is Oppenheimer’s atomiser which Mr. Tncker 
produced, and there were two which I put to Mr. Tucker 
as coming from Mr. Rogers. 

Mr. Justice Ridley : He has found some that will produce 
vapour. 

Mr. Eldon Bankes: I am only dealing with the four 
which Mr. Tncker dealt with and he admits that all those 
four produce equally good vapour, but his complaint about 
them was that they did not produce as much. I just want 
to identify the four. 

There are the two of Mr. Rogers' and there is Mr. Tucker’s 
and there is Oppenheimer’s (handing same to the witness). 
Have you made tests with those to Bee the quantity of the 
liquid which is atomised in a given number of compressions? 
—I have. 

So as to see the volume of vapour which each one will 
produce with a given number of compressions !—The weight 
of vapour. 

With you please give us the result ?—With Messrs. Oppen¬ 
heimer’s we found that 100 compressions of the bulb gave 
0 48 grain of spray. Am I to give the figures of Mr. 
Tucker's 1 

Yes, if you please.—With Mr. Tucker’s 100 compressions 
of the bnlb gave similarly in the same hands 0 ■ 60 grain of 
spray. 

As to the atomisers of Mr. Rogers, have you them here ? 
Those which you have are the ones which were put to Mr. 
Tucker, are they not ?—Yes, one with a black bulb, the other 
with a white bulb. This one, the black bulb with 100 com¬ 
pressions, gave 1 • 08 grain weight of vapour. 

And the white bulb ?—The white bulb with 100 compres¬ 
sions gave 1 07 grains weight of vapour. 

Did you use them under similar conditions .’—Precisely the 
same conditions. 

And the same liquid ?—The same liquid and in the same 
hands. 

Is the result of those examinations that Oppenbeimei’s 
is slightly less powerful than Mr. Tucker’s?—That is so. 

To the extent of the difference between 0 48 and 0 1 60 per 
100 compressions 1 —Yes. 

But both the atomisei s of Mr. Rogers are more powerful ? 
—Yes. 

Do they each produce equally good vapour ?—Equally 
good. yes. 

Equally fine spray ?—Equally fine and dry vapour. 

We have had the prices of those, I think. 

Mr. Justice Ridley : Not of Mr. Rogers’s. 

Mr. Eldon Bankes (to the witness) : Can you give me the 
price of Mr. Rogers’s 1 —No. 

Mr. Eldon Bankes: Mr. Rogeis will tell us that. 

Mr. Justice Ridley : I have the price of Mr. Oppen¬ 
heimer’s. 

Mr. Eldon Bankes: Peihaps my friend will take it 
from me. 

Mr. Duke : Certainly. 






The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 367 


to you that I did to the plaintiff when I checked them 
calling their witnesses. I know the old advice I used to get 
—I used to be told not to call any witnesses more than I 
could help. 

Mr. Eldon Bankes : I feel that in the exercise of my dis¬ 
cretion I ought not to go on calling more witnesses than I 
think is necessary. I feel that I have called really as many 
eminent men as I ought to call, and therefore the only 
question is that I may have one or two other witnesses, but 
they are not present here at the moment. Would your 
lordship allow us to adjourn now ? I will undertake not to 
call any more medical witnesses, and the two witnesses I 
want to call, if I can get them, are quite short, but they are 
not here now. 

Mr. Justice Ridley : What are they to prove, if one may 
ask without being inquisitive ? 

Mr. Eldon Bankes : One is a special witness and I will 
not refer to him at the moment because I am not sure 
whether I am going to call him ; the other witness I want to 
get is a gentleman of the Bar to prove the American law 
with regard to the sale of poisons. 

Mr. Justice Ridley: I can see that it would be totally 
immaterial. 

Mr. Eldon Bankes : Your lordship will rule on that when 
the time comes 

Mr. Justice Ridi.ey : You charge a gentleman with fraud 
in this country and you want to prove what the American 
law is. 

Mr. Eldon Bankes: This gentleman has given us a good 
deal of evidence about the sale of this specific in America. 
Our case is that it is dangerous, and as evidence of that we 
desire to give evidence of what the law is in those particular 
places where this gentleman has chosen to say there is an 
enormous Bale. 

Mr. Justice Ridley : That will not prove the fact that there 
is an enormous sale. 

Mr. Eldon Bankes: No, but it will be very strong 
evidence, surely, that it is regarded as dangerous, not only by 
our doctors but by the doctors in America who are vouched 
by the other side. 

Mr. Justice Ridley : There are a great many patent 
medicines which are consumed in enormous quantities in this 
country which are regarded as dangerous by the medical 
profession, but their consumption has not decreased, and it 
never will, in my opinion. 

Mr. Eldon Bankes : Yonr lordship will remember the 
evidence of the last witness, Professor Cushny. He said they 
had gone a great deal further with regard to cocaine in 
America than we have. What I seek to prove is that the 
sale of this actual specific is actually forbidden. 

Mr. Justice Ridley : Let us see what your libel is in this 
case. I cannot see what bearing it has upon this. 

Mr. Eldon Bankes : It is evidence that these things are 
dangerous. I do not want to keep np the discussion. I 
have not the witness here now, and therefore I cannot 
tender him. 

Mr. Justice Ridley : You must do as you think proper. 

Mr. Eldon Bankes : I will undertake that I will not take 
any appreciable amount of time with my evidence on 
Monday, 

Mr. Justice Ridley : Then I suppose we mnst adjourn. 

Mr. Smith : Unless there should happen to be a short 
witness from The Lancet whom my friend is going to call. 

Mr. Eldon Bankes : No ; not from The Lancet. 


FOURTH DAY. 

Mr. John Arthur Barratt, examined by Mr. Eldon 
Bankes. —I think you are an English barrister, and that yon 
are also a Member of the Bar of the Supreme Court of the 
8tate of New York and the Bar of the United States Supreme 
Conrt ?—Yes ; I am. I have practised actually in the United 
States for 18 years. 

Have you been asked to make yourself familiar with what 
the law of the State of Massachusetts is with regard to the 
sale of proprietary medicines containing cocaine 1—Yes; I 
have. 

Mr. Duke : I believe that my learned friend now proposes 
to tender evidence as to the law of the State of Massachusetts 
upon this matter. I object that no such evidence ii relevant 
in this case. Whatever may be the position with regard to 
cross-examination upon such topics, I submit it is impossible 
to make the law of the State of Massachusetts relevant in 
this case. 


Mr. Justice Ridley :’ No, I do not think it is relevant. My 
opinion is that it is not relevant; but perhaps it would be 
better to see the evidence. You know what I think the 
point in this case is. 

Mr. Eldon Bankes: If yonr lordship is strongly of 
opinion- 

Mr. Justice Ridley : I think there is no doubt about it. 
We know what the law is here under the Pharmacy Acts; 
that is the point really. If it is not material that is an 
end of it. 

Mr. Eldon Bankes: Except that this particular law is 
stronger. 

Mr. Duke : No. I object to statements whether the law 
is stronger or weaker. It can only be introduced for the 
purposes of prejudice. 

Mr. Justice Ridley: I must ask you to show me how it 
is relevant, Mr. Bankes. To my mind it is right off the 
point. 

Mr. Eldon Bankes : My submission is this, but I will not 
argue it if your lordship is against me- 

Mr. Justice Ridley : I would like to hear you. 

Mr. Eldon Bankes : My submission is that our case is that 
this specific containing these poisons is dangerous. 

Mr. Justice Ridley : That is not enough ; that will not 
help you. If that is all yon lose your verdict. 

Mr. Eldon Bankes: It is an element in the case and I 
submit that this evidence as to the law of a State of New 
York upon that particular point is relevant. 

Mr. Jnstice Ridley : I do not think it is. 

Mr. Eldon Bankes : If yonr lordship says so of course I, 
do not persist in it. That is my case. 

Mr. Jnstice Ridley : I will assume that it is contrary to 
law and that they have a law relating to poisons in the same 
way that we have. I think it has appeared already in evi¬ 
dence that there is such a law in the United States or in the 
State of Massachusetts. I rather think that is so, but I forget 
whether I merely got it through an observation of one of the 
witnesses. 

Mr. Duke : The plaintiff said that he heard that one had 
been proposed. I omitted before closing my case to put in 
an answer to an interrogatory. 

Mr. Eldon Bankes : By all means. 

Mr. Duke : It is answer 2, with regard to the knowledge 
of the defendant upon the main question, the plea of fair 
comment 

Mr. Justice Ridley : Will you hand it up, please 1 (Same 
handed np to his lordship.) 

Mr. Duke : It is question No. 2 and the answer to that 
question ; this is the defendant’s answer : “ In answer to 
Interrogatory 2 I made no inquiry as to the truth of the 
statements set out in the said interrogatory before print¬ 
ing and publishing the said statements and took no 
steps to test the reliability of the information which I had 
previously received as to the said statements because such 
information was derived from (1) a cutting from the Morning 
Advertiter of Wednesday, January 2nd, 1907, and certain 
printed instructions as to the use of Tucker’s asthma specific 
which said cutting and printed instructions were forwarded 
to The Lancet by Dr. F. J Waldo, the coroner, before 
whom the inquest referred to on the said Cushing was held ; 
(2) the advertisements mentioned in my answer to Interroga¬ 
tory 4 and my general experience and knowledge in regard 
to the danger likely to result from following the treatment 
recommended in such advertisements.” 

Mr. Justice Ridley : They are not advertisements of this 
specific but of others. 

Mr. Duke : Yes, not of this specific but of large numbers 
of patent remedies. 

Mr. Eldon Bankes : May it please your lordship, gentlemen 
of the jury. I am sure you must be glad that we are approach¬ 
ing the end of this inquiry and I will not delay you longer 
than I can help; but in openmg this case to you I desired 
to deal, and did deal, though I am afraid in rather a dis¬ 
jointed manner, with what seemed to me to be matters of 
general importance in this case which you should bear in 
mind before I called my evidence. But now my duty seems 
to be different. I want to get if I can to what I may call 
closer quarters with what are undoubtedly the material 
matters in this case: first of all, the libel itself; secondly, 
the law as applicible to that libel—and I shall deal then I 
hope sa'isfactorily with the points which have been indicated 
to me by my lord more than once duriDg this trial ; and 
finally, with the evidence which has been given, because 





368 The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


your doty, as I submit, is to come to a decision to-day, as I 
am sure you will quite fairly and quite impartially, upon the 
evidence as it has been laid before you in the course of this 
trial. 

First of all, let me deal with the libel, and if you have your 
copies before you I should like to read it through with you 
to see exactly what it is that is Baid, how much of it is 
applicable to the plaintiff, and what it is that it says about 
the plaintiff. You see it comes under a part of the paper 
which is called “Notes, Short Comments, and Answers to 
Correspondents." I do not mind whether you call this a 
note or short comment, but I should think the best way 
would be to speak of it as a note or an article. You will see 
that it has a heading and it is headed “ Quack Advertise¬ 
ments”; and of course the object of the heading always is 
to indicate to the reader what the article or note is about. 
1 shall submit to you when I have read it that the primary 
object of this writer in writing this note or comment was 
to deal with quack advertisements, and in dealing with these 
quack advertisements he did introduce incidentally this story 
with reference to Cushing and Dr. Tucker’s specific. Now 
let me read it. It begins : “ Quack advertisements. lathe 
course of an inquest held at the beginning of the year it was 
stated that a labourer who had died from consumption had 
been using Dr. Tucker’s asthma specific inhaler, for which 
he had given, according to a newspaper report which has 
reached us, three guineas, while the material with which he 
had sprayed himself bad cost him 8*. an ounce.” Now may I 
pause there. That is a statement as to something which had 
occurred at an inquest, and now you know that this is truly 
stated and that is a correct statement as to what had 
occurred at that inquest. Then the writer goes on: “Dr. 
F. J. Waldo, the coroner, rightly stigmatised this kind of 
dealing as a fraud.” There again the writer is stating 
something which happened at the inquest, and he is also 
stating that he considers that what the coroner said was 
right. We know now that the coroner did say it and the 
question which you have to consider is whether the writer of 
this article was justified in his opinion in saying that the 
view which Dr. Waldo expressed was a correct view. He 
goes on: “and it is a humiliating thing for journalists to 
remember that such frauds could not be committed with any 
profit to the quack save with the cooperation of the press.” 
Now he is travelling off into the question of quack advertise¬ 
ments generally, which does not, as I shall submit to you, 
refer to the plaintiff. “A correspondent has recently sent 
us a collection of advertisements of so-called proprietary 
medicines which he had cut from papers of high reputation 
in the country.” It is now admitted, and you know, that 
those advertisements are advertisements referring to other 
remedies and do not include an advertisement of Dr. Tucker's 
specific. Then he goes on ‘ ‘ inviting our opinion of them ”— 
that is, of those advertisements. “Our opinion is that the 
misery wrought by quacks must be unknown to a good many 
proprietors of newspapers or they would hardly share with 
the quacks the plunder extracted from the public, mainly 
from the sick poor. The remedy is in the hands of the public 
who have only to signify their displeasure at reading in their 
journals invitations to be robbed and poisoned to find those 
invitations immediately cease. But the public are largely 
nninstructed and credulous and, alas, those responsible for 
the conduct of many of our journals take no trouble to 
enlighten them. They prefer to regard all protest against 
quack advertisement as emanating from the narrowness 
of the medical profession ; this is certainly a convenient 
faith, but how it can be truly held by educated people 
passes our comprehension.” That is the whole of it. The 
words of this article, taking it as a whole, which are 
objectionable, or which can be said to contain a libellous 
meaning, I think, are four. There is the first word “quack,” 
there is secondly the word “ fraud,” there is thirdly the 
word “rob,” there is fourthly the word “poison.” Now 
there is no doubt whatever that as used in this artiole the 
word fraud does refer to the plaintiff in this sense that it 
refers to his course of trading. I shall ask you to consider 
whether the word “quack ”or the words “rob” and “poison” 
refer to him. I will ask you in that connexion to bear in 
mind a letter which the solicitor for the plaintiff wrote when 
he complained of this article. You will find there that he 
thought and said that the word “ quack ” as used in this 
article referred to Dr. Tucker, the plaintiff's brother, and of 
course if that is so, if it refers to the inventor of this 
specific and not to the person who sells it in this country, it 
is quite plain, and my learned friend would not contend that 


he would be entitled to rely upon that word, because the 
plaintiff is here claiming damages for himself for some¬ 
thing which is said about him, and he cannot complain nor 
can he ask damages for anything that is said about his 
brother. This is the letter which my learned friend read of 
the 9th May, 1907, which the solicitor wrote, and he says in 
that letter that this paragraph “ has very recently come to 
his notice.” That is on the 9th May. Then he goes on to 
say, “ Our client is the general manager in England for 
Dr. Tucker and has a considerable personal and direct 
interest in the sale and distribution of the atomiser and 
specific. The statement with reference to the inquest and 
to the sale of the inhaler (or atomiser) and the spraying 
material (or specific) that Dr. J. F. Waldo, the coroner, 
rightly stigmatised this kind of dealing as a fraud and 
the use of the word quack in connexion with Dr. Tucker 
are subject of very serious complaint by our client.” So it 
is quite plain that the plaintiff's solicitor himself read this 
article as though the imputation arising from the word 
“quack” was an imputation upon Dr. Tucker of Mount 
Gilead, Ohio, or wherever he lives, and not on the plaintiff. 
I will ask you to consider these matters when you come to 
consider the libel, not that in my judgment they are very 
material, because the essence and sting of this libel is, 
according to my learned friend’s case, that the word 
“ fraud ” is used with reference to plaintiff’s course of deal¬ 
ing. and with that I am perfectly content to deal. 

Now you will also notice that this paragraph standing by 
itself makes reference only to the plaintiff’s course of deal¬ 
ing as evidenced by what occurred at the inquest, and if 
both parties had been content to try this case upon that fact 
alone of course this inquiry would not have taken the time 
that it has. I should have been quite content to take your 
judgment if the plaintiff had been willing that it should be 
so taken upon the question connected with that inquest as 
relating to the plaintiff’s course of dealing, because what do 
we know those facts to be 1 We know that a man earning 
weekly wages died of long-standing consumption in the year 
1906. We know that two years previously he had paid a 
sum of money which to him must have been a large sum for 
a specific which, according to the plaintiff’s own statement 
before you, was not intendod to do him good and could have 
done him no good, and, what is more, that it was supplied 
to him when the plaintiff himself had information in his own 
possession which if he had chosen to look at it would have 
indicated to him that this mac was suffering from a 
disease for which his specific would be of no assist¬ 
ance, and yet he took that man’s money. Why do I say 
that ? You remember the questions that that man Gushing 
was told to answer when he applied for the specific. One of 
these questions—I shall have to deal with the questions 
later—said : “What remedy are you in fact using to relieve 
attacks’? Answer: Cod-liver oil as tonic.” I said to Mr. 
Tucker as you remember : “ Did not the fact that this man 
was taking cod-liver oil as a tonic indicate to you that he 
was possibly or probably suffering from such a disease as 
consumption?” His answer was: “It did indicate to me 
that the man was in a run-down state." I asked him: 
“ Would not that fact indicate to you that he was possibly 
or probably suffering from consumption?” and his answer 
was “ Yes ” ; so you find a man with the knowledge in his 
possession that this man is suffering from a disease which he 
himself admits this specific does not cure, and will not 
assist, taking that man’s money and taking what for him 
is a large amount, impoverishing him to enrich himself. I 
venture to say that anybody criticising that state of things 
alone would be entitled to use as strong language as his 
vocabulary admitted. But bear this in mind; the plaintiff 
is not content that his kind of dealing should be judged by 
that circumstance alone, and he comes before you and says 
in substance: “It is not fair you should judge my kind 
of dealing by the case of Cashing alone.” Before I pass 
from the case of Cushing I want you to bear in mind 
that the facts are proved here beyond contest, and 
Mr. Tucker has offered no explanation of how it was or 
why it was he supplied this specific to him or what 
possible justification there was for so doing; not a word. 
Therefore he cannot come into any court of justice ; he 
cannot come and ask any jury to say that the strongest 
language is not warranted with regard to that case. He 
comes here, therefore, before you and says : “ Do not judge 
me, gentlemen, upon that one case alone. I bring before 
you these facts : I bring before you the fact that I supplied 
this treatment on a fortnight's trial,” from which he desires 






The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908 . 369 


you to come to the conclusion that everybody has a fair 
chance of taking it or rejecting it. He comes before you and 
says: “This treatment of mine may have been no good in 
this instance but I can prove to the jury that it has bad 
extremely beneficial effects in other cases. I desire to tell 
the jury that I have had 25,000 patients and I have had no 
complaints; I desire to tell the jury that this was invented 
by my brother who is a qualified doctor, and therefore I 
was justified in assuming that it was all right.” So that 
he is not content to leave the case to be judged upon the 
case of Cushing but he comes before you aud he lays evi¬ 
dence before you which I hope I have fairly summarised in 
this short summary which 1 have just given ; but of course 
if the plaintiff wishes to make further statements to you 
about what his kind of dealing really is, equally the de¬ 
fendant comes before you and says : “ Before you can form a 
true judgment as to whether these words were warranted or 
cot, if we are not to deal with the case on the facts of 
the Cushing inquest alone you must know the whole facts 
with regard to this treatment”; and what does the defendant 
come before you and in substance say 1 He says : “ 1 want 
to tell the jury that the view which the plaintiff has pre¬ 
sented is only a partial view of this statement; I want to 
tell the jury that this liquid contains two extremely 
potent and dangerous poisons ; 1 want to tell the jury that 
this man is selling those poisons in flagrant defiance of 
the laws of this country and ignoring all the precautions 
which the law says must be taken in the interests of the 
public generally; I want to tell the jury that tbiB specific 
used as directed by the plaintiff is a great source of danger 
to the public health; I desire to point out to the jury that 
this sale is accompanied by statements in the nature of 
advertisements which are in themselves gravely misleading ; 
I desire to tell the jury that the price charged for this 
specific under the circumstances under which it is sold is 
not justifiable ; I desire to tell the jury that the way in which 
this man carries on his business leads people to think that 
this specific is only sent out under competent medical 
advice.” Those are the additional sets of facts which the 
plaintiff on the one side and the defendant on the other side 
have desired to bring before you, and in a moment 1 shall 
deal with the question how far those statements on the one 
side and the other have been proved, and upon those facts 
of course you will have to say : Does the evidence establish 
what the defendant says is this plaintiff’s real course of 
dealing ? If you find, as I shall ask you to find, that the 
defendant has established these facts, then the question 
arises whether in point of fact the language which was used 
was beyond what the occasion warranted. Now upon that I 
desire to deal with the points which my lord has more than 
once put to me in this case, and I will endeavour to explain 
to you what I understand the law to be. This is a case in 
which the defendants have not justified ; that is to say, have 
not gone so far as to take upon themselves the burden of 
proving that the words which they have used are absolutely 
true. But- the position which they take up is this, that this 
sale by the plaintiff of this specific in these enormous 
quantities is a matter of public and general interest and so 
were the events which were proved at that inquest. I am 
entitled as the editor of a newspaper, or as, indeed, any man 
is entitled, to comment fairly and freely upon those facts. 
What is fair comment and what does the law allow under 
the privilege of fair comment ? It allows anything that any 
honest man may think or say, whether you thick the thing 
is exaggerated, whether you think that the view which the 
man took was prejudiced or not, so long as you think that 
any honest man might, having regard to the circumstances 
which are proved before you, think he is entitled to say this, 
whether you agree with him or whether you do not agree 
with him. 

There are just three cases to which I should like to refer 
as showing what I mean. The first one, from which I will 
only read a few passages to you, is the very well-known case 
of Merivale v. Carson, which is always quoted in this con¬ 
nexion and which is reported, I may say for my lord’s con¬ 
venience, in 20 Queen’s Bench Division at page 275. The 
only distinction between that case and this case which l 
wish you to bear in mind while 1 read this passage is this, 
that this was a criticism of a book or a play and therefore 
the learned judges used the words ‘‘criticism upon the 
work,” but the law is the same and my learned friend would 
not dispute that it is the same whether it is a book or 
whether it is a play or whether it is any other incident 
which may be said to be of public interest and import¬ 


ance. What the learned judges there said is this, and 
it is Lord Esher’s judgment from which I am going to 
read : “ What is the meaning of a ‘ fair comment ’ ? I think 
the meaning is this : is the article in the opinion of the 
jury beyond that which any fair man, however prejudiced or 
however strong his opinion may be, would say of the work 
in question? Every latitude must be given to opinion 
and to prejudice, and then an ordinary set of men with 
ordinary judgment must say whether any fair man would 
have made such a comment on the work. It is very easy to 
say what would be clearly beyond that limit; if, for instance, 
the writer attacked the private character of the author. But 
it is much more difficult to say what is within the limit. 
That must depend upon the circumstances of the particular 
case. I think the right question was really left by Field, J., 
to the jury in the present case. No doubt you can find in 
the course of his summing up some phrases which, if taken 
alone, may seem to limit too much the question put to the 
jury. But, when you look at the summing up as a whole, I 
think it comes in substance to the final question which was 
put by the judge to the jury: ‘ If it is not more than fair, 
honest, independent, bold, even exaggerated criticism, then 
your verdict will be for the defendants.' He gives a very 
wide limit, and, I think, rightly. Mere exaggeration, or 
even gross exaggeration, would not make the comment un¬ 
fair. However wrong the opinion expressed may be in point 
of truth, or however prejudiced the writer, it may still be 
within the prescribed limit. The question which the jury 
must consider is this: Would any fair man, however 
prejudiced he may be, however exaggerated or obstinate his 
views, have said that which this criticism has said of the 
work which is criticised ? ” That is the general expression of 
the law with regard to what fair comment is. I desire to 
refer to two other cases, one a very recent one, and one an 
older one, because the older one is very remarkably like this 
in its facts and because it deals so appropriately with the 
point which my lord has more than once put to me. 
That is the case of Hunter v. Sharp which is re¬ 
ported in Foster and Finlason, the fourth volume, at page 
990. The case refers to some newspaper articles about 
a man named Hunter who was advertising a specific for the 
cure of lung disease, and curiously enough it was claimed 
that the specific would cure lung disease by inhalations 
by means of an atomiser. The newspaper wrote very strong 
articles about It. They are very long but I need not read 
them, because Chief Justice Oockburn, who tried that case, 
puts forward his view of them on page 997 and takes in 
from the innuendoes. He says that the defendant says that 
not only is the whole system delusive but that he (that is Mr. 
Hunter) has put it forward fraudulently and by fraudulent 
means and articles; so that the Bame word is used, and in 
that case defendant did two things; he justified; he said, 
first of all, “ it is true,” but secondly he said “ whether it is 
true or not, what I said is only fair comment upon this 
system as I can prove it to the jury.” Chief Justice Cock- 
burn, in summing up, dealt with the question first of all 
of justification. He said to the jury ; “Now you must con¬ 
sider whether these statements are true or not ”; and then 
he says : “ But suppose you cannot go that length that will 
not conclude the case. It will bring the defendant to his 
second ground of defence which in that event you must con¬ 
sider. Under that head of defence he says that it was a 
matter of public interest and public concern; that the 
plaintiff by his advertisements invited people to submit to 
his system of treatment and that if he, the defendant, really 
believed it to be a delusion then he had a right to maintain 
that it was so ; and that even if in drawing inferences of 
imposture and of intention to fall into error, yet if he wrote 
honestly and with the intention of exercising his vocation 
as a public writer fairly and with reasonable moderation 
and judgment he is entitled to the verdict.” 

I rely upon that as showing that there may be cases in 
which the word "fraud” is used with reference to a man’s 
course of dealing in which a jury may, if they take that view, 
hold that it is an expression of opinion as to a man’s course 
of dealing, and if that opinion is honestly held it may be 
fearlessly expressed. The last case to which I deBire to 
refer is one which I think is very appropriate also, and it is 
a very recent case ; it may be within your memory. It is a 
case which was tried in these Courts recently of Dakhyl v. 
I.abouchero, in which Mr. Labouchere’s paper, Truth , had 
said of Mr. Dakhyl that he was a quack of the rankest 
species. In that case the defendant ju.titled ; he said it was 
true, and he said also that it was a matter of fair comment. 




370 The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


r?EB. 1, 1908. 


Mr. Justice Ridley : But he justified there. 

Mr. Eldon Bankes : Y'es, and he said it was a matter of 
fair comment. 

Mr. Justice Ridley: Which you have not ventured to do. 

Mr. Ei.don Bankes: Gentlemen, justification is not 
needed if the words come within the region of fair comment. 
That is what Chief Justice Cockburn points out there, and 
curiously enough in this case when the case was first tried 
the learned judge who tried it took the view that if you call 
a man a “quack of the rankest species ” that was accusing 
him of want of skill and capacity, and that you must justify 
it or else you must fail; and upon that the jury arrived at a 
certain conclusion. But the defendant appealed from that 
because he contended that he was entitled to rely upon the 
plea of fair comment, and the case went to the House of 
Lords. I have the judgment of the House of Lords here and 
I will read you a short passage from the judgment of the Lord 
Chancellor. It deals not only with this point, but with the 
point which I understand from my learned friend’s opening he 
desires erroneously to rely upon. That being the statement 
of the libel the Lord Chancellor said, “In the Becond place 
the defendant was in my opinion entitled to have the jury’s 
decision as to the plea of fair comment, whether or not in all 
the circumstances proved the libel went beyond fair 
comment on the plaintiff and on the system of medical enter 
prise with which he associated himself as a matter of public 
interest treated by defendant honestly and without malice.” 
Why I emphasise these words is this. Yon see that the Lord 
Chancellor’s statement is that the defendant is entitled to 
have the opinion of the jury on the facts proved. My learned 
friend has been more than once indicating to you that the 
question for you is wbat did the writer actually know at the 
time when he wrote! That is not the question. If the 
plaintiff chooses to bring an action for libel and to bring his 
case into court the jury have to decide as to whether the 
comment was fair comment upon the facts proved by them. 
It is quite immaterial that the writer knew. If he was right 
and if the jury upon the facts proved before them that he did 
not exceed the limits of fair comment it does not matter 
whether that writer was right by accident or by design ; the 
point is not what exactly he knew at the time but the ques¬ 
tion is, aye or no, upon the facts proved at the trial, was the 
comment fair or was it not ? 

Now, gentlemen, that being what I submit is the question 
before you—whether upon the facts proved before you the 
writer could honestly come to the opinion which he has 
expressed here—let me ask you to consider again what this 
writer says and whether it is not obvious that this writer is 
speaking of a matter of his opinion and is not stating a fact 
as a fact. The words are quite short. You will see what 
the writer says: “Dr. Waldo, the coroner, rightly stigma¬ 
tised"—now what?—“this kind of dealing as a fraud." 
What is the meaning of the word “stigmatised ” ? I suppose 
the only meaning is that he branded it, but whether you use 
“ stigmatised ” or whether you use “branded” or whether 
you say the coroner 1 ‘ called it ” or whether you say the 
coroner stated that "in his opinion it was” it is equally 
immaterial. It is quite plain that the coroner was not 
speaking of the man but he was speaking of the man’s 
dealing. It is quite true that the man’s character may be 
involved in his dealing, but he is speaking of the man’s 
course of dealing and he is expressing his opinion of his 
course of dealing, and the writer of this article is saying, 
“In my opinion the coroner was right”; both the coroner 
and the paper are stating that in their opinion this course 
of dealing was a fraud. I Bay that if you think that that 
opinion may have been honestly held it may be fearlessly 
expressed and it does not exceed the limits of fair criticism, 
and it is not a correct view of the law to say that if you say 
that a man's course of dealing is fraudulent you must prove 
it offhand. Let me ask you to remember for a moment what 
is meant by the word “fraud.” Of course, there are technical 
meanings of “ fraud ” and there is a meaning of “ fraud ’’ in 
the Bense in which it is not usually used by the public 
generally. There are differences in fraud. There is legal 
fraud and there is moral fraud ; there is criminal fraud 
and there is fraud which makes a man responsible for 
damages. One knows what criminal fraud is; a criminal 
fraud is clearly defined. For instance, I suppose obtaining 
money by false pretences is a criminal fraud. Fraud in 
relation to an action for damages has been often defined. It 
may be an actually dishonest statement or it may be a state¬ 
ment made recklessly without knowing whether it is true or 
false. Those are definitions, but how does the ordinary man 


use the word “fraud” and how does the ordinary reader 
who is reading a newspaper understand the word “ fraud ”? 
Does not everybody habitually use the word "fiaud”in a 
general sense, as meaning that the thing of which he is 
speaking is calculated to mislead and is deserving of severe 
censure ? Is not that the ordinary meaning of the word 
"fraud”? And can I give a better illustration of that 
than has occurred in this case and has fallen from my 
learned friend t This is introducing a matter which I must 
deal with rather out of its logical order, but I want to deal 
with it and I want to deal with it at this moment because 
of what my learned friend said about it. You will re¬ 
member that Messrs. Oppenheimer’s specific has been intro¬ 
duced iDto this case. Of course, it has been introduced 
into this case for the purpose of leading you to suppose 
that what Oppenheimer does Mr. Tucker can do, and that 
the two thiDgs are practically identical, and therefore that 
what Oppenheimer has done ought not to be called fraudu¬ 
lent or dishonest. I hold no brief for Mr. Oppenheimer but 
I can point out to you what seemed to me to be a very 
material distinction between the two cases. Our complaint 
here is that this specific is sold by Mr. Tucker indis¬ 
criminately to the general public without any warning, and 
indeed with directions that it is harmless and that it may 
be used or should be used as often as possible—the direct 
contrary to what ought to be the instructions accompanying 
this dangerous liquid. Oppenheimer’s are chemists ; they 
prepare this specific, they sell it to physicians and chemists, 
they sell it only to qualified men, and accompanying the sale 
is the statement in their catalogue of what it contains. 
Therefore they are telling skilled people that what they are 
selling is dangerous. They label the bottle ; they put on the 
bottle “Poison." They accompany it with directions on the 
bottle. I have not the bottle here but I can find you exactly 
what it says ; the bottle says, “ Poison; not to be swallowed ; 
must only be used with an aeriser or vaporiser." Then in 
print, “To be used as directed by the physician." Then it 
says, “ In compliance with the Bale of Poisons Act, this 
preparation is labelled ‘ Poison ’ but nevertheless is perfectly 
safe if inhaled by means of the aeriser or vaporiser.” First 
of all they send it out to people who are qualified people, 
telling them what it contains ; they put on the bottle a 
notice indicating to everybody that it is only to be used as 
directed by the physician—that is to say, it is only to be 
given in a proper case and it is to be only used in the quantities 
directed by the physician. It would appear to me to be 
obvious that there are distinctions between that case and 
this case and they emphasise better than anything I can Bay 
to you the distinction between what I suggest to you is a 
legitimate dealing in such a liquid as this and an illegitimate 
dealing ; but please bear this in mind, I am not setting up 
Oppenheimer’s as being the right thing to do, as over and 
over again you have heard from my witnesses that they 
would apply the same language to Oppenheimer’s as they 
have done to Mr. Tucker if the liquid were sold under the 
same circumstances. Therefore please do not be misled by 
this incident of Oppenheimer but see it in its real light, and 
when you see it in its real light you will see it has got 
nothing in the world to do with the case, because it is not 
the constituents of the specification of which we are com¬ 
plaining but it is the way in which it is indiscriminately 
disseminated with most misleading directions as to its 
qualities and its use. 

But now I am coming to the point as to which I told you 
I wanted to use this in connexion with the word “fraud.” 
You will remember my learned friend Mr. Duke in opening 
this case rather indicated that he was going to attack the 
coroner for making observations about people when they had 
no opportunity of answering it. I will just call your atten¬ 
tion to wbat Mr. Duke said about Oppenheimer and their 
treatment. He says to the witness, Dr. Willcox, “ Read it 
out, please ”—that is to say, read it out from the catalogue. 
"Many inquiries from important medical men having 
reached us regarding a certain preparation for asthma 
recommended by an American doctor, we introduced our 
Neboline compound. No. 21, which Is similar in every respect 
to the preparation in question and which from the reception 
accorded to it seems to meet all requirements.” You will 
see that Mr. Duke had got in his mind that Oppenheimer 
had been doing a thing which was not quite according to his 
view, “ cricket,” if I may use that expression—it was not 
quite right of them ; they had been copying Mr. Tucker, a 
thing which deserves severe condemnation. 

Mr. Doke : I did not so suggest; certainly not. 



The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Fbb. 1, 1908. 371 


Mr. Eldon Bank is : Let me read his question. I have 
read yon what he read from the catalogue, and this was his 
question : “ A very fraudulent transaction, is it not ? ” 

| Mr. Duke : I think my learned friend must know quite 
well that I was putting to the doctor, who had come here to 
say that Mr. Tucker’s was a fraudulent transaction, that he 
was in the position, if he was consistent, of having to say 
that that sale of a thing by Oppenheimer must be in the 
same category. There is no attack upon their commercial 
integrity. 

Mr. Justice Ridley : Yes ; it must have meant that. 

Mr. Dukb : It meant that if Tucker’s was a fraud 
Oppenheimer's was a fraud. 

Mr. Justice Ridley: That is how I understood it. I 
remember it. 

Mr. Eldon Bankes : I am sorry if I misunderstood my 
learned friend, and we must accept this explanation. 

Mr. Justice Ridley : Of course he meant that. 

Mr. Eldon Bankes : It seemed to me so at the time, and 
when I read it I was more convinced that my learned friend 
was using that expression with reference to Oppenheimer’s 
because he considered that it was a matter which deserved 
condemnation. 

Mr. Justice Ridley: Dr Waldo laid : “Oppenheimer is 
fraudulent also if he says that” ; he accepted it. 

Mr. Eldon Bankes : No, that came much later your 
lordship will find. 

Mr. Justice Ridley: I know it is a little bit later, but 
that shows what the coroner meant. 

Mr. Eldon Bankes : I will not discuss it. Gentlemen, I 
was only nsing it as an illustration, it really was not neces¬ 
sary for my purpose to use it as an illustration bnt it was 
convenient to use it as an illustration. My friend says I am 
mistaken. 

Mr. Duke : Absolutely. 

Mr. Eldon Bankhs : Therefore I say nothing more about 
it. It is sufficient for my case to appeal to your common 
sense as to whether the word is not rightly used in the sense 
which I have indicated to you, that it is a misleading 
transaction, a transaction which deserves severe con¬ 
demnation. Within your own knowledge there must be 
heaps of instances in which you have heard the word 
“ fraud ” used without imputing moral dishonesty and with¬ 
out imputing a criminal offence ; and I do not know whether 
you have not habitually used it so yourself. 1 can give you 
heaps of instances. Is it not common knowledge that with 
reference, for instance, to the sale of articles by the coupon 
system, that system has been denounced in trade journals 
and everywhere to everybody's knowledge as a fraudulent 
system—fraudulent because it deceives the public—fraudulent 
because it induces servants to buy things which otherwise 
are not needed in the household, and so on? It is not 
necessary that I should give you instances, but I can appeal 
to yonr common knowledge and common experience to 
multiply instances in which the word “fraud” is used in 
that sense and is so accepted and so understood. 

If I am right so far, that this article fairly read is an 
expression of the writer’s opinion as following Dr. Waldo 
upon the system of dealing of the plaintiff, if I am right in 
suggesting to you that the word “ fraud ” can be read, and 
ought to be read, in the general sense which I am indicating 
to you, the only question is whether any honest man 
could entertain such an opinion upon the facts which 
have been proved before you in this court. If that is 
the qnestion, I submit to you that there can be but one 
answer to it, because you had here multiplied instance 
after instance of men occupying the highest positions 
in their respective walks of life who have come into 
this court and told you upon their oath that they think 
it a fraud, that they call it a fraud; and if one 
honest man may hold that opinion, why may not another 
honest man hold it ? Let me call attention to what I mean 
in that connexion. There is Dr. Waldo, a man who occupies 
a very responsible position in this great City, a man who has 
come before you and whom you have seen and heard. He 
tells you that at the time he spoke of this thing as a fraud 
and applied the word to the course of dealing. He has come 
here and tells you that he still thinks so, and he comes here 
and tells you : ‘do my judgment, all The Lancet did was 
to reproduce what I had said and to say that in their 
judgment they considered I was right." There is Mr. Tilley 

_and upon this I must ask you to bear in mind that these 

various witnesses whom I pnt into the box I could not ask 
straight out whether, in their judgment, they considered 


this system a fraud, because that would not have been 
admissible ; we could only get their opinion if my learned 
friend chose to cross-examine them about it, and he refrained 
from cross-examining all of them in this particular point, 
but all those whom he did cross-examine upon this particular 
point gave the same answer, with the exception possible of 
Dr. Willcox. Mr.Tilley said : “ I consider it a fraud” ; and 
he gave the reasons why he considered it a fraud. One man 
may consider it a fraud for one reason, and another incident 
in this history may appeal to another man who will call it 
a fraud for another reason. It does not matter what the 
reason is, the qnestion is whether you think that any 
honest man could come to this conclusion npon the 
evidence. There is Mr. Francis, a man who has had 
great experience in the treatment of asthma, and 
who has seen many cases who have suffered according to his 
view from Mr. Tucker’s treatment. He says eo, and Mr. 
Pepper, a very eminent man, ordinarily known as Professor 
Pepper, has come and told you the same thing ; so yon have 
here gentlemen who have come before you and upon their 
oath have said, “ I have held that opinion, and 1 hold it now ; 
I am an honest man, and I am entitled to express, if I am 
asked, what my opinion is.” So much for that. 

Now let me deal with the evidence which has been given 
on the one side and the other. I have indicated to yon what 
the plaintiff’s case is, and I will deal quite shortly with the 
points. It is necessary that I should get to close quarters 
with his evidence in order to ask you to look at it in the 
light in which I submit it ought to be looked at. First of 
all he says, “ I want you to consider this fortnight’s trial of 
mine before yon come to any opinion as to the view which a 
man may express about my treatment.” I have said a word 
about that, bnt I desire to refer to it again, because I 
suggest to you that the inference, if inference there be, to he 
drawn from that fortnight's trial is against the plaintiff 
rather than in his favour, and I will tell you why. He deals 
in this liquid which contains these powerful poisons. We 
know how potent they are and how powerful they are, 
and we know that if anybody suffers from asthma or 
kindred complaints a dose from this atomiser will give 
them relief. We know that; whether it will do them 
ultimate harm or not is another matter; whether their 
disease is one which is appropriate to that stuff at 
all is a matter with which I will deal in a moment, 
but we know that they will get relief. What is the plaintiff 
giving away when he sends the stuff which he knows will 
give relief to a person suffering from such a distressing 
complaint as asthma ? The fact that they get relief will be 
the greatest possible inducement to them to take it, and there¬ 
fore he sends this thing out. knowing practically that every 
person who can use the atomiser at all will buy it. Some of 
them may send it back, because they cannot get the thing to 
work, bnt everybody who can get it to work he knows quite 
well will keep it. If that is so, ought he to take credit to 
himself for the fact that he allows them a fortnight's trial ? 
It is a most material point in bis way of dealing, because 
you will see that if you give a man a fortnight’s trial, and he 
takes it, he is for ever debarred from making any complaint 
about it. When the plaintiff says, “I have had 25,000 
people and none have complained,” what nse is there in 
complaining to a man who has given yon a fortnight’s trial 
of a thing 1 You do not complain, and you do not complain 
because he has given you this opportunity which he knows 
you will take ; and, further, about these complaints let me 
say this : one of the strongest objections which we have to 
this liquid is the fact that people will use it too much with 
disastrous results to themselves. Do you think that those 
people who are suffering in that way will complain ? It is 
not that they do not like it enough, the mischief is that they 
like it too much ; and do you get complaints as to this 
system of his, and is not this liquid in which he deals one in 
which he shuts the door to complaints by the system which 
he adopts, and cleverly adopts ? Gentlemen I suggest to 
you that so far from thiB being a point in his favour the fact 
is that by this trial he gives people nothing and leads them 
to believe that they are getting a great deal. 

I have dealt with the complaints, I have dealt with the 
fortnight's trial, and it only remains to deal with the 
patients that he has called. You will remember what our 
case is about those. Our case is not that it will not do 
people good ; our case is that there are certain classes of 
people to whom it will not do good ; our case is that there 
are a great many people to whom it will do harm. We say 
that it will do harm to persons suffering from heart disease ; 



372 Thh Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Fbb. 1, 1908. 


we say it will do harm to persons suffering from kidney 
disease, from consumption, or bronchitis—all diseases which 
to the patient very often present the same indications and 
the same symptoms as asthma. We say it will do harm to 
these people and we say it will do harm to people who from 
their temperament or from their surroundings are likely to 
take too much. To meet our case he ought to have called 
people of that class to say that they had not been hurt. 
Then there would have been some substance in this evidence 
which has been given, but he has selected people who aTe 
not likely to be hurt, partly from their character, partly 
from their surroundings, and mainly from the fact that with 
one single exception he has not produced before you a single 
person who consumes any quantities of this liquid at all. 

I am going through them quite shortly to justify the state¬ 
ment which I am making but before I do that I want to bring 
to your minds as far a9 1 can some indication of the 
quantities of this liquid which people take if they follow the 
directions which Ur. Tucker has issued. I do not want to go 
into minute calculations but I think I can put it to you in a 
few words. You see in his instructions he says that an ounce 
will last from two to four months. In his evidence in chief 
he suggests that an ounce would last on an average three 
months. Of course, if you take an average of the 25,000 
people, or whatever the number is, who are using it for 
three months, and you find that many are taking from 12 to 
18 months to consume an ounce, there must be a great many 
people who are consuming it in a week or two in order to 
arrive at an average of three months. But there is an 
answer of the plaintiff’s which I should like to look into a 
little more carefully, because that will be an indication to 
you as to the quantity which people take. He says this : I was 
pressing him as to whether he had made any experiments to 
see how much people did take. “ The amount of fluid fn the 
bottle would last at least two weeks of constant using four, 
five, or six times a day.” Let us just follow that out. We 
have shown that if you use it to the full extent, with ten 
squeezes for each inhalation, and six inhalations a minute, 
you will get 300 in a minute. With those 300 compressions 
we know that you would inhale l/66th of a grain. If 
you did that six times a day you would get 1/Llth 
of a grain and if you did it to that extent, instead 
of taking, as the plaintiff says, two weeks, it would 
take rather more than three weeks, so that it is plain, 
according to the plaintiff’s own view, that we have under¬ 
estimated and not over-estimated the amount which a person 
takes by this number of compressions. He says that the 
amount of fluid in the bottle would last at least two weeks 
using it four, five, or six times a day. Just compare that 
with the evidence of the people who have been called before 
you. It Is quite true that 1 did not ask all of them the time 
that the ounce lasted. I wish I had ; but one sees after¬ 
wards the importance of questions which one does not ask of 
all of them. But I asked a good many of them and they told 
you that their ounce lasted from 12 to 18 months. Just 
think; compare the case of a man with whom an ounce 
lasts 12 months or 18 months with the case of a man whose 
ounce lasts two weeks. You cannot compare the two things. 

Mr. Duke : There is no evidence of any use of an ounce 
in two weeks, or anything like it. It was a small quantity at 
the bottom of a bottle which you were asking Mr. Tucker 
about, and he said : ”1 look at that quantity in the bottle 
and I say it will last three months.” 

Mr. Justice Ridley: Yes, three months; there is no 
evidence that I know of except that he said three months. 

Mr. Eldon Bankes: I will read his answer. 

Mr. Justice Ridley: “The average time for one ounce 
would be three months by daily use.” 

Mr. Duke : Y’ou had a small quantity in a bottle. 

Mr. Eldon Bankes : I am reading the answer. It may 
be I am wrong, and if my friend corrects me I will accept 
the correction ; but this is the answer : “ Have you made any 
experiment which will enable you to say the quantity of 
liquid which is atomised if you follow the instructions here 
detailed ?—The amount of fluid in the bottle would last at 
least two weeks of constant using four, five, or six times a 
day.” My friend tells me he was not speaking of a full 
bottle, but he was speaking of a part of a bottle. I will 
accept the correction. I do not remember it myself, but if 
that is so I will accept the correction. 

Mr. Justice RlDLEr : I have not any evidence about two 
weeks at all. 

Mr. Eldon Bankes : I could have worked it out in a 
different way, but I have not got the figures for the moment. 


I have got as far as this, that in one day you take 1/lltb of a 
grain. Therefore you would take 11 days to take a grain. 
There are 21 grains in a bottle, and therefore you would want 
about 25 days ; using it according to the directions of 
the pamphlet it would take you about 25 days supposing 
you were able to compress to that extent. But please keep 
this in mind. It would take 25 days if you were to use it to 
the full extent indicated on the pamphlet. How can you 
compare that with a man who is using an ounce in 12 to 18 
months ? You will remember that I could not go into this 
because I could not give particular instances, but my learned 
friend asked Mr. Francis with regard to a patient of his. 1 
could not have done that, but he did it, and the name haB been 
passed down. It has not been made public, and of course 
it ought not to be made public, but the facts with regard to 
that case are that Mr. Francis has told you that that man 
was using it 20 or 30 times a day, and that is a case of the 
kind of user that does harm. How can it assist you as to 
whether or not in certain cases this specific does harm to- 
call a number of persons who have not used it to a sufficient 
extent to do harm and who are not in a position in which it 
is likely to do them harm. Upon that let me call your 
attention to this. What kind of person do you think would 
be most likely to be affected by this stuff 1 Who is the person 
who is most likely to be addicted to a too frequent use of 
it? Is it the busy professional man whose one object is to 
get relief and go back to his work, and when he gets back, 
to his work he will be engrossed in hie work, and he will 
not think about his horrid complaint until he gets another 
actual attack; or is it the person sitting at home with 
nothing to do who dreads these attacks, who takeB the stuff 
to relieve the attack, and sits there wondering when an 
attack will come again, and takes a dose because he thinks 
an attack is comiog on, and so forth ? The great bulk of 
the people who have been called before you are the busy 
professional people, the people who are not likely ever 
to take this to excess. They are not only that, but they are 
healthy people—I mean healthy in the sense that they are 
not suffering from any of these diseases. You will remember 
what Mr. Bateson, the first witness, the barrister, Baid. I 
asked him if there was anything the matter with his heart, 
and he said: “Heart? No, I am passed every year as a 
first-class life by the insurance office.” Those are not the 
people likely to be injured, and if you run through the list 
you will Bee that I am speaking correctly about that. There 
was Mr. Bateson, a professional man, a barrister; he says 
he hardly requires it at all now. He used it constantly—I 
mean constantly in his sense—at one time and he says that 
the ounce lasted him 12 to 16 months. There were two 
peers, Lord Ashburnham and the Earl of Harewood. It is 
true they are not professional men, but they are men with 
many interests in life who have a great deal to think about 
and, therefore, I think I may fairly class them for my pur¬ 
pose in that class. I mean they are men who are not sitting 
morbidly contemplating their ailments, but they have to be 
out and about became they have so much to do. There is 
Mr. Coombs, the borough treasurer of Kensington—I refer 
to his evidence because I notice in his evidence he says he 
worked the thing at the rate of 10 up to 15 compressions a 
minute. When I spoke to you before I thought 10 was the 
highest, but he has got up to 15. There is Mr. Mansfield, 
the barrister, who for 18 months has used it very little. 
There is Mrs Stewart, the wife of Major-General Stewart; it 
is quite true that her husband ought to be put in a different 
category, because he is a man who has retired and an old 
man ; but my comment upon him is this: it may be that 
be is a man perhaps of strong disposition and strong 
temperament, and he is not likely to allow anything to 
become with him a source of danger. There is Mr. Belfield, 
the solicitor; Mr. Fort, the master at Winchester ; and Mr. 
Symons, a barrister, who also mentioned that the ounce 
lasted him from 12 to 18 months. There is Mr. Denton, 
the commercial traveller, and General Lane. Mr Pick- 
meyer, the wine merchant and the active cricketer ; Mr. 
Lowry, the wine merchant, and Mr. Venn, the solicitor; and 
then came three doctors. I want to say a word about the 
three doctors. 

Mr. Justice Ridley : There are some more besides. 

Mr. Eldon Bankes : I think I have mentioned them all. 

Mr. Justice Ridley : There is Mrs. Pimm. 

Mr. Eldon Bankes : Yes, she came after the doctors. 

Mr, Justice Ridley : A very fine specimen. 

Mr. Eldon Bankes : A very fine specimen as I was just 
going to say—a very active woman because she said she had 




The Lancet,] 


TUCKER P. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 373 


got back to her work. I do not think she mentioned what it 
was. It is quite plain that she is not suffering from any 
disease which would make it dangerous to use the stuff. 
There is no indication that she used it too much. She is one 
of the people who benefited I do not doubt, and I have 
always tried to make it plain that you may have a thing, 
and you may deal in a thing, which may do good to some 
people and which yet may be characterised as fraudulent if 
you are sending it out indiscriminately, and you are certain, 
or reasonably certain, that it will do harm to others. The 
doctors I want to speak about in a different category. I 
should have thought the very last person to whom my friend 
would have referred to as being an instance in his favour was 
a doctor, and for this reason, that a doctor is aware of 
the dangers. A doctor is a person who is in the position 
of somebody who is warned, because he does not require 
warning, and he knows the danger; therefore, if you sell a 
thing to a doctor who knows of the danger of using or 
abusing this vaporiser, you are selling it to a person on 
exactly the same conditions as if you told him all about it. 
These doctors, of course, stand in a different category. Dr. 
Clark was a strong witness in the plaintiff's favour, but he 
is a man who, I suggest to you, holds very curious views 
because he went so far as to say that he would recommend 
this to his patients, and apparently without any warning, 
although he knew of 20 cases in which he knew it had given 
people the cocaine habit. There is no accounting for differ¬ 
ences of opinion, but to hear a medical man go in the box and 
say that- 

Mr. Justice Ridley : Although he was told of such things 
he did mot know of them. 

Mr. Eldon Bankes : If he were told of such things, yes. 
Supposing he were convinced that 20 people had acquired 
the coc-aine habit from the use of this thing he would still 
recommend it. 

Mr Justice Ridley: He said it would never do anybody 
any harm at all and he would not believe it. 

Mr. Eldon Bankes: That is quite true, but what I am 
saying is quite right, I submit, and it is this: You must 
judge what kind of a man this is by his answers. He says: 
“ I do not believe it will do any barm. I have never known 
it to do any harm, but even if I was satisfied that 20 people 
had acquired the cocaine habit from using it I should still 
advise my patients to take it.” The next witness, Dr. 
Rawlings, takes a very different view. I want to remind you 
of his evidence, although, perhaps, I am taking too long as 
it is; bat you will remember he said he considered cocaine a 
very daDgerous thing. He said it ought only to be used 
under the most careful restrictions and under medical super¬ 
vision, and so on. There is a man who took an entirely 
different view ; he had recommended it to a patient, it is 
true, but he could not tell you what the effect had been upon 
the patient. Of course, he had not sent for it, but that is 
a case in which it was recommended under medical super¬ 
vision, and that is au entirely different case from the 
case with which I am dealing, and the dangers which 
I am trying to point out to you. The last witness 
I deal with separately because he is the one man 
of all those who have been before us who apparently 
used it, at any rate to the extent of an ounce in 
three months. There may be people, of course, to 
whom the use even to that extent is not harmful, but he 
did make use of a plaintive expression, it seemed to me. 
He said “ unfortunately,” and you will remember the tone in 
which he said it. Then he was asked which he meant by 
that and he said that had reference to the price. Whether 
he used it once in three months or once in a year would only 
make a difference of about 32*. a year, and whether he really 
used that expression of ** unfortunately ” almost with a sigh, 
a gasp, because it was really a question of price, is a matter 
for you to consider. However, that is the plaintiff's evidence. 
Now 1 have dealt with it, and I submit to you that, looking 
at it fairly and lookiog at it reasonably, as I am sure you 
will, and bearing in mind the words which you have to try, 
it does not really assist you to call a number of witnesses 
who have been benefited, unless they come into the class of 
people whom I have been indicating who would be injured, it 
does no good. Now let me pass to our evidence, and I will 
deal with that as shortly as I can, and I am sure you will 
not grudge me the time. 

Mr. Justice Ridley : It is half-past twelve, Mr. Bankes, 

Mr. Eldon Bankes : I hope I have not been unduly long, 
but I must deal with this evidence, gentlemen, shortly, after 
the view that has been indicated to me more than once 


as to my position in this matter. I must deal with our 
case. We say this first of all; we say that this liquid 
does contain these poisons. You know it, and I need 
not go into it again; it does. We say that those are 
being sold in flagrant violation of the law of the land; 
and the importance of that is this: it is for the 
plaintiff, of course, to say whether he will take upon 
himself the risk of doing what the law forbids ; that is 
one thing ; but from my point of view the importance is that 
that law would not have been passed unless it had been 
recognised that the restrictions which the law imposes are 
necessary for the public safety. What are those restric¬ 
tions 1 The restrictions in the case of atropine—and this 
contains atropine—it so happens are stronger than the 
restrictions in the case of cocaine. In the case of prepara¬ 
tions of atropine (which this is) the law says that you may 
not sell it except to a person you know, or who is intro¬ 
duced by a person whom you know, and the law says that 
nobody may sell it except a registered chemist. If that is 
the law for the Englishman why should it not be the law for 
the gentleman who has been an usher in a school in America 
and comes over here and sells these thiDgs over here in 
enormous quantities ! Why may you not form a strong 
opinion about a man who comes over here and disregards—I 
do not care anything about the law—but disregards the pre¬ 
cautions which the legislature of this country, which means 
our representatives—your representatives and my repre¬ 
sentatives—have passed into law in Parliament because they 
recognise that in this country, at any rate, those are neces¬ 
sary precautions for the safety and well-being of the com¬ 
munity? Nobody may sell a preparation of atropine unless 
he is a chemist, unless he has gone through the course of 
training which the law prescribes before a man shall be put 
into that responsible position ; he may not sell it except to a 
man he knows or to a man introduced by a man he knows; 
he may not sell it unless he keeps a poisons book and enters 
every name, and so on. I need not go through the pre¬ 
cautions but the fact that this man disregards those pre¬ 
cautions which are reasonable and proper precautions is one 
ground, I submit, why a writer may use language of the 
strongest possible character. 

The next point is, we say that it is sold under conditions in 
which the sale is likely to do serious harm. Why do we say 
that ! May I put it shortly ’ We say it because he adver¬ 
tises it as a cure for asthma. Asthma to the patient presents 
the same symptoms as all those other disorders which I have 
enumerated, and therefore if a patient writes to him 
because he thinks he has got asthma he may be suffering 
from heart disease or consumption, as that man Cushing was, 
and he will get a thing for which he has to pay a large sum 
of money which will be positively harmful. It would not be 
fair to you that I should go through the evidence of medical 
gentlemen whom I have called, but I do ask you to re¬ 
member who they are. They are the heads of their profes¬ 
sions. I have called, amongst others, the man who, I 
suppose, at this moment is the actual head of the British 
medical profession, Sir Richard Douglas Powtll, who occupies 
at this moment the position of the President of the College 
of Physicians. They one and all have told you that in 
their opinion this sale in this way is calculated to do 
harm. They ridicule the opinion that because it is given 
in such infinitesimal doses it will not do harm and some 
of them rest their opinion, not upon the knowledge of 
the effects of these poisons, but upon their actual expe¬ 
rience of cases which have been brought before them. 
There is Sir Richard Douglas Powell; there is Mr. Francis ; 
there is Mr. Tilley, all of them speaking from an actual 
experience of what they have actually seen. I need not go 
in detail into the reasons they gave, but 1 should like 
just to refer to one reason to remind you of it. You 
will remember the emphatic language used by Sir Richard 
Douglas Powell when he said that one of the great dangers 
of this thing is that asthma is a most distressing complaint, 
and if a patient finds anything that relieves it, to use his 
expression, they fly to the remedy and take too much. I 
submit to you that no evidence could be more cogent, and it 
ought to be convincing. Why are you not to accept it ? Can 
you possibly disregard it ? What answer is it to say that 
there may be many hundreds of people who have not suffered 
harm if you find this evidence that there must be people 
who do suffer harm and that there are people who have 
suffered harm ? Gentlemen, remember, please, that you are 
considering that evidence in reference to a course of dealing 
in which this stuff is sent out without any sort of inquiry as 





374 The Lancet ] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


to whether the person to whom it is sent is going to be 
benefited or whether he is going to be harmed. 

I will pass from that point, and I want to deal now with 
our third point. We say that this is sent out, in itself 
harmful in its effects, accompanied by statements which 
are calculated to mislead. You will remember that 
those st dements are contained in three documents, so 
far as they are before you ; there is the pamphlet, there 
are the instructions, and there is the circular. What is the 
first thing that is said ! All three emphasise that this liquid 
is absolutely harmless. Can you conceive anything which 
justifies stronger language than that ! If you believe the 
evidence of our doctors, is any word too strong for a system 
under which a man sends out this dangerous stuff, telling 
people that it is harmless ? X should like, if I may, 
to give you an illustration drawn from what Sir Lauder 
Brunton said. Of course, he is a scientific man and 
he referred to alcohol in a scientific sense as a poison. Y'ou 
know, and I know, and everybody knows, that people do 
take quantities of alcohol without the smallest harmful 
effectB. Many people think it does them a great deal of 
good. But let me put this to you: Mr. Tucker has said 
that so safe is this that it may be taken by children of three 
years old. What would you think of a man who gave a 
bottle of rum to a child of three and told him at the same 
time it was harmless ? Have you words sufficient to express 
your indignation at such conduct or to characterise the action 
of such a man? But the analogy is quite sound. You arc 
telling a child that what, if used in too large quantities, 
would probably kill it, is absolutely harmless. What distinc¬ 
tion can you draw in principle between that man aDd the 
man who trades as Mr. Tucker trades ? There are other 
expressions in the pamphlet which have been referred to. 
There is one particnlarly which X want to mention. 1 suggest 
to you that the pamphlet not only says that the stuff is 
harmless, but it says that it will cure asthma. A good deal 
of criticism has been directed to that. Mr. Tucker says : “ I 
ask you to read that as saying, not that it will cure asthma, 
but that it will relieve an attack of asthma.” The question 
is, how would any honest person read that—how might an 
honest person read that when he receives the document ? 
Yon are familiar with the distinctions; he draws the dis¬ 
tinction in places between the relief of the attack and the 
cure. Y'ou will remember one passage in which he says : 
“It reaches the lungs in order to arre.-t the attack, 
heal the mucous surfaces, and cure the disease.” 
All I say, and all I desire to say, is that any 
honest, reasonable man reading that might very 
naturally, and I could put it a great deal higher, that he 
would necessarily, come to the conclusion that he claimed to 
cure it. But whether that is his meaning or not, that is a 
meaning which it may bear, and any critic criticising that 
system is entitled to form an opinion upon his reading of 
that language as ordinarily understood. I submit that I hare 
established shat point also. 

There are only two other points to which I have to refer 
and then I have finished about the evidence. One is as to 
the price. I do not want to go into this in any detail, but 
you will remember the strong expression is used that It was 
an exorbitant price, or that it was robbing the public, or 
words to that effect. You have to take two things into con¬ 
sideration. It is not merely the actual price, but it is the 
circumstances in which the stuff is sold. It is nothing to 
those witness s who have been called for the plaintiff to pay 
3 guineas ; they do not mind whether it is 3 guineas or 
20 guineas, probably, as long as they get relief. But the 
writer of this article has in his mind the poor people and he 
calls attention to it. He says this kind of thing attracts 
the poor people. He was dealing with the case of a poor 
labourer; ami I a-k you to carry your minds into the house 
of any working man at weekly wages and to realise for 
yourselves the privations that ttiat family would have 
to undergo in order to raise this sum of £3 to give to 
Mr. Tucker. They very likely would raise it—we know 
they do raise it ; but is it justifiable to ask a man to 
raise that sum, with all the surroundings which it means 
to him and all the consequences which it means to him, 
unless you have taken some reasonable means to satisfy 
yourself that he comes within the category of people who 
would be really benefited ! This man does not care. He 
says he believes, and I will accept his statement, that it is 
absolutely harmless. But that is not sufficient. Are yon 
justified in taking £3 ont of a working man's home simply 
because you believe that the stuff will not do him any harm ! 


Yon have to bear that in mind in connexion with the price, 
and when we come to the price you will re member quite 
shortly what the figures are. The price of the constituents 
of the liquid is in (i nitesimal—about 3d. It is sold to the 
plaintiff at about 2s. and he sells it at 8s. The price of the 
vaporiser, or an equally good vaporiser, is about 6». 6d., 
because I ask you upon onr evidence to believe that thoBe 
vaporisers which were put before you were equally good ; 
they all produce an equally good spray and he admits that 
they all produce an equally good spray, but his only com¬ 
plaint of the one which he produced was that it was nob 
strong enough. We produced two which upon examination 
proved to be stronger. My learned friend had some little 
complaint that he had not had the opportunity of testing them. 
That evidence was given on Friday and it is now Monday. 
If he had wanted to challenge that evidence there was plenty 
of time for him to have done so. He has not done it and 
therefore I ask you to believe that we have produced vapor¬ 
isers wnicb produce equally good vapour and are stronger 
than the plaintiff's, the price of which in this country is 
from 6s. 6 d. to 7s. 6 d. He sells his at 2Bs. He gets it 
from America at about 9s. without the bottle and 
the bulb. The result of all this is that his gross 
earnings in the year are £19,800, I think, of which 
he sends £5600 to Dr. Tucker in America and the rest is 
all profit, except the expenses. What do those expenses 
come to? He has told you it is about £1000 a year for his 
staff and something for his agents, but we do not know how 
much. He has no means of enabling us to judge and he has 
no means of judging for himself what the actual profit is, 
but he says that for the purposes of the income tax he puts 
it at 3d per cent. Bearing in mind that he pays £5600 to 
Dr. Tucker, the brother, that he pays £1000 for assistance— 
that is £6600 -and that on the top of that he has to pay the 
agents, whatever it is, and that he has only got the expense 
of the bottles and bulbs on top, it is a very generous estimate 
to himself to say that he is making only 33 per cent. I do 
not care what he makes. We know what they can be sold 
at and if he does not choose to carry on his business so as to 
be able to sell them at that price to the ordinary Englishman, 
it is equally true to say that he is selling these things at an 
exorbitant price, and at an exorbitant price which, having 
regard to the fact that he takes no pains to ascertain 
wbether this stuff is going to do harm or good, does justify 
as strong language as anybody can find in the English 
vocabulary. 

1 have finished our evidence and I ask you to say that we 
have established, when you know the whole story of this 
sale, a case upon which severe comment is justified and that 
we have not exceeded the limit of what any honest man 
might say nnder the ciroumstances of this case. I will 
not occupy you more than a minute, but 1 want just 
to conclude with a word about damages. Of course, you 
may take a contrary view. I do not know in the least what 
view you do take. I respectfully submit to you that 
we have made out that this comment is not in excess of what 
may be called for, but as counsel for the defendants I am 
bound to deal with the case as a whole, and I am bound just 
to touch upon the question of damages. Upon that all I 
have to say is this : This is not the case of a man who has 
suffered any pecuniary loss at all. Y'ou will remember this 
libel was in March, 1907. His sales during 1907 are higher 
than they were in 1906, although since May he has kept out 
of the returns the amount he has paid to the agents. There¬ 
fore, if that is any considerable amount bis sale- are consider¬ 
ably higher in 1907 than they were in 1906. He has suffered 
no actual damage, but he comes here to ask for your verdict. 
Y'ou will, I am sure, if you give a verdict to him, give him a 
verdict which, under all the circumstances, you think he 
deserves. Bat, gentlemen, I ask you not to give him a 
verdict which will be the very finest advertisement which he 
can possibly have for this system of trading unless you think 
that the system of trading is absolutely without reproach. 1 
ask yon to say that if yon think that the defendants have in 
substance established what they desire to say about this 
treatment, though possibly in your view they have not 
expressed their condemnation in right language -if that is 
your view of this case the verdict you ought to give to the 
plaintiff ought to be measured by the smallest possible 
amount of damages, and you will only give to him substantial 
damages if you wish it to go forth to the public that this sale 
by him, conducted by him, is legitimate, that it is safe, that 
it is not one which justifies any comment in such a sense as 
we have passed upon it. In conclusion, all 1 want to 





The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 3 75 


say is this upon this word “ fraud.” You will remember 
that the plaintiff said that he is selling thiB stud Indis¬ 
criminately, and indeed without apparently caring what 
the constituents are. It is quite legitimate to say of his 
system of dealing that it is a fraud upon the public without 
imputing any moral blame to him, if the fact be that he 
honestly believes that the stuff is genuine ; but if a man 
puts himself in this portion that he undertakes the sale of a 
thing without knowing what its contents are, he cannot 
shelter himself, if it is properly said of his system of trading 
that it is a fraud upon the public, behind the fact that he 
has thought that ignorance is bliss, and that it is folly to be 
wise, and he has not taken the trouble, for some reason best 
known to himself, to endeavour to ascertain what the con¬ 
tents are. He takes upon himself the responsibility of 
disseminating this stuff wholesale, and if he takes the 
responsibility, so he must take the blame if the fact be 
that the system is one which deserves the severest censure. 

I am much obliged to you. I hope 1 have not taken too 
long, but you will realise that there is an important question 
involved in this case, as I said before, beyond the mere 
interests of the plaintiff and defendants ; and I respectfully 
ask you to say that now that this thing has been thrashed 
out it is proved, and proved beyond any question, that this 
system of trading is one which admits of severe condemna¬ 
tion, and that the condemnation which has been passed upon 
it is not beyond what the occasion permitted. 

Mr. Di ke : May it please your lordship, gentlemen of the 
jury. The attack whi h Tre Lancet newspaper, that is the 
defendant in this action, made now nine months ago upon 
Mr. Tucker has been very grossly aggravated by what has 
taken place in the course of this trial. The attack which 
was made in The Lancet was an attack made confessedly 
without any knowledge of either Dr. Tucker or of his 
specific. Up to this morning one hardly conceived it 
possible that where a defendant in an action of this sort was 
going to ask the jury to say that whether the words he used 
were strong or not at any rate they were fairly and honestly 
■used—one hardly thought it possible where that was going to 
be one of the defences relied upon, that the defendant should 
close his case and not put into the box before the jury which 
was to try the case the man who had written the libel in 
order that the jury might see whether that man had taken 
any sort of pains whatever or gained any information 
whatever before he launched against a man who was carrying 
on a large business in this country a charge of fraud which 
if it were true and if it were found to be true must not only 
destroy his business but destroy his character. 

This defendant, the proprietor of Tiik Lancet, coming 
here with that responsibility upon him, that he has chosen to 
make such an attack as he has here upon another man’s 
business and another man’s character, treats your intelligence 
with such contempt that he does not go there to say that he 
believed a word of this and if he did not write it himself 
he does not call his servant who did write it before you to 
say that he believed it or thought there was the least 
justification about it. That is a very remarkable state of 
things. Instead of that he relies upon an array of expert 
witnesses who have been occupying your time now ior nearly 
three days, gentlemen, a part of whose business it is to go 
into the witness-box and to give evidonce to tell you that 
cocaine under certain circumstances is a dangerous poison. 
That is what he has done, and for the rest of it, for any 
other inducement which could be utilised to cause a jury to 
give their sanction to a charge of fraud against a man who 
is said by his customers, and by every customer of his who 
can be found, to have carried on a business which conferred 
upon them the highest benefits and earned their grat tude so 
that they were glad to come here and testify on his behalf, 
but has in order, as my learned friend says, to brand that 
man as a fraud, to brand his business as a fraudulent busi- 
ness, to brand his remedy as a fraudulent remedy, there are 
an array of expert witnesses and my learned friend Mr. 
Bankes. That is. why, feeling that the labouring oar was 
left with him this morning and that the expert witnesses did 
not seem to have come to much, my learned friend has had 
to spend the whole of this morning in the elaborate effort 
which he has made here before you to induce you to say 
that an honest transaction was dishonest, an honest business 
was a dishonest business, and that an honest man was a dis¬ 
honest man, because that is what you are asked to do. 

There has been a good deal of trilling with the charge 
that is made here, but we have had it out this morning. 


because point by point has been sought to be made and 
directed against Mr. Tucker to induce you to say that he 
was personally dishonest, and to thiuk so—to come to that 
conclusion; so that we know now what they meant and 
what the language of this libel meant. The words of it, I 
am sure, must be fresh in your recollection. Having got an 
opportunity furnished by some wild observations—wild 
and unwarranted observations—of Dr. Waldo, observations 
as injudicial as any observations made by an officer holding a 
judicial position possibly could be—having got She oppor¬ 
tunity of those, and having had them sent to him by Dr. Waldo 
for the purpose, the defendant without inquiry and without 
knowing anything about Dr. Tucker, without analysis of the 
remedy or anything of that sort, writes this article and he 
stigmatises Mr. Tucker’s system of dealirgas a fraud, and he 
goes on to say in effect that there are in this country a 
number of persons who sell fraudulent specifics, that Mr. 
Tucker is one of them, and that these frauds amount to 
robbery and to murder—frauds which he says Mr. Tucker 
commits ; and then he says, “ Why do the newspapers of this 
country help Mr. Tucker and these other people, these 
fraudulent people, to commit their frauds ? ” That is the 
effect of what he says. When you come to see what warrant 
he bad for Baying it, by an answer on oath which is made 
here this morniDg on the part of the defendant, the warrant 
is: “1 made no inquiry as to the truth of the statement set out 
in the said interrogatory before printing and publishing the 
said statements and took no steps to test the reliability of the 
information which I had previously received as to the said 
statements because such information was derived from a 
cutting from the Morning Adrertiucr of Wednesday, Jan. 2nd, 
1907, which said cutting was forwarded to The Lancet by 
Dr. F. J. Waldo the coroner ” and certain advertisements of 
quack medicines. Having said that originally he corrects it 
months afterwards and says, “ I also had your directions for 
treatment.” Having made that attack upon a man’s business 
integrity and personal integrity he now has to justify it or to 
excuse it and you have seen the sort of means by which it is 
proposed to be done. There are two answers, so it is said—- 
I believe there is only one, but my lord will tell you—to an 
action which is brought against you if you have charged a 
man with fraud. I anticipate my lord will tell you, if my 
lord takes my view of the law, that if you charge a man with 
fraud, if you say a man is a fraudulent man and you do not 
prove it, you must pay for it. 

Mr. Justice Ridley : Y’es ; that is right. 

Mr. Duke : 1 so understand. 

Mr. Justice Ridley : I have not any doubt about it at all. 

Mr. Dike : It has been established a very long time. It 
has been said that public writers have the privilege of doing 
this sort of thing. A man who is invested with judicial 
functions may do injustice to his fellowmen and not pay 
for it- 

Mr. Justice Ridley: It would never do at all. Yon 
cannot justify an attack vilifying a man’s character by 
saying that it waB fair criticism upon a matter of public 
interest. Where would the character of individuals be 1 
1 shall lay that down very strongly to the jury without any 
hesitation at all. There are authorities without end upon 
the subject. The question for the jury is, Is this an attack 
upon the plaintiff’s character? If it is, he is entitled to a 
verdict, but if it is not, and is a mere criticism upon a 
matter of public interest, therefore not attacking his 
character, then the defendant would be entitled to a verdict. 

Mr. Dijke : If your lordship pleases. 

Mr. Hugh Fraser : I do not know whether 1 ought to 
ask your lordship to hear me on the point of law. 

Mr. Justice Ridley : I have heard Mr. Bankes and X 
shall not hear any more. 

Mr. Hugh Fraser : I know he cited the authorities in 
the course of his speech. 

Mr. Justice Ridley : He cited the authorities but he has 
cot cited the leading one. I have no doubt be knew about 
it. I have no doubt about the law, but it there is anything 
wrong about it you must take it elsewhere. You cannot 
justify an attack upon a man's character which charges him 
with robbery and fraud—an attack of an off csive character— 
by saying that it is a fair criticism upon a matter of public 
interest. 

Mr. Duke : That is what I understand to be the law. I did 
not bring a lot of hooks here, gentlemen, and read you 
passages out of them because, of course, before you would be 
able to gain enlightenment from them you would have to 
have some knowledge as lawyers, and you would have to 



376 Thh lanobt,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


know the facts of the particular case. The business of the 
judge in these courts, as I said a long time ago, is to tell ns 
what the law is, and I hear from my lord- 

Mr. Justice Ridley: I cannot myself distinguish the 
speech made by Mr. Bankes from the speech which he would 
have delivered if there had been a justification upon the 
record, except on this point where he argued very pointedly 
to the jury as to the meaning of the word fraud and as to its 
application to the Bystem and not to the man who carried on 
the system. 

Mr. Duke : I follow. 

Mr. Justice Ridley : It will be for the jury to say which is 
the right view of this matter. 

Mr. Duke : We get to that now, that if the defendant has 
thought fit to attack the personal character of the plaintiff 
and to charge him with fraud, if it is not true that 
the plaintiff is a fraudulent person then the defendant 
must make amends to the plaintiff ; and I said that this 
case was aggravated by what had taken place in the trial, 
because every doctor who was put into the box went into 
the box with the intention not of discussing a matter 
of public interest but of striking down Mr. Tucker and of 
destroying Mr. Tucker. My learned friend’s speech when he 
opened this case, and every question he has asked in the 
course of the case, and the long speech with which he 
summed it up, have been aimed at destroying Mr. Tucker, 
at making you believe that Mr. Tucker is a dishonest and 
unworthy man who ought to be held up to opprobrium, and 
that it is a misfortune of the defendants that they have not 
put it here plainly on the record that he is a dishonest man. 
They did not venture to say it. They had months to decide 
whether they would say that he was a dishonest man and 
they did not dare to put it on the pleadings, but they 
bring a multitude of eminent expert witnesses and my 
learned friend, and they seek to do by a side wind what 
they did not dare to do on the pleadings. Is it true to 
say that Mr. Tucker has behaved like a dishonest man with 
regard to this remedy ? You have heard all there is about 
it. You know how it came into existence ; you know what 
he has done with it ; you know the benefits which have been 
derived from it. It is not true and it is not fair ; aDd I am 
going to deal with the two questions together, as in fact the 
defendant has had to deal with them. Knowing it is not 
true he has said, if it is not true it is a thing a man 
might honestly say about him. I am going very shortly to 
deal with the case upon that footing. Let us see what 
was being dealt with. You had got here a disease which is 
a grievous burden upon people who are afflicted, which 
disables them. It does not kill them, but it disables 
them ; it takes a man in his employment, takes him in his 
bed, takes him as may happen on any occasion and prevents 
him from living the ordinary life, from drawing his breath, 
and puts a weight upon him. and a burden upon him, and he 
cannot 'get his breath. You have seem them, I daresay, 
struggling painfully to get the breath. A man knows if he 
could gets his breath and relieve that disability of the lungs 
he would be right again. Y'ou have it arising in people who 
are otherwise in strong health at times, but asthma takes 
them in that spasmodic way. Y’ou have the medical 
profession failing; during all the generations which the 
medical profession has had to deal with the matter it has 
failed to deal with it by any prompt and efficacious means, 
and that is confessed by the medical men whom you have 
seen in the witDes6-box. Down to this time they have been 
content to go on with old methods which fail in the multitude 
of cases as they failed in the cases which you have had 
before you to relieve the ailment. I called before you ten or 
a dozen, perhaps, of patients out of 25,000 who have testified 
to the benefits of this remedy, who have been Mr. Tucker’s 
real advertisement. I have called them before you and they 
have come here and told you : “ Our life has been changed 
by this specific. We were subject to this disabling malady ; 
we are not subject to it now, we are masters of it because 
here there is this specific which if you get into your lungs 
checks the attack, and that sets you free to go about your 
business ” An objection is made that I do not call all of 
them. Do you remember how eager my learned friend was 
that I should not call any more ? Do you remember how he 
suggested to me what he was willing to admit, and how 
I thought that, at any rate, those who were here in court 
had better come before the jury, and the jury had better 
Bee them. My learned friend did not want to see them. 
You had that disease of asthma, you had tint con¬ 
dition of things in the medical profession that they had 


failed to grapple with it, then you had this remedy and this 
remedy did grapple with it. I do not know whether it could 
have a higher recommendation than it got out of the mouth 
of Dr. Francis who was called by the defendants when he 
said that he knew of no remedy which supplied such imme¬ 
diate relief in the case of asthma as this specific of Mr. 
Tucker. That was Dr. Francis’s own statement. So you 
have it that the disease is almost universal, the failure of the 
medical profession virtually confessed by large numbers of 
medical men who have come here to join in the attack by 
which Mr. Tucker is to be hounded down and prevented from 
curing asthma which doctors failed to cure, and you have the 
Tucker’s specific. What The Lancet people knew about it 
was as every medical man, and every man of common sense 
knows, that there was the disease, that there was the failure 
to find in the pharmacopoeia the remedy. Did The Lancet 
know that Mr. Tucker had found a remedy ? Had they 
become aware, as Oppenheimer's had become aware, and as 
the doctors had become aware, that where the old fashioned 
medical skill had failed Dr. Tucker had succeeded—that 
his sufferings for ten years and his medical knowledge 
operating together had solved this difficulty! Did 
The Lancet know it—and that public attention was being 
directed to it, that asthmatic people were getting to hear 
from their friends: “Well, the doctors cannot cure you, 
but Tucker’s specific can, and Tucker’s specific can drive 
off these attacks ” ? Had they become aware of that ? It is 
exceedingly likely they had. Oppenheimer’s had been putting 
in that book which was produced here a catalogue of drugs 
sold by wholesale without any restrictions of the Pharmacy 
Act, without any interference of the law, an advertisement 
of a specific which the doctors say is obviously an imitation 
of Tucker’s but is not so good. That is what their doctors 
say. They say in their advertisement of it : “ We have 
compounded this because of great numbers of applications 
we have been getting about it from esteemed members of the 
medical profession ; we have published to meet that demand, 
and we are able to tell you that we believe it will produce 
the same results ” ; and they send it out. Do you suppose 
that when a medical man has supplied his patient with the 
fluid once, and that patient has got an atomiser once, if in 
fact the atomiser does produce a vapour which relieves the 
attack of asthma, that patient is ever going to relrain from 
the use of that as long as he is subject to attacks of asthma ? 
It is not common-sense to suggest it, and it does not seem 
to me that it can be honestly suggested. That is the 
position—great knowledge in the country of which we 
have become aware to some extent in the last few days, 
300 declared doctors, doctors who have sent as doctors to 
Mr. Tucker to get this specific, with Sir Stephen Mackenzie, 
an eminent specialist, at their head (who happens to be on 
the continent just now, or he would have adorned the 
witness-box), with the two or three doctors I have had to 
call on this charge of fraud—all these doctors using and 
presumably recommending this specific, Oppenheimer’s intro¬ 
ducing a specific and selling it as the same in effect, 
although the medical witnesses here say: “No, it is not 
as good as Tucker's, it is not as effective.” And Oppen- 
heimer saying with regard to that specific that it is 
perfectly safe: “In compliance with the Sale of Poisons 
Act this preparation is labelled ‘Poison,’ bnt never¬ 
theless is perfectly safe if inhaled by means of the 
aeriser or vaporiser.” That is Oppenheimer’s attempted copy 
and that is the state of the case when The Lancet comes to 
publish this attack on Mr. Tucker and, of course, it is very 
material with regard to the question of the damages which 
you ought to give to Mr. Tucker in this case to see what 
skilled people knew about this before they let themselves 
loose to destroy Mr. Tucker by stigmatising him as a 
fraudulent person. It is material to see that the medical 
profession was aware of the benefits of his remedy, was 
aware that large numbers of persons were using it 
beneficially, was aware that wholesale druggists were 
putting up a compound in imitation, not by way of 
invention, but by way of imitation, and that was adding 
to the use of this specific. That is what they knew if they 
knew anything about the public part of this matter before 
they set out to attack and to destroy Mr. Tucker. It makes 
their attack more serious. There are certain things they are 
entitled to do. They are entitled next week to publish an 
article and say : “ We believe that this composition of Dr. 
Tucker's contains cocaine and atropine in small quantities 
but those are drugs which if they are taken in quantities 
which we could mention are poisons and have deleterious 


I 




I 

it 

si 

i\ 

it 

(I 


si 

h 

n 


Thh Lancet,] 


TUCKER *. WAKLKY AND ANOTHER. 


[Feb. 1, 1908. 377 


effects ; and we warn people against using Tucker’s remedy.” 
They could have said that. They could have said: “We 
believe this cannot be sold, except by a member of the 
Pharmaceutical Society, and Dr. Tucker ought not to sell 
it.” They could have said that. They could have said : 
“Things of this kind ought not to be sold or dis¬ 
pensed by anybody except doctors and any member of the 
public who uses a thing of this kind, except when it 
is prescribed by a doctor ought to be sent to prison.” They 
could have said that. It would have seemed a little startling 
but it would have protected the medical profession in that 
way by saying : “ This is a public danger ; you may get so 
fond of cocaine if you inhale a specific two or three times 
in which there is some slight medicinal trace of cocaine—you 
can get eo fond of it that you may take to drinking it and 
you will be poisoned.” That they could have said; they 
could have used all the army of bogeys which they have 
raised here before you. It is quite open to them to do it. 
Those would have been legitimate means of attack upon Mr. 
Tucker. That is what they could have done when they were 
discussiDgit ; butthat would not do for them. They had got 
to destroy him apparently, according to their view of it, so 
it would not do to discuss him in that way. Having taken 
upon themselves to say that he was a fraudulent man, what 
could they have done in order to find out whether he was a 
fraudulent man or not ? They did not know whether he 
was or not. You may think it was either their fault or 
their misfortune. It is an astonishing thing that you should 
say about branding people with charges of fraud without 
knowing anything about them, but apparently that is not 
regarded as anything out of the way in The Lancet Office. 
They had made the charge. What could they have done ? 
First of all they got discovery in this action of all the 
names of his patients. They have had his books and they 
have ransacked his books. I am entitled to tell you in 
answer to wbat Mr. Bankes said just now that we should 
have done something or other, I forget what it was, about a 
patient of Dr. Francis who was mentioned last week, that 
they have been down 6ince Friday and investigated Mr. 
Tucker’s books about that matter to see whether there was 
anything there upon which they could further attack Mr. 
Tucker. Having that command of Mr. Tucker’s books which, 
confident of his integrity in the matter, Mr. Tucker readily 
gave them, they had access to these 25 000 who had used the 
drugs and used the specific. They had his little pamphlet 
here with sheaves of testimonials which had been received at 
the end of it. They could have gone to every one of them, 
and you can consider for yourselves whether they probably 
did. They had all that means of knowing whether Tucker 
was doing good or doiog evil, and having that means of 
knowledge what is the position ? They do not call one 
single person who has had any direct dealing with Mr. Tucker 
and they do not call one single person who has used this 
specific—not one. Having that means of condemning him 
if be was guilty of this charge of theirs, they give it the 
go by. My lord asked in the course of my learned friend's 
opening of this case whether part of the defence was to call 
people here said to have been injured by this specific. 
You beard the sort of answer which was got. Ultimately 
it was said : “We are going to call doctors who know of 
people who have been injured,” and then Dr. Francis comes 
into the box, and he says there was a gentleman who said 
that he got a great benefit for five years from using 
this specific, whom he found using it, but when he came 
under Dr. Francis’s treatment he told him he had better not 
use it so often: thereupon he said, "If you think that 
I will give it up,” and Dr. Francis burned his nose. That 
U Dr. Francis, and that is the evidence against the Tucker 
specific—that there was a man who is not called, but who 
is here in London—whose name and address they do not 
mention to Mr. Tucker, and about whom they do not 
challenge him in the least—a man here in London, and 
known to them as well as to Dr. Francis, who can be put 
into the box if there is any ground at all in any dealing of 
Mr. Tucker with him for this charge of fraud ; and they 
called an expert witness to attack Mr. Tucker and he is 
chiefly valuable to them, because he is able to slip out a 
statement that he knew a man who had taken it for five 
years and who nevertheless came to him with regard to a 
condition of asthma. 

That is the evidence, really, against Mr. Tucker, with 
regard to this specific. On the one side there are the 
25 000 persons who have had beneficial user, the 300 
doctors with Sir Stephen Mackenzie at their head, the 


testimony of the defendants' witnesses in the box, the 
testimony of the fact that Oppenheimers put np an in¬ 
effective imitation of this specific and sold it at 3s. 6 d. 
an ounce, the testimony of witnesses who have gratefully 
come here to repel this charge of fraud and to support 
Mr. Tucker in the attack which is made upon him ; and 
on the other side there is Dr. Francie, whose view of 
the proper treatment of asthma is that it includes the 
burning of the patient’s nose, and who has found a person, 
who cannot be produced here, who does not come here, 
whom he advised not to use the specific so often and who 
thereupon said, “Very well, you are dow my medical man 
and if you do not like my using it so often I will give 
it up altogether.” That is the foundation in fact for all 
this machinery for suggestion and alarm which has been 
elaborately raised by the doctors. You have had them 
here—I will not say in a never-ending procession, but 
one did get a little tired even of cross-examining them. 
Ask yourselvfs with regard to those doctors, Does either 
of them know anything about the Tucker specific ? 
Neither of them has ever used it ; neither of them has 
ever—if he had asthma—tried this remedy ; neither 
of them has apparently prescribed it; but certain of 
them have sanctioned the use of it by their patients. 
That is a remarkable thing, because you cannot tell, whether 
you are a doctor or not, whether a man may run a risk of 
acquiring the cocaine habit, as it is called, the habit 
of relying upon a drug ; you cannot tell that because you are 
a doctor; the only thing which can show it is if it happens. 
But these doctors tell you “ Yes, I have allowed my patients 
to go on using it, and I have told them they had better not 
use it,” I think it was, “ more than two or three times a 
day.” Oddly enongb that is the number of times which 
Dr. Tucker prescribes for the use of it in his directions which 
are attacked. Three times a day, ne says, is about the number 
of times—I forget whether it is three or four, but something 
of that kind. That iB the position with regard to the army of 
doctors. They have said, “ Yes, cocaine is a poisor.—that is, 
it might do barm. It is used medicinally,” they say. It is 
used to a large extent medicinally. I venture to say if you 
buy a box of lozenges for jour throat you are exceedingly 
likely to find that one of the ingredients in it is a 
trace of cocaine, because cocaine, as one of the doctors told 
you, repeating a matter of common knowledge, is the 
product of a plant which the natives of some part of South 
America use in great quantities to strengthen themselves 
or to relieve themselves against the consequences of fatigue. 
That is what cocaine is, and they all know it. That 
is the way in which the doctors became aware of it 
originally, because they found the beneficial use of it 
by these South American natives. “ But it can hurt 
people” they say; “you may get the cocaine habit.” We 
did not go into the detail of finding out what happens 
to a man if he has got the cocaine habit, but we were 
told about atropine—that if you took enough of it it 
would cause madness. I do not know whether anybody has 
been taking atropine in large quantities in this case, but 
there has been a vehement inflammation about the sort of 
attack which has been made upon Mr. Tucker which might 
be accounted for, perhaps, by the resort to an excessive 
quantity of atropine. However, cocaine and atropine are 
said to be the ingredients, and then these gentlemen forth¬ 
with treat Mr. Tucker as though be had taken some fluid 
which was cocaine and atropine and had given it to people 
to introduce into their systems—to drink or to intro¬ 
duce into their vein or something of the kind—regardless 
of the true facts of the case. Wbat are the facts of 
the case about the use of these things, assuming there 
is a trace of cocaine and a trace of atropine ? The 
fact is this—that if those doctors are right and there 
is the cocaine which they say in an ounce of this 
fluid, in the course of three inhalations, which is what 
Dr. Tucker tells the man who uses the atomiser to 
take, you will get, according to Dr. Willcox's evidence, 
vapour, diffused throughout which there will be 3/20000th 
parts of one grain of cocaine. So that filling your lungB 
according to the treatment—that is wt at Dr. Tucker 
says quite clearly—you will inhale three times ; he says 
you will be able to get into your lungs “ three shots,” to 
use an expression which I used, with a little practice; 
so there will be 3/Z00O0th parts of one grain of cocaine 
and that will be diffused through a volume of vapour 
which will fill the lungs and which you are directed by 
Dr, Tucker to blow out, because he says If you exhale and 




378 The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. X, 1908. 


see the vapour issue from your mouth you will know that 
the vapour has entered your lungs. Therefore your risk 
of cocaine is the risk of a quantity of vapour large enough 
to fill the lungs which is medicated to the extent of 
3/30000th parts of a grain in, 1 suppose, two quarts of it— 
a volume sufficient to fill the lungs. Doctors come here one 
after the other and tell you, ‘‘We call that poisoning people; 
we say that the use of that remedy is the use of a poison, 
because we say there is that trace of cocaine in it.” I 
venture to say to you that whatever the doctors say about 
it, the common-sense of the matter is that there is nothing 
poisonous at all in it, and that the reason why nobody 
is produced here who has been either poisoned or hurt is 
because nobody ever has been poisoned or hurt, and that 
it would be as reasonable to speak of the man who had 
got his dose of this vapour into his lungs as having 
undergone poisoning as it would have been for Sir 
.Lauder Brunton to tell me when I got back from my 
lunch that because I had taken a little whisky-and-soda 
with my lunch I had been poisoned. It is the abuse of 
a thing which you refer to when you speak of poisoning 
in such a connexion. Sir Lauder Brunton compared it to 
the case of a man who used a stimulant, ag we call it, 
habitually. He Bays that is a poison. Of course, if that 
is the kind of thing which you are dealing in, very well; 
if it is a temperance platform you are speaking from so 
that when you hear the orator you know that what he has 
got in his mind is a notion which leads people to speak 
of good creatures of the earth as though they were foul 
things, without discrimination, as though they were neces¬ 
sarily evil, whereas they are only capable of evil. If 
you have got that explanation then we know that when 
a man talks of poisoning he is talking in what we used 
to call a Pickwickian sense about poisoning ; but when 
you say that a man who sells a specific medicine is 
poisoning and robbing people and that he is carrying on 
a system of fraud you are not talking in a Pickwickian 
sense, but you are talking language in the sense in which 
it is understood, aDd whether it is true or not you mean 
people to understand, and The Lancet meant people to 
understand, that Mr. Tucker was dishonestly selling poisons, 
and that he was robbing and injuring people by a sale 
of poisons, and fraudulently doing it. 1 venture to say 
that after you had heard what fcjir Lauder Brunton had 
to tell you about his justification when he compared this 
inhalation of the vapour of cocaine with the habit people 
have in this country of taking alcoholic liquors, and 
said it was the same thing—I venture to say he had 
given away the case for the defendants, and that it was 
idle to pretend that there was any real danger against 
which these doctors had come here to warn you. There is 
nicotine in tobacco ; very well. If you take pure nicotine 
you will be poisoned, so if I give yon a cigarette, gentlemen, 
I am poisoning you. There is caffeine—a very powerful 
drug—-in coffee. If you take it neat it will kill you, perhaps ; 
if you give me coffee you have poisoned me. There is 
cocaine, it is said, in some infinitesimal quantity in this 
vapour. You are a free man and you can go about your 
work, but the man who has provided that relief is fraudulent 
and dishonest and a rascal, and he has poisoned you. I ask 
you to attach no more importance than it deserves to that 
body of medical evidence. It was an attempt, I venture 
to say, to raise a bogey in the public mind against any specific 
medicine which is not prescribed by medical men. It is 
not the first time it has happened and it probably will 
not be the last. Medical men naturally enough take an 
extravagant and unreasonable view about these things. 1 
ask you to assume that they took that extravagant and un¬ 
reasonable view because they were medical mea and not 
because they were expert witnesses, and I ark you to take a 
reasonable and sensible view and to say whether it is an 
abuse of language if a roan knows all the facts to say that 
Mr. Tucker was a man who was poisoning his fellow-men, 
which is what they say with regard to him. 

1 have come pretty well to the end of what 1 have 
to say to you, because you have listened to this case 
and 1 am not going to make you a long oration. They 
say cocaine can only be sold under the restrictions of 
the Pharmacy Act. If their evidenoe is true these medical 
men have known for years that there was cocaine in this 
specific. How is it, if it was true, that Mr. Tucker has 
not been stopped by means of the Pflarmacy Act 1 The 
Pharmacy Act is quite simple in its operation : it says that 
-you shall not sell poisons. There are decisions on the 


Pharmacy Act, and one of them is to the effect that if 
the trace of poison is infinitesimal, if you cannot fairly 
say that the mixture is a poison, then the man is not 
guilty of an offence. That may have something to do 
with it, but when they brandish the Pharmacy Act before 
you my answer to that is, “ You know all about the Pharmacy 
Act and you evidently know all about Mr. Tucker. If it 
applied to his case and you are so anxious to stop him 
why did not you stop him 1 ” Nothing of the sort. The 
Pharmacy Act had nothing to do with it; they did not even 
consider it; but it came in as an after-thought. Then 
what else is it that is said ? Cashing is spoken of; I 
must not omit that. It is said: “You sold this to Cushing 
for £3." Cushing was an intelligent fitter, a mechanic, who 
in 1904 found himself troubled with asthma, and said so, 
and who from 1904 to the end of 1906, apparently carried 
this inhaler with him, and relieved his asthma ; and Cushing 
by that means was able to go on and earn his and his 
wife’s livelihood down to the time when he died of a 
different disease with which he was also troubled -namely, 
consumption. As was shown by the evidence, this intelli¬ 
gent man, knowing of his occasional trouble, and knowing, 
no doubt, of the deep-seated trouble which must kill 
him eventually, and having no -faith in anything the 
doctors could do for him, but knowing the effect of this 
remedy, having tried it, he bought it, and, having bought 
it, he went on using it; and the last supply to him had 
been within a very short period of the time when he was 
no longer able to use any remedy. Then it is suggested, 
forsooth, that that was a fraud upon Cushing. They have 
not even ventured to call his wife. His wife was at the 
inquest, as they knew, and you would have thought if 
there was any fraud on Cushing that Mrs. Cushing would 
have known something about it. The report of the inquest 
said, of course, that she was in court. The fact is 
that Cashing was a man who had derived benefit, who had 
saved himself from the possibility of asthma, and from 
doctors’ bills for asthma, for two or three years before 
the time of his death, by the use of this remedy. That 
is the true position about Cashing. Never a word of com¬ 
plaint has ever been made from first to last, but a resort 
to the one means of relief which was found to be 
open to him. No wonder that they did not, in their 
defence in this action, venture to suggest that Cushing was 
defrauded ; and they did not; not a word has ever been 
said to that effect. It is reserved for my friend’s innuendo 
in a question and his suggestion to you in his speech. That 
was the case of Cushing. In addition to that it was said, 
“You say this thing is harmless "—the very same thing 
which the medical profession through Messrs. Oppenheimer 
say with regard to the imitation—“If you inhale this it is 
quite harmless," which is the same thing as Dr. Tucker said 
in the latest circular which he sect out. He has been 
attacked as to the constituents and he says, “ Well, however 
that may be, the use of this vapour cannot be otherwise than 
harmless, and it is found highly beneficial.” It is said, 
“You said it will cure asthma.” The specific attack un¬ 
doubtedly is cared. The testimonials here are the best 
means of showing what they said. I have read to you three 
or four of them, and every one of them said : “ We do not 
say it has cured asthma ; we say it effectually relieves it and 
it is very much better.” Then it is said : “ It is an extravagant 
price." There are some of the witnesses here who have had 
experience of the prices. 

When this defendant wrote his charge of fraud against 
Mr. Tucker be was not thinking of the extravagance of the 
price, he was not thinking of the question of whether there 
was more or less of a trace of cocaine, he was not thinking 
of whether it was immediately beneficial or permanently 
beneficial, he was not thinking of poor Ciuhii g ; he was 
thinking of what he regarded as the interests of the great 
medical profession. He desired, and be permitted himself, 
to bracket Mr. Tucker with a class of people who he said 
were robbers and murderers, and now he comes and he has 
to justify himself. You have heard all his evidence ; you 
have beard the devices wbich have been resorted to in 
the vain attempt to convert these matters of disputed 
opinion, of disputed fact even, into a ju tification of acharge 
of fraud. I venture to say to you that that charge is proved 
to be untrue, and it is proved equally to be grossly unfair; 
and I venture to say, further, that having come into a posi¬ 
tion in which it was open for them to have shown courage 
and honesty in dealing with this man whom they had libelled, 
the defendants, after they have become aware for many days 




TOT LANCET,] 


TUCKER v. WAKLEY ANT) ANOTHER. 


[Feb. 1, 1908. 37£ 


that they have libelled him, have gone on wilfully, 
obstinately, upon grounds which in no way warranted 
their conduct, persisting in a charge of fraud, and that 
instead of public spirit and courage in dealing with a 
situation in which they have done wrong they have resorted 
to mean and cowardly attacks which have greatly aggravated 
the wrong they have done. Bearing in mind that they knew 
nothing about this man when they attacked him. and bearing 
in mind that when they had found that they had wrongfully 
attacked him and that there was no just charge upon his 
personal honesty or his personal integrity, they went on to 
fabricate imputations against him, to support them out of 
little passages here and there in the pamphlet and in the 
instructions, and to base them upon the bitterness with 
which medical men regard the unlicensed competitor, I ask 
you when you come to do justice to Mr, Tucker in this case 
not to stint the damages with which you will show resent¬ 
ment of conduct which is unworthy of journalism as it is 
of the best interests of the public or of the medical pro¬ 
fession. 

Mr. Justice Ridley, in summing up, said: Gentlemen of 
the jury, 1 daresay you will be glad at having arrived at the 
final stage of this matter, when it will be for you to decide 
who is entitled to succeed in this case. You must not 
suppose that I wish to interfere in the slightest degree with 
your province in that matter, because it will be for yon to say 
in this case who is to succeed, whether the plaintiff, so that 
he should recover damages for the attack which has been 
made upon him, or the defendants upon the ground that it 
was a fair comment. 

The first question which I shall have to ask you is 
this: Was this an attack upon his character at all ? 
and in order that you may understand how that question 
arises I thiDk it will be necessary that I should say just a few 
wordB upon how it is that it is a question for you. When 
people are attacked by way of defamatory statements 
there is one defence which is always attempted to be 
made, one which makes defamatory statements cease to be 
a libel, which is Urn—a fair criticism on a matter of 
public interest. It is very much analogous to the 
criticism upon authors’ works, upon books, or upon plays, 
but in this case there is no question of the latter sort, 
the question is whether this is not a public matter upon 
which fair criticism is allowable so as to prevent a 
defamatory statement from being a libel at all; and that 
is what the defendant has said that it is. If that were 
true, and if it satisfied you that although it does attack, 
and is a defamatory statement, yet that it is a fair 
criticism upon a matter of public interest, he is entitled 
to succeed. But there is an exception ; there is a 
qualification to that rule. It is this : that if the statement 
is not merely a defamatory one but it does attack the 
personal character of any individual that individual has a 
right to say, You shall not do that as a matter of public 
interest, but you mu-t justify it if it is true. My character is 
sacred to me, says the plaintiff in this case, every bit as 
much as that of any other person who is living in this 
country, ai d is is no answer to me to say that it was a matter 
of public interest that I should be charged with fraud, with 
robbery, and with poison ; that will not do. I am quite 
clear upon this matter as far as I am concerned and as far 
as my opinion goes, and therefore it will be neoessary for 
you to say in the first place, Was this an attack or not upon 
the personal character of the plaintiff ! 

Before I leave that part of the case, although it is not 
necessary for me to argue points of law, or to explain how 
that point is arrived at as a matter of law, I should like to 
quote just two cases upon this matter. The first of them 
was decided a long time ago, in 18Z8; it was decided against 
Wakley, the editor of The Lancet —the same defendants 
that are preset t in this court to-day. I do not use that as a 
matter of prejudice; but the editor of The Lancet was 
sued in 1828 for libel. In those days there was a London 
Medical and Lhyaical Journal current which was a rival of 
The Lancet, and in The Lancet was published a libel 
which is not set out in the report as far as I know, but it was 
sued upon as havirg been written in order to cast ridicule 
upon the journal of the plaintiff who was the proprietor or 
editor of the other journal ; it was one against the other. The 
defence set up was that it was a matter of public interest 
and that it was fair criticism. The Lord Chief Justice in 
summing up the ca-e said this : “ It ha8 been stated on the 
part of the defendants that the matter contained in this 


publication relates to the plaintiff only as an author p 
but still there is no doubt that a man who is an author 
has a right to have his character protected just the same 
as if he aoted in aDy other capacity.” Now you might say 
the same here—that it relates to the plaintiff only as the 
advertiser and vendor of a certain specific ; still, there is no 
doubt that he is as much entitled to have his character 
protected as if he had acted in any other capacity. “ How¬ 
ever. notwithstanding that, whatever is fair and can be 
reasonably said of the works of authors or of themselves as 
connected with their works is not actionable unless it 
appears that under the pretext of criticising the works the 
defendant takes the opportunity of attacking the character 
and then it will be a libel.” That is the case here. There 
is a case which I should like to add to that and then I will 
pass on. It was decided in 1904, where precisely the same 
rule appears to have been laid down by the Court of Appeal. 
That is the case of Joynt v. The Cycle Trade Publishing 
Company. Therefore that is how the question arises. You 
will be good enough to answer that according to the best 
opinion you can form of the libel itself. 

After that there is another question—namely, whether it is 
a fair criticism at all, which, of course, must be submitted 
to yon ; but as to that I say nothing for the present. Now 
was it an attack on the character of the plaintiff is the first 
question, because you will see that if it is, there being no 
justification, it should entitle the plaintiff to a verdict 
according to the authorities which I have quoted to you and 
according to a most beneficent and proper principle of the 
law as I understand it. Therefore, I shall ask you first of 
all to consider the words of the libel and the way in 
which they have been construed by the witnesses put 
before you with a view of saying whether this was 
an attack upon the character of the plaintiff or whether 
it is merely, as was put by Mr. Backes in his very able 
speech beiore you, merely an attack on the advertisements 
of quack medicines and as a statement not of fraud meaning 
dishonesty but a statement that there was a fraud in 
the sente of statements calculated to deceive put forward 
in those advertisements. I think I do not unfairly state the 
argument which he puts before you. He says : It was not 
fraud in the plaintiff that we alleged, but fraud in the 
system—namely, advertisements which contained statements 
calculated to deceive ; that is what we said : we did not 
say he was fraudulent, and we did not say anything 
against his character, but we said it was the advertise¬ 
ments which were bad ; we said it was the system which 
was bad, and we did not say that he was ; the word 
“fraud” was indeed used of him, but only in the sense 
which I have indicated, and the other words, such as 
“quack,” rob, and “poison,” were not used of him at all. 
Before I refer to the evidence let us test that for a 
moment. Supposing this had not been medicines at all, 
but supposing it had been provisions—a provision dealer. 
He is subject to the Adulteration Acts as the vendor of 
medicines is subject to the Pharmacy Acts. It he offends 
against the Adulteration Acts be may be prosecuted accord¬ 
ingly. Supposing you put in the newspaper of a provision 
dealer, “He is a fraud; he sells goods which poison the 
public ; he has robbed the public.” If. is no answer to say 
that is a criticism on a matter of public interest and a fair 
criticism, because you attack his character. Is it not the 
same here ! Which is it therefore ; is this an attack upon 
him or upon a system ! Now let us look and Fee for a moment, 
forgetting that it is medicine at all, “ Quack advertise¬ 
ments ” ; no doubt I think it is fair to say that the gentle¬ 
man who wrote this article had quack advertisements in 
his mind, I agree, for he heads it “ Quack advertisements.” 
“In the course of an inquest held at the beginning of the 
year it was stated that a labourer who had died from con¬ 
sumption had been using Dr. Tucker's asthma specific 
inhaler, for which he had given according to a newspaper 
report which has reached ns, three guineas, while the 
material with which he had sprayed himself cost him 8i. an 
ounce. Dr, F. J. Waldo, the coroner, rightly stigmatised this 
kind of dealing as a fraud and it is a humiliating thing for 
journalists to remember that snch frauds could not be com¬ 
mitted with any profit to the quack save with the cooperation 
of the press.” I do not think that I need read the next 
sentence at this moment but I shall have to read it after¬ 
wards. It goes on to say : “ The remedy is in the hands of 
the public, who have only to signify their displeasure 
at reading in their journals invitations to be robbed 
and poisoned to find those invitations immediately 




380 The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


cease.” There is no doabt that the quack advertisements 
which appear in other newspapers are alluded to, and it 
states that the object desired to be arrived at of passing the 
medicines on to the public could not be arrived at with¬ 
out the assistance of such newspapers. There can be no 
doubt about that; but is it correct to say that there 
has been no attack upon the character of the. plaintiff ? 
Mr. Bankes says I think this: The man’s character is 
only involved in his system of dealing ; that is to say, 
if I have to attack the system of dealing X must 
attack his character. If you do attack his character he 
is entitled to his remedy, and you must meet him in 
that way which Mr. Bankes characterised as a brave one— 
come forward and say it is true. In this case is it not 
almost enough to find that Dr. Tucker's particular asthma 
specific, and the inquest which was held upon Cushing in 
which it was mentioned by the coroner as a fraudulent 
scheme—that that was the foundation of the article, 
to show that it was an attack upon Dr. Tucker ? Would 
anyone in reading this article exclude him from the 
denunciation or not ? “ Dr. Tucker’s asthma specific 

inhaler ” is mentioned as the beginning; it is made, as it 
would appear to me (but it is for you to say whether that 
is correct or not), the foundation for the observations which 
are made with regard to the general scheme of publishing 
these advertisements and passing poisonous medicines off 
upon the public. If it is made the foundation for those 
observations is it not the necessary consequence to the mind 
of anyone reading this article that Dr. Tucker’s asthma 
specific inhaler is precisely one of those things which is so 
foisted upon the public? If it is. then does not the word 
“ fraud” which is passed as the right word for this kind of 
dealing apply to Dr Tucker? That is the sort of argument 
which has presented itself, I will admit, to my mind. I will 
read it again : “ He had been using Dr. Tucker's asthma 
specific inhaler. Dr. F. J. Waldo rightly stigmatised this sort 
of dealing as a fraud.” What sort of dealing? Why Dr. 
Tucker's asthma specific inhaler. Would not the mind of a 
person reading this refer it to Dr. Tucker? You go on and 
you find this about those newspaper advertisements and 
then you come to this : “ The remedy is in the hands of the 
public, who have only to signify their displeasure at reading 
in their journals invitations to be robbed and poisoned.” It 
is argued that robbing and poisoning have nothing to do with 
Dr. Tucker. Not so directly perhaps, yet those observations 
read by an attentive mind appear to me clearly to indicate 
(though it is for you to say whether they do or not) that 
Dr. Tucker was one of those people who by such a system 
passes his wares off upon the public. I pause for a moment 
because I ought to remember that Dr. Tucker is not 
Mr. Tucker the plaintiff ; but, gentlemen, do you think that 
will do ? Mr. Tucker is so associated right through with this 
matter as the agent for his brother who is the inventor of 
this specific that it appears to me hardly possible at 
this stage of the case that we should distinguish between 
the two. If you charge Dr. Tucker’s inhaler as being a fraud 
is it not Mr. Tucker who in this country circulates it. I do 
not think it is possible to pause very long upon such an 
argument as that. It would appear to me that if you think 
it is an attack upon the character of the man who made 
this medicine, who invented this specific, you will think 
that this is also an attack upon the character of the 
man who disseminated it. What is said to the contrary ? 
I think I have put the point that Mr. Bankes urged 
upon you as plainly as I can. It may be that you do not 
think that those observations which certainly do occur 
to my mind are properly made, and that the writer of 
those advertisements was merely alluding to a Bystem and 
casually mentioned Dr. Tucker’s name; I do not know, how¬ 
ever, what force you will attach to that. I think it is true 
that he had another object in this matter, and I think it is 
fair to remember that he does mention the advertisements 
which occur in other papers ; but I wish to say this, that if 
in the course of his observations upon that subject, be it his 
chief object or be it not, he found it necessary to make a 
charge against the plaintiff’s character he cannot shelter him¬ 
self here under a plea of public interest, but he must justify 
it and say that it is true. That is what I have to say upon 
the first point ; do you find that this is an attack upon the 
character of the plaintiff so far as the observations may arise 
upon the libel itself. 

Now I want to call your attention, which I must do upon 
this point, to what was said by the witnesses who were 
called for the defendant—most valuable witnesses among the 


leaders of the medical profession. I should not like to be 
found saying a word against them, and I have no wish to do 
any such thing. They gave some evidence of great value 
which I think is completely incontrovertible. I do not wish 
to suggest to you that you should controvert it any more 
than 1 do, but it was not a necessary part of their evidence 
to use the word “fraud ” at all ; it is quite out of the way, 
and some of them did not use it. Let me see how each of 
them did use it, in order to ascertain in what way they treat 
this word which I take as the key of the situation merely 
for shortness, meaning to express thereby an attack on the 
plaintiff's character. Dr. Willcox, an eminent gentleman, 
gave valuable evidence about cocaine and atropine, and the 
undesirability of selling it in a bottle without “poison” 
upon it, and without the supervision of dootors, with all of 
which I for one find myself in agreement. He says upon 
the question of fraud: “I could not say that you were 
guilty of fraud for doing it because it would be unjust.” 
What does that mean 1 

Mr. Eldon Bankes : May I interrupt your lordship? That 
was his answer to my friend's question: “ Should you say 
that I was guilty of fraud if I recommended it to a friend 
believing it to be all right ? ” 

Mr. Justice Ridley: Yes ; that is the very thing which 
was done as it appears to me : “I could not say that yOu 
were guilty of fraud for recommending it, for it would be 
unjust.” Therefore fraud in his sense as he used it means 
to say that it was a dishonest thing to do. If so, where is 
the argument for the defendant that the word “ fraud ” used 
in this article does not apply in a dishonest sense to the 
plaintiff, but is merely a general reference to a sjstem, and 
is used to indicate not any dishonesty but a statement 
calculated to deceive : “I do not think it is fraudulent to 
sell the article, but the man ought to be qualified before he 
deals with it.” There again, does that show that the 
defendant's reading of the article is right I I should certainly 
have hesitated to say so. I think Dr. Tilley, the next 
witness, used this expression, “I think it is fraud, because 
he did not cure his patients when he said that it 
would,” and then he quoted the different sentences in the 
instructions from which in his opinion it followed that 
tnere was a statement that it would cure ; so Dr. Tilley 
thought it was fraud in him, because he did not cure his 
patients when he said it would. That also seems to me to 
show that in his opinion this word " fraud ” in this article 
was pointed at the man who did it and not at the thing 
itself. Dr. Waldo we know. He says, " I thought it was a 
fraud, not because of the Government stamp, a matter which 
I think I may leave out of the question, but because he said 
that it was a cure," taking the same view as Dr, Tilley. 
“ If a medical man said it was a specific for asthma I should 
still say it was a fraud in his case, because it is incurable.” 
So that there you see it is a personal matter which the fraud 
indicates and not a system. Sir Douglas Powell did not say 
a single word about this point. Though his evidence was 
extremely valuable upon the general point he said nothing 
so far as I know about this. Sir Lauder Brunton in a similar 
way I thiDk was silent about the point which I am now 
dealing with. 

Mr. Eldon Bankes : They were not asked, if your lord- 
ship remembers. 

Mr. Justice Ridley: They were not asked; that was the 
reason. That is quite sufficient. I did not suggest there was 
any other reason, or that any question was put about it which 
they did not answer. Mr. Francis said, “ I never thought of 
fraud in this matter one way or the other,” so he does not 
assist us very much. Mr. Pepper says, “ I came here in the 
belief that it was a fraud. However innocent in his inten¬ 
tion I should say it was a fraud from his statement of the 
operations. It is a mis-statement to use the word ‘heal’ ” ; 
and he took the line that because the word “ heal I only 
take it as one instance—was used when as he said there was 
no laceration of the membrane, that was a mis-statement 
which would make it a fraud. That is a view which I do not 
think is concurred in by anyone of the several witnesses who 
have been called, and I give it to you for what it is 
worth. Dr. Cushny, the last witness to whom I 
need allude in this matter, said that-its administration 
was not fraudulent. You do not get very much 
light by these statements, and I do not suggest that you do, 
but still they are there, and it is necessary to mention them 
to you. I think that upon this point it is the article itself 
which ought to guide you, and having read that, also what 
your opinion is as to the difference which is suggested and 



The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 38 L 


which may exist between an attack upon a system and upon 
the man who does it. I would suggest as to that that the 
man who takes upon himself to attack a system has this 
burden upon him, that he does not mix up with that 
criticism the character of any one person who has done it, 
because if he does be is subject to this law, that he must 
justify that which he says to the detriment of any other 
person, whereas if he merely confines himself to a criticism 
of the system he is entitled to say : " I am only doing that 
which it is my right to do ; I am putting forward in the 
interests of the public a fair criticism upon a matter of public 
interest.” That is the nature of this case. Which is it 1 Is 
it a matter in which the man's character is brought in or 
is it not 7 

The next question is this : Was it a fair criticism upon a 
matter of puolic interest ? I shall ask you to answer that 
question as well because it is for you, and not for me, to 
answer it. Supposing it was not an attack upon the 
character of the plaintiff; still the defendant must show 
that it was a fair criticism. That is his defence. Will he 
be able to make it out? Will he be able to get under 
the general rule, having escaped the exception which I 
have been putting before you now as the one which prevents 
him raising the other defence ? Was it a fair criticism 
upon a matter of public interest ? It is in that way 
that the general question which we have been discussing 
in this case arises and it is in that way that it becomes 
material to find out what was the state of facts about 
the use of this specific and what can be said about it 
by the doctors. The doctors have established, I should 
think to your satisfaction, that in their opinion--mind you, 
it is in their opinion, and in their honest opinion—there is 
a risk in the use of this specific. It is not altogether estab¬ 
lished as a fact, because, on the other side, it is sworn that 
there is not. There are, however, as it is said, circumstances 
in which it has been found to be so among the patients of 
Dr. Francis, and possibly among the patients of one 
other medical gentleman who has been called ; but that 
point does remain in doubt, because it is challenged 
on the other side by other medical men who say that in 
the quantities in which this cocaine could possibly be taken 
—in the utmost quantities—under the treatment suggested 
for the use of this specific it could not possibly injure 
anyor e ; but that is the position of affairs. Now I 
think it is necessary in order to see whether this is a 
fair criticism to make out some sort of summary of wbat 
the state of facts is on one side and the other before you 
come to a final conclusion as to whether or no the thing 
is justifiable as a fair criticism or not. Let us see wbat 
it is that is said about him from this point of view. It 
is necessary now to read the sentences which I previously 
omitted: “A correspondent has recently sent us a collec¬ 
tion of advertisements of so-called proprietary medicines 
which he had cut from papers of high reputation in 
the country, inviting our opinion of them. Our opinion is 
that the misery wrought by quacks must be unknown to a 
good mat y proprietors of newspapers or they would hardly 
share with the quacks the plunder extracted from the 
public, mainly from the sick poor. The remedy is in the 
hands of the public, who have only to signify their dis¬ 
pleasure at reading in their journals invitations to be robbed 
and poisoned to find those invitations immediately cease. 
But the public are largely uninstructed and credulous and, 
alas, those responsible for the conduct of many of our 
journals take no trouble to emigbten them. They prefer to 
regard all protests against quack advertisement as emanating 
from the narrowness of the medical profession ; this is 
certainly a convenient faith, but how it can be truly held 
by educated people passes our comprehension.” Now, 
gentlemen, I think I may safely say that in those words 
there is not one hint, not one suggestion, of the faintest 
possible character, that any good bad ever been done 
by this medicine, and it is as though the curtain had 
been pulled down permanently before the eyes of the 
man who wrolfc this advertisement hiding from him the fact 
that there are 30 000 people who have been benefited by the 
use of it. There is not one word to suggest that any human 
being was ever the better for the use of it. He says : 
"You are robbed and poisoned ; you are nninstrncted ; you 
are credulous ; plunder has been extracted from you.” It 
is all on the wroi g side. That may be true to a certain 
extent. It has its loundation in the evidence given before 
you that there is a trace—a certain quantity—of three 
poisons in this specific; but, gentlemen, is it the fa r [ 


! thing to do to leave out the good side, and to put in only 
the bad ? We have it before us—in fact, we have it in 
this pamphlet and we have it upon the general evidence 
in the case—that whilst some people are said to have been, 
and one person rather more than said to have been, the worse 
for the nse of this drug in that he has contracted an undue 
liking for it which will cause him to have the cocaine habit, 
and whilst we have been told by the medical men that 
it is the result of using such a thing we have been 
told that there is an immense quantity of good whicli has 
been done by it. Where is that in this article 7 I should 
have thought that in criticising this matter from the public 
point of view you ought to say this : A man may invent a 
specific by his own learning, by his own experience it is 
true, yet by an accidental piece of good lortune which 
has not befallen other men as eminent as himself ; it may 
be that it has got poison in it, we must be protected 
against that, and we must see that he is prosecuted under 
the Pharmacy Act ; we must see that that is done to protect 
the public ; but we muBt not shut our eyes to the fact that 
there are thousands of people in this country, who by the 
use of that specific have become able men, able to do their 
own work, to rise in the morning, and do their day’s work, 
and to take their rest at night owing to the invention 
of this specific. Where is that in this article? There 
is not one word about it; and it is no answer to say that 
the writer did not know it because he ought to have done 
when he wrote that article. That is the way in which this 
question arises, which by no means is to ne answered in 
iavour of the defendant, merely because you do not think 
there is a personal attack upon the character of the 
plaintiff. Let us see. I have before me here a long list of 
witnesses who were called before you who spoke to the 
benefit which they had derived from this specific. I think it 
is true to say, as Mr. Bankes did, that they did not use it in 
great quantities so far as the evidence has proved before 
you. It may be true, but without one exception, they all 
of them spoke to the benefit which they had derived from 
this specific which they could get from no other. There are 

15 of them—barristers, peers, solicitors, a commercial 
traveller, people from all ranks of life. Some of them have 
used it ior five years, six years, seven years; some only for 

16 months, and some for even a shorter period. But there 
it is, and not one has felt the slightest evil effect from it. 
The doctor who was called, whose name has been mentioned 
by Mr. Bankes in particular, Dr. Clark—I think, perhaps, it 
might be advisable to read wbat he said, but I do not care 
to do so, for I thiDk if I did, I ought to read the evidence 
of many others. I do not think it is necessary that 1 should, 
but I believe I have fairly put before you wbat is the effect 
of their evidence. No I am not going quite to leave it there, 
but I am going to say that there are 143 testimonials in this 
book which is at your liberty to read, it you thiDk proper, 
from people in England, Wales, Scotland, and Ireland. I am 
not going to read them. They are of all sorts and all kinds ; 
but l thought that I would pick out one from each country 
and read them to you. I do not know whether any objec¬ 
tion will be made on the part of the defendant to my doing 
so ; if so, I will not do it. 

Mr. Ei-don Bankes : I do not think my learned friend 
would have used them in that way as evidence. 

Mr. Justice Ridley : Then I will not use them. 

Gentlemen, I think you are entitkd to read them if you 
Jike, and I shall leave it there Some of them are of the 
most touching character. I do not mind sajiog this much : 

I would rather have one of those testimonials put in the 
scale than I would have the adverse opinion of a doctor. If 
the question was, Have 1 been guilty of something wrong in 
disseminating this specific? one of those testimonials weighs 
that opinion down. There I leave it. This man is entitled 
to ssy that the good side of the business which be has been 
transacting has been left ont; he is entitled to say that. 
It is for you to say whether you agree with him. That is 
the position. 

Having regard to that being the case, what is said on 
the other side as a fact against it ? It is true it is 
made out that this is a poison administered in it. It 
is true that it is made out that it ought to be under 
the Pharmacy Act. What else is said ?—that it is ad¬ 
ministered as a fraud in this sense that people have to pay 
tor it more than it is worth, and Mr Binkes ssys : You are 
asking the poorer classes to pay no less than £3 for the 
atomiser and the first two ounces and 8*. for the subsequent 
ounce when they cannot afford it, I am not going to read 



•382 The Lancet,] 


TUCKER V. WAKLEY AND ANOTHER. 


[Feb. 1,1908. 


further from these testimonials, but 1 think you will find, if 
you take trouble to read them, that some of these people 
were not working men indeed, but those who bought this 
specific have been very glad to get it for the money and 
some witnesses called before you said so. What is it7 It is 
not that you have sold it and that you have to pay for it; you 
have to pay for it if you like it, but if you do not like it you 
can send it back again. It is not possible to say that £3 is 
the price of the inhaler. It is not. It is the prioe of the 
inhaler and the two ounces with the knowledge that it will 
do you good. 

The Jury : Four ounces. 

Mr. Justice Ridley : That makes a great deal of difference. 
That is not the price of the thing itself, for I do not see how 
it can be shut out of the case after the argument that has 
been put before you about this, that you do not pay at 
all and you could not be asked to pay unless you signed 
this : “At the expiration of the two weeks’ trial I agree 
to pay for the treatment or 1 return the atomiser and what 
fluid there may be left, by mail, charges prepaid”; that 
is to say, if it does not suit me I send it back; no cure, 
no pay. You do not get that out of many doctors. I do 
not mean to say that it would be right for the medical 
profession. 1 do not say it would, and 1 do not for a moment 
think they ought to come and say: “ You need not pay 
me unless my medicines cure you” ; but it is not a fraudulent 
thing to say to a person. It is not robbery and it is not 
poisoning. It may be objectionable, but why not ? What is 
there that is wrong in itself? When a man is not a member 
of the medical profession, he is subject to certain laws which 
he must observe—I mean the Pharmacy Acts ; and if he does 
not, he may be prosecuted for not observing them. He 
could not be prosecuted for that, and why is that to 
be wrong, and why is that to be called robbery oj fraud ? 
Surely it is nothing of the sort. You may think it 
is wrong, and you may think, as I do, that it would not 
be the right thing for a medical man to do; but are you 
to charge him in words of this serious import with having 
done that which is improper because he has done it? 
Surely not. Then I say what is the next ?—that you said 
it was a cure when it is not. Gentlemen, I think it is 
scarcely possible to lay down this that he did say it was 
a, cure, without making a long explanation about it. He 
said that it cured the spasms, and he said it prevented 
them from recurring. He said it modified them when they 
did recur; but he also said that he could not cure it as 
an absolute cure so as to prevent the possibility of its 
recurrence. That is the long and the short of it. He 
says in the witness-box that he does not cure the liability 
to asthma. He said in the pamphlet, and in the instruc¬ 
tions, after considerable explanation as to how it worked, 
and the way in which it modified the spasms, and rendered 
it less likely that they would recur, that it was a cure; 
he did say so. Here are the words, and they are in 
several places, 1 think. At the head of the pamphlet 
which I have been reading to you there are words of that 
kind if I am not mistaken : “A physician cured of asthma 
and hay fever after 20 years of suffering ”—that is Dr. 
Tucker himself, the brother—“and experimenting on his own 
chronic case.” That is called a cure, but then it is subject 
to the observations which appear in the subsequent intro¬ 
duction in the pamphlet which show the way in which it 
will work. It is for you to say whether he did say in so 
many words that this is a cure or whether he did not. 
In the instructions in a similar way there is this; after 
several sentences about how you are to use this atomiser 
comes this : “ You will notioe by the above instructions that 
it is neoessary for the vapour to reach the lungs in order 
to arrest the attacks, heal the mucous surfaces, and 
cure the disease.” That is the statement which is relied 
upon by one of the witnesses, I think Mr. Pepper, but 1 am 
not quite sure—the word “ heal.” He says: "That will 
not do. That is a statement which is a fraud. There is no 
healing because there is no wound.” But think ; there is 
no wound, but suppose it is inflamed, suppose it is in that 
condition that it gives rise to the asthmatic attacks at once, 
and you induce a quieter condition in the membrane so that 
it does not do so any longer, is not that healing 7 I should 
have thought you could have used the word heal not merely 
with the meaning of healing a wound which has been made 
in your flesh, but as meaning the surface which has not 
been broken, or as healing you from a disease which never 
had any wound in it at all. I should have thought it 
was a general expression. Perhaps not; that again will 


be for you. Those are the two chief attacks which have 
been delivered in this matter. Of course, there is the 
third one—namely, that it was not a tbing which was 
to be used without the supervision and the management of 
the medical profession. With that I think I have suffi¬ 
ciently dealt. Having regard to that on the one side and to 
the certain good which it has produced to the witnesses 
called before you on the other, do you think that this 
criticism on a matter of public interest, which undoubtedly 
it was, was a fair criticism or not ? Did it make the 
right allowance for the good that has been done whilst it 
attacks the other 7 That is what I think a fair criticism 
ought to be. I do not say you are to measure criticism 
with accurate care and detail, regarding each word, but in 
doing this did they make allowance for what the man has 
done of a good sort, whilst they attacked that which he 
was doing which was of a bad sort and which might result 
in the extension of what is known, as we now understand, 
as the cocaine habit 7 Gentlemen, it seems to me, 
although 1 have bei-n longer than I meant, that I have at 
all evtms covered the ground now. You will, first of all, be 
good enough to say, haviDg regard to all these matters, do 
you think that this was an attack on the character of the 
plaintiff, and if you think that it was an attack on the 
character of the plaintiff he will be entitled to a verdict in 
my judgment, although you should think that the other 
part of the case showed a fair criticism on a matter of public 
interest because the defendant has attacked the plaintiff's 
character, and has not justified that attack. But it may be 
that there may be other opinions upon this matter, and I 
think it is desirable that you should answer the second 
question which I have been discussing before you. Was it 
fair criticism at all on a matter of public interest 7 I do 
not say, nor do I think you can, that it was a matter of 
public interest,, but were the comments fair .’ 

If you fiod for the plaintiff what are the damages to be 7 
That is all that remains. It is true, I think, that be has not 
suffered in a pecuniary sense ; but, gentlemen, this is an 
important matter to him. I do not think that it is of the 
importance which Mr. Bankes thinks for the defendant, for 
I do not take the same view: I do not think the principle 
is at stake for which he contends. The principle which is at 
stake is this : Can a man’s character be attacked with 
impunity ? That is a much more important matter. If it 
can, then the defendant is in a better position here than I 
have taken it any defendant could be in this country. 
The question here is what damages you award if this man's 
character has been attacked as being guilty of fraud, robbery, 
and poisoning, which, as I understand it, is meant in being 
a quack. With regard to the word “ qnack,” it is used in 
various senses. It generally means in its harmless sense a 
man who is not a qualified medical practitioner, but it may 
also be meant in the harmful sense, a man who pre¬ 
tends to a skill which he does not possess—a charlatan. 
I do not know which it is meant for here, but I should 
think in the more harmless sense. A quack may be 
simply a man who is not a medical man ; but then 
what would other people understand it as meaning ? Most 
people, I take it, would take it as meaning that this 
man pretends to cure, and he pretends to have a specific 
wnen he has not got one at all. What do you say to that ? 
Then there is this, that he is one of those who carry out a 
system of robbing and poisoning upon an uninstructed and 
credulous public. I think, although juries must be moderate 
in all the verdicts which they give in cases of this kind, this 
is a case in which, whilst you are moderate you ought, if 
you find in favour of the plaintiff, to give him some sub¬ 
stantial sum to show that in your opinion, although it may 
be correct to say, and is correct to say, that these drugs 
which have a poisonous character ought to be under the 
Pharmacy Acts, and that they are not to be administered 
without the direction of doctors, yet those who have found 
out a specific which is of value, containing though it docs 
some portion which is poisonous, and which has largely 
benefited the public, whom they can call before a jury, are 
entitled to have a sum which shews that in the opinion of 
the jury they have not been guilty of fraud, robbing, or 
poisoning. I do not say anything more about the case but 
leave it simply in your bands to answer those questions: 
“Was it an attack on the character of the plaintiff 1 Was it 
fair criticism on a matter of public interest ! What are the 
damages 7 ” If you wish to take with you either the 
pamphlet or 'the instructions or any of the papers they 
shall be put into your hands to deliberate upon in your room. 


Ii 

I 

k 

i 


j 


> 

3 

3 

) 

i 

3 

t 

3 

1 

i 

i 

t 

ii 

i 

i 

a 

: 

I 

i 

s 


1 


I 


3 

lj 

1] 


I 


I 

3 


t 




The Lancet,] 


TUCKER v . WAKLEY AND ANOTHER.—LOOKING BACK. 


[Feb. 1, 19C8. 383- 


The Foreman of the Jury : May we take your paper with 
the questions on, my lord 7 

Mr. Justice Ridley : Yes ; I will hand it to you. Here is 
the letter of CushiDg asking for the stuff. I do not think I 
need hand you the letters. 

The Jury : No. 

(The jury retired to consider their verdict at 3.7 and 
returned into court at 3 39.) 

The Associate: Gentlemen, are you all agreed 7 

The Foreman of the Jury : Yes. 

The Associate : Do you find for the plaintiff or for the 
defendants ? 

The Foreman: For the plaintiff. 

The Associate : For what amount? 

The Foreman : £1000. 

Mr. Justice Ridley : Did you answer the particular 
questions put to you ! 

The Foreman: Yes, my lord. 

Mr. Justice Ridley : Will you give me the answers to them 7 

The Foreman : “ Yes ” to the first; “ No” to the second. 

Mr. Justice Ridley : The second question you answer with 
a negative 1 

The Foreman : Yes, my lord. 

Mr. Justice Ridley: It is not a fair criticism, you say. 
(The answers weie handed to his lordship.) 

Mr. Smith : On that I ask your lordship for judgment. I 
think it was my special jury. Your lordship will certify for 
a special jury 7 

Mr. Justice Ridley : Y’es. (To the jury:) I can discharge 
you, gentlemen. The parties came to an agreement which 
will be satisfactory to you, I hope. 

Mr. Hugh Fraser: I ask your lordship for a stay of 
execution having regard to the fact that there are important 
questions of law to be dealt with in the case. 

Mr. Justice Ridley : The jury have thought that it is 
not a fair criticism. 

Mr. Hugh Fraser: As I understand, the jury have found 
Yes to the first question and No to the second. 

Mr. Justice Ridley : Yes, that is so; they have found 
that it was an attack on the character of the plaintiff and 
that it was not a fair criticism on a matter of public interest. 
That means to say in any case you had not criticised fairly. 

Mr. Hugh Fraser: Of course, your lordship appreciates 
the point taken by my learned leader ? 

Mr. Justice Ridley: Yes, perfectly. I think If that had 
been the only point I should have been more inclined to 
agree, but they found that even assuming you are right you 
have not criticised it fairly. 

Mr. Hugh Fraser: Put shortly, our point was this, that 
in an attack on a system yon may necessarily attack the 
individual conducting the system, and if that view of the law 
is correct, with respect to your lordship the direction given to 
the jury would be wrong. 

Mr. Justice Ridley : I know it would, but then the eecond 
question puts the matter out of all difficulty, does it not 7 
What do you say, Mr. Smith 7 

Mr. Smith : I do not desire to make any particular objection 
to my friend having a stay of execution. 

Mr. Justice Ridley : I will stay execution if you can make 
anything of it. 

Mr. Smith : On the usual terms. 

Mr. Hugh Fraser : Yes, on the usual terms. 

Mr. Justioe Ridley: I indicate no opinion beyond what I 
have said, but I think I summed it up fully. I will grant the 
stay. 

Mr. Smith : That, of course, will be on the usual terms 7 

Mr. Justice Ridley : What are they? 

Mr. Smith : The money, I imagine, will be paid into court 
and the costs will be paid on the usual undertaking. 

Mr. Hugh Fraser : Does my friend want the money in 
court having regard to the position of the defendants 7 

Mr. Smith : No, the money need not be in court, but I 
think the costs should be paid on the solicitors’ under¬ 
taking. 

Mr. Justice Ridley : Yes, certainly. 

Mr. Smith : There is one thing I should mention to your 
lordship. Your lordship knows that some evidence was 
taken on commission. 1 do not want to trouble jour lord- 
ship with the matter. I think my learned friend agrees that 
possibly that might be left to the Master. It is a question of 
the additional costs occasioned by the commission. 

Mr. Justice Ridley : Was there any order made about it 7 

Mr. Smith : Ibe order made by your lordship was, I 
thiuk, on an application by my learned leader that the case 


should not be taken before the conclusion of last sittings, 
and by my learned friend Mr. Duke, who led me, as a con¬ 
dition asked that Lord Ashburnham, who was not in a very 
robust state of health, should be allowed to have his evidence 
taken on commission if necessary. What happened next was 
that we got a letter from Lord Ashburnham saying that 
although he hoped to be here and would be here it he could, 
his health was not very stroDg, and he thought it would be 
safer, as he was developing a chill, that wc should take his 
evidence on commission, and under those circumstances we 
thought we should not be well-advised in running the risk : 
so we applied for his evidence. Your lordship sees that his 
evidence was valuable and he was ultimately able to come. 
I think that is the only question which arises. 

Mr. Hugh Fraser : Lord Ashburnham’s evidence was 
taken on a Saturday on commission, the case was in the 
list on Monday, and actually started last Wednesday. 

Mr. Justice Ridley : I will leave it to the Master, I think. 
The stay will be on the usual terms. How many days do you 
wish to have—eight days 7 

Mr. Smith : Ten days, my lord. 

Mr. Justice Ridley : It must be eight days. 

Mr. Smith : Very well, my lord. 


Xooktno Back. 


PROM 

THE LANCET, SATURDAY, Jan. 30th, 1830. 


THE FIRE KING. 

To the Editor of The Lancet. 

Sir,—T am ready to drink oil heated to 350 degrees, and 
to administer my antidotes to various poisons given to 
animals. You say that my feats respecting the oven, and 
oil, are unworthy the tire king. 1 Now, Sir, if you or any 
of your friends will enter, and remain in the oven with me 
at 600, I will then go in at 800 degree s, and if anyone will 
drink oil at 350 degrees 1 will then drink it at 600 degrees. 

You may bring two dogs, and yourself administer the 
prussic acid. Should one dog die, and the other (taking my 
antidote) live, I hope you will then allow that I am not an 
impostor. Both the dogs must be left with me three days 
after the experiment. Your obedient Servant, 

Thursday, Jan. 28th. Xavier ChabERT. 

Monsieur Chabert must recollect that the Editor does 
not profess to be a Fire King, or a F'ire Kirg’s subject, and 
feels no inclination, therefore, to remain in an oven at 350°. 
Nevertheless, he is deeply interested in the subject of poisons 
and their antidotes, and therefore begs of M. Chabert to 
name an early day on which he may attend with the two 
dogs, and a few gentle doses of prussic acid. M. Chabert 
has forgotten to state whether he will drink a tumbler or two 
of boiling water. _ 

1 Vide “Looking Back” in The Lancet of Jan. 18th, 1908, p. 178. 


Medical Sickness and Accident Society.— The 

usual monthly meeting of the executive committee of the 
Medical Sickness and Accident Society was held at 
6, Catherine-street, London, W.C., on Jan. 17th. There 
were present Dr. F. de Havilland Hall (in the chair), 
Mr. J. Brindley James, Dr. Walter Smith, Dr. M. G. Biggs, 
Dr. H. A. Sansom, Dr. J. W. Hunt, Dr M. Greenwood, Mr. 
F. S. Edwards, Dr. St. Clair B. Shadwell, Dr F. J. Allan, 
Mr, Edward Bartlett, Mr. J. F. Colyer, and Dr. J. B. Ball. 
The accounts presented showed that the sickness experience 
of the society during the month of December had been ex¬ 
ceptionally good. The claims were rather less numerous 
than is n-ual at that period of the year, and as they were in 
nearly all cases of very short duration tlie amount disbursed 
as sick pay was well under the expectation. The business 
during the year 1907 has been very good, an unusually large 
number of new members have joined the society, and a 
substantial increase in the funds has been made. Pro¬ 
spectuses and all information may be obtained on application 
to Mr. F. Addiscott, secretary, Medical Sickness and Accident 
Society, 33, Chancery-lane, London, W.C. 







384 The Lancet,] 


TUCKER v. WAKLEY AND ANOTHER. 


[Feb. 1, 1908. 


THE LANCET. 


LONDON: SATURDAY , FEBRUARY 1, 190S. 


Tucker v. Wakley and Another. 

We publish in our preeent issue a full account of the 
libel action in which we have been involved recently. 
It has seemed to us important that an opportunity 
should be afforded to the medical profession of read¬ 
ing the case as a whole, for in this way only can 
a proper conception be obtained of the value of the 
decision which has been registered against us. As the 
result of the case was a verdict for the plaintiff for 
£1000, and as our legal position in appealing against 
this verdict appears to be one of considerable complexity, 
we are manifestly unable to complain of the isBue. 
Merely to comp’ain and at the same time to take no 
steps for remedy would be a childish course to pursue, 
but we do not understand by this submission to a 
verdict, which verdict seems to have surprised our 
readers very much, that we are precluded from drawing 
attention to the manifest necessity that a journal, having 
our aims and objects and receiving the support which 
we do from the medical profession, should have taken 
throughout the attitude that we have done, whatever errors 
in detail we may have committed. No other attitude was 
possible to us, and if anybody wants to feel as certain of this 
as we are on reviewing the whole situation he has only to read 
the plaintiff's evidence in chief and in cross-examination. It 
is transparently clear that medical practice of the kind which 
is there fully described, by whatever word it is designated, 
must be condemned by the medical profession, and as it is our 
duty as well as our privilege to make ourselves the mouth¬ 
piece of that profession, such condemnation must always 
appear in our columns. The expressions used must be those 
which cannot be so easily challenged, but our policy must 
remain unaltered. The verdict leaves us strictly unrepentant, 
and Mr. Justice Ridley's disapprobation of our whole point 
of view, though invested with all the dignity lent to it by his 
position as a judge of the High Court, fails to inspire us with 
any desire of regeneration. 

The case is of importance to the public, to the medical pro¬ 
fession, and to ourselves, and we place the interested parties 
in their order of importance. The public and the medical 
profession must always seem to us, so far as regards 
questions of unlicensed medical practice, to be rowing 
in the same boat. The public have to choose the fittest 
people for their medical advisers. The competitors for their 
suffrages are two—the medical profession consisting of 
a body of trained and educated men tested in all the 
necessary scientific requirements; and the irregular practi¬ 
tioners, whose names are not on the Medical Register. 
In every profession except medicine the public would 
at once give their vote In favour of the properly 
trained body, and it is certain that as the public 


become more generally educated this is the view that 
will prevail. The nonsensical idea that the medical 
profession desires to become a tyrannous priesthood 
will disappear, and the public, growing day by day 
in comprehension of our hopes as well as of our perform¬ 
ances, will perceive how valuable—how invaluable—to the 
community a properly ordered medical service must be. 
Medical men have also their lesson to learn. We have 
spoken of the public as growing in wisdom; already 
they are vastly improved in general knowledge com¬ 
pared to what they were even a decade ago, and 
they require from their medical advisers a recognition 
of this act. The professional man, as we have often 
pointed out without confining the remark to members 
of the medical profession, can no longer out of a superior 
learning counsel his clients dogmatically. He must be 
ready and willing to explain to them the reasons for his 
advice, and in this way the fact that the interests of the public 
and of the medical profession are identical will soon appear. 
The recent trial has demonstrated in the clearest way to the 
public the dangers that may be associated with unqualified 
medical practice, and they cannot fail to see that the attitude 
of the medical profession towards such practice is not 
dictated, as they are sometimes told that it is, by jealousy 
of the large sums of money that may be earned by their 
unregistered rivals, but by the sure and certain knowledge 
that only the trained physician can supervise the treatment 
of the sick. 

We come now to ourselves. We have had many urgent 
recommendations to appeal against the verdict. Our legal 
advisers have not been wholly adverse to such a course, and 
many kind friends have suggested the institution of a 
subscription as a guarantee against further expenses. 
But despite all this we decided not to appeal. The 
paragraph as written contained an indefensible in¬ 
accuracy, but it was impossible for this to be explained 
in our columns without the extension to the methods 
of the plaintiff of a consideration which we were quite 
unable to give. Hence the action for libel became 
inevitable, and our admitted error would in the case of a 
new trial have remained as an embarrassment to us in 
discussing the really important features of the case. 
Hampered in this manner the verdict might be upheld 
against us even if, as seems probable, we should have 
had no difficulty in obtaining certain different readings of 
the law. It was our duty, as we conceived it then and 
conceive it now, to say some of the things which we said. 
It will be our duty to go on saying them, whatever the cost. 


The Importation of Unwholesome 
Meat Foods. 

Amongst the meat foods which are imported into this 
country without smy restrictions beiDg at present placed 
upon their admission are: (I) boneless scrap meat; 

(2) pork (in regard to tuberculosis); and (3) tripe, 
tongues, and kidneys which are heavily preserved with 
boron or other antiseptics. We have already referred 
in these columns to the reports issued from time to 
time by the medical officer of health of the City of 
London (Dr. W. Collingridge), in which he has dealt 





The I.ancet,] 


SANATORIUMS AND TUBERCULOSIS, ETC. 


[Feb. 1, 1908. 385 


with the question of the importation of frozen bone¬ 
less meat packed in boxes which reaches this country from 
America. Mere inspection of this particular form of meat 
can affiord no safeguard and the only satisfactory plan 
of dealing with it would appear to be to exclude it 
entirely from the country. This view is shared by 
Dr. G. S. Buchanan in a valuable report recently 
submitted to the Local Government Board. As he 
points out, the matter is one with which the enact¬ 
ment of the Public Health (Regulations as to Food) Act, 
1907, will enable the Local Government Board to deal. 
At the present time the traffic in this commodity is 
small and to prohibit its importation would cause little 
interference with trade. Boneless scrap meat regarded as a 
portion of our imported meat-supply is, he says, practically 
a negligible quantity and as yet it is only a small portion of 
the imported meat which finds its way to makers of sausages, 
minced meat, and like articles. If it is urged that this scrap 
meat is after all for the most part wholesome, the obvious 
answer is that in that case it is free to come in other forms— 
for example, as joints or portions of meat readily identifiable 
with definite parts of the dressed carcass—which are less 
open to suspicion. In the case of foreign scrap meat no 
inspection in this country can suffice to detect disease in the 
animals from which the meat was derived and no in¬ 
formation can be gained as to the unwholesome conditions 
under which handling, chemical treatment, packing, and 
the like may have been carried on in the country ol 
origin. As it is, the frozen meat packed in boxes has 
been found to show signs of decomposition at an early 
stage after it has been thawed and it is undesirable that 
such meat should be accessible to the sausage or mince¬ 
meat maker. 

Similar difficulties arise in regard to the inspection of 
imported pork, the proper place for judging the condition 
of pigs being the slaughter-house in which the carcass can 
be inspected together with its various organs. The adminis¬ 
trative difficulty which is encountered in regard to imported 
pork results mainly from (a) importation of pork in portions 
of carcass— for example, the American pork alluded to ; 
and (A) importation of “ itripped" carcatses —i.e., pigs from 
which the head has been removed low on the shoulders so as 
to take with it the lymphatic glands which are commonly 
the seat of tuberculosis, or of carcasses which though having 
the head attached have been deprived of the lymphatic 
glands, these having been cut away no doubt in order that 
no question of condemnation on account of tuberculosis may 
arise. Again, the powers conferred upon the Board by the 
Public Health (Regulations as to Food) Act, 1907, would 
permit of useful interim measures being taken in regard to 
checking this undesirable importation. It is suggested that 
pork imported as carcasses should be required to consist of 
entire carcasses including the head and lymphatic glands 
about the throat, and that pork imported in portions less 
than the entire carcass should be inclosed in boxes, barrels, 
bags, or other receptacles bearing an official mark which 
has been accepted by the Board. The officers of the 
Hoard, of course, would be able to satisfy themselves 
as to the authenticity and genuineness of this official 
mark. 

Finally, in this recent report the question of the 


importation of tripe, tongues, and kidneys heavily pre¬ 
served with antiseptics has been dealt with. Having 
regard to the fact that tripe forms a considerable item 
in the food of the working classes, something over 10,000 
tons from all sources being consumed in a year in 
the United Kingdom, the question of its wholesomeness 
is of considerable importance. The conditions of its 
manufacture and preparation for food purposes in this 
country appear on the whole to be generally wholesome 
and cleanly. It is quite a different state of things, however, 
in regard to tripe which is imported already boiled into this 
country. In order to prepare such a readily decomposable 
commodity as cooked tripe for the British market it is 
packed in kegs containing strong solutions of boron pre¬ 
servative and this treatment results in the tripe absorbing 
and retaining considerable amounts of boric acid. The 
quantity found was seldom less than 60 grains per pound 
and sometimes it was over 150 grains per pound. As is 
pointed out, a quarter of a pound of this tripe—which may 
be considered a moderate meal—must often contain more 
than the maximum dose of boric acid prescribed for an 
adult by the British Pharmacopoeia. The uncooked “ barrel 
tripe ” which is imported into this country chiefly from 
America is also preserved in strong solutions of boric acid, 
while some tripe imported from Canada contained sulphurous 
acid in addition. The observations made in regard to 
foreign preserved tripe appear to apply with equal force 
to imported tongues and kidneys which are preserved in 
a similar antiseptic liquor. The Public Health (Regula¬ 
tions aB to Food) Act, 1907, may again be turned upon 
this kind of importation with doubtless distinct advantages 
to the health of the community. This important inquiry, 
for the thoroughness of which Dr. Buchanan deserves a 
word of praise, illustrates what a valuable step in public 
health administration was taken when this much-needed 
extension of the Public Health Act was made at the instiga¬ 
tion of Mr. John Burns. The questions raised are obviously 
of the first importance from the point of view of public 
health and that being the case any political or economic 
considerations which may be involved in the reforms 
indicated cannot seriously be entertained. 


Sanatoriums and Tuberculosis: Dr. 
Bulstrode’s Report to the 
Local Government 
Board. 

In a leading article last week we referred to the com¬ 
prehensive inquiries into epidemiological questions which 
from time to time have been made, under Mr. W. H. 
Power’s direction, by medical inspectors of the Local 
Government Board and to the great public utility of work 
of this kind. A notable example has been furnished by the 
i-suefrom that department of a volume on “Sanatoria for 
Consumption and Certain other Aspects of the Tuberculosis 
Question.” Its author, Dr. H. Timbrell Bulstrode, has 
been engaged for five years in official inquiries into this 
subject and his initial qualifications for dealing with it 
may be judged from his well-known series of Milroy lectures 
which were published in our columns in 1903. Dr. 





386 The Lancet,] 


SANATORIUMS AND TUBERCULOSIS, ETC. 


[Feb. 1, 1908. 


Bulstrodi: has visited practically every sanatorium arid 
hospital for tuberculosis or diseases of the chest in 
England and Wales; he has discussed and investigated 
various aspects of the prevention of tuberculosis with 
medical officers of health wherever special lines for 
attacking this problem have been developed ; and he 
has obtained much detailed information as to the con¬ 
ditions associated with the prevalence of pulmonary 
tuberculosis in foreign countries. The bulky volume now 
issued presents a mass of important data derived from these 
sources, together with the results of Dr. Bulstrode's own 
studies, and it furnishes an invaluable critical summary of 
the present state of our knowledge regarding the etiology 
of pulmonary tuberculosis and the different factors which 
appear to be concerned in the maintenance, diminution, 
and prevention of this disease. 

We propose to devote some special articles to certain 
portions of the report, particularly those which deal in detail 
with sanatoriums, their construction, management, finance, 
records, and classification of results. Here we may note 
that Dr. Bulstrode is satisfied from the evidence which he 
has collected as to the curative results which are so fre¬ 
quently secured by sanatorium treatment if only the case 
is seen at a sufficiently early stage, and also with regard 
to the decided amelioration which is often produced by 
the sanatorium regime in more advanced cases. Sanatorium 
statistics as to cases which are discharged as “ improved,” 
"cured,” “fit for work,” and the like are, however, 
notoriously uncertain and difficult of comparison, and 
it is to be hoped that the section of the report 
which relates to tabulation of results will do something 
to enable statistical information regarding these institu¬ 
tions as a whole to be compiled in future with some degree 
of confidence. In considering the effect which the treat¬ 
ment of oases of pulmonary tuberculosis in sanatoriums, 
municipal institutions, and Poor-law infirmaries may have 
in checking the prevalence of the disease the report 
speaks with considerable caution. It is true that by 
these meaDS potentially infectious persons may for longer 
or shorter periods be isolated from the community and 
that many will there be educated in precautions against 
spreading infection when they return to their homes or 
to their work. But it must be admitted that administrative 
measures for the prevention of pulmonary tuberculosis during 
the past decade have sometimes been based rather too 
exclusively on the assumption that the one thing essential 
to the control or extinction of this disease is the safe dis¬ 
posal of visible sputa. It is useful to have placed before us, 
as in this report, other and not less important considerations. 
The death-rate from pulmonary tuberculosis has been de¬ 
clining at a fairly uniform rate throughout England and 
Wales for over 50 years. A similar decline, steeper or more 
gradual, has occurred in individual counties and towns and 
in particular foreign countries. Contrary perhaps to ex¬ 
pectation, the rate of decline has not been materially 
accelerated either as a consequence of the new era of 
sanitary administration which began in the late “seventies,” 
or as a result of the discovery of the tubercle bacillus in 
1882, or after the general recognition in England of tuber¬ 
culosis as an infective process. So far as is disclosed 
by the data available, it has not been conspicuously 


quickened in particular localities in consequence of 
special local methods for the repression of pulmonary 
tuberculosis which have only come into operation in recent 
years. The evidence that the tuberculous person with 
expectoration is a direct source of serious danger to his 
associates is far from complete; our experience as to 
the communication of pulmonary tuberculosis by husbands 
to wives or vice versa, like our experience as to the 
spread of pulmonary tuberculosis among nurses and 
attendants in hospitals for consumption, tends to the con¬ 
trary conclusion, though we rely on the figures before it 
was customary to enjoin any special precautions in regard 
to sputa. 

Infection from person to person, whatever its effect 
may be, seems as likely to result from aerial trans¬ 
mission of virulent tubercle bacilli by invisible droplets 
produced by coughing or speaking as from dust con¬ 
taining comparatively inert bacilli derived from dried 
sputa. Direct infection of the lungs by way of the 
respiratory passages cannot be demonstrated to be the 
customary method of infection in pulmonary tuberculosis ; 
It is probable that the infective bacilli often reach the 
lungs as a result of infectious matter having been swallowed 
and having reached the blood stream by way of the thoracic, 
duct. In modern conditions of life many healthy people 
carry about cured tuberculous lesions, the result of a 
past lung infection which gave no clinical sign of its 
identity with pulmonary tuberculosis. The part played 
by bovine tubercle bacilli in the production of pulmonary 
tuberculosis has yet to be determined, but the evidence 
suggesting that this disease in adults may result from an 
infection of bovine origin in childhood cannot be overlooked. 
It is, of course, impossible to present the conclusions of a 
closely reasoned report in a few lines, but it seems clear that 
Dr. Bursthode, in discussing considerations such as the 
above, desires very properly to insist that from the point of 
view of modern preventive medicine the condition of the host 
in regard to the parasite must be considered at least as 
important as the repression of the parasite itself. If, setting 
aside speculative questions of change of type of the disease 
or development of racial immunity, some general phrase is 
sought to explain the steady diminution of the mortality from 
pulmonary tuberculosis in the last half century much may 
be said for the broad term, “improved social conditions.” 
As acute poverty has decreased, food becomes cheaper, 
temperance more common, and the air of dwellings fresher; 
people have to an increasing extent approximated towards 
those conditions of living which recent sanatorium experi¬ 
ence has shown to be most desirable in order that tubercu¬ 
lous infection may be conquered by the host at an early stage. 
Dr. Burstrode's study of the behaviour of pulmonary tuber¬ 
culosis in the German Empire and its relation to the improved 
social conditions of the German working class is in this and 
other respects one of the most instructive portions of the 
volume. In a different way, unhappily, the experience of 
Ireland appears to point to the same conclusion. 

The chapters in the report which relate to the discussion 
of the results obtained from the local notification of 
pulmonary tuberculosis have special interest. The bene¬ 
ficial effect of notification in securing the earlier treat¬ 
ment or cure of individual cases and the diminution of 



Thb LAJ.OET,] THE MEDICAL INSPECTION OF SCHOOL CHILDREN.—"TUBE FEARS." [Fbb. 1, 1906. 387 


the prevalence of the disease which may perhaps 
be looked for as a result of notification, are matters 
which necessarily depend on the character of the local 
organisations available. A scheme of voluntary notification 
has been provided in some towns but in practice, for 
various reasons, no nse is made of it. In other towns, 
however, such as Manchester, notifications under a 
voluntary scheme are numerous and this has been 
markedly the case where very careful and tactful use 
has been made of the information supplied, where 
the patient is in no way harassed in a social sense, and 
where (as in Brighton) something is done as a result of the 
notification which the patient at once recognises to be to 
his own interest and advantage. Compulsory notification, 
under special clauses of local Acts, is operative in only 
two English towns—Sheffield since 1903 and Bolton 
since 1902. Dr. Bulstrode considers that more time 
and experience are necessary before conclusions can be 
drawn as to any advantages which compulsory notification 
may have in affording means by which the prevalence of 
pulmonary tuberculosis may be reduced. His advice on this 
as on several other matters may be said to be based on the 
text, “ He that believeth shall not make haste.” There will 
perhaps be critics of his report who consider his pace too 
slow bnt all will join in welcoming the substantial con¬ 
tribution to the foundations of belief in regard to the pre¬ 
vention of tuberculosis which this volume affords. 


Slitmrfattons. 


11 Ne quid nlmli.” 


THE MEDICAL INSPECTION OF SCHOOL 
CHILDREN. 

The Board of Education, in response, we understand, to 
requests from local educational authorities, has issued a 
circular to those bodies containing a schedule for the 
guidance of medical officers inspecting school children under 
the new Act; at the same time the Board acknowledges the 
expediency of leaving considerable latitude in its adminis¬ 
tration in different cases or oircumBtanoes. We are not 
printing in this issue of The Lancet the 24 clauses of the 
schedule and shall withhold any detailed comment upon 
them until we lay them before our readers. The schedule 
is framed, as the Board points out, more with a view to 
administrative than to educational or scientific expediency, 
many points of antbropometrical and statistical interest 
being purposely omitted, so that it does not profess 
to be a guide to a full clinical examination of the 
child. The aim of the Board is to hasten slowly 
towards a desirable end and not to arouse the prejudices 
of ignorant parents or to throw too much strain on the 
cooperation of the educational and public health autho¬ 
rities, which for the first time are working officially 
together in the public service. It is hoped that by the 
proper use of this schedule few cases of serious physioal 
defect will escape detection and we think this may be so. 
The schedule certainly covers the necessary ground bnt we 
are inclined to doubt whether the Board is not too sanguine 
in considering that each child can be examined in accord¬ 
ance with it “in the space of a few minutes.” A specimen 
card accompanies the circular, on the back of which is 
printed the schedule, as in the circular, with black spaces to 


record the results of the examination of a child. On the 
front of this card the following is printed :— 

SCHEDULE OF MEDICAL INSPECTION. 

I. —Name. 

Surname first. 

Date of Birth . 

Address. 

School . 

II. —Personal History : 

(a) Previous Illnesses of Child (before admission). 

Meaalee... Scarlet Fever... H . 

Whooping Cough. Diphtheria.. 

Chickenpox... Other Illnesses... 

(i) Family Medical History (if exceptional). 

A third of this side of the card is reserved for general 
observations and directions to parent or teacher. These 
cards will not be supplied in bulk by the B >ard but are 
intended as a model for local authorities which are recom¬ 
mended to obtain similar cards for the systematic record of 
the physioal condition of the children under their charge. 

“TUBE FEARS.” 

There can be little doubt that the minds, at all events 
of some of the public, are uneasy about the safety of 
travelling on the underground electric trains, but more 
particularly the ‘ tube” railways. There are not a 
few people who confess to a nervous feeling when 
travelling on the “tubes,” while others avoid this 
expeditious method of travelling altogether beoause they 
have terrible pictures in their minds of possible disasters 
in circumstances which admit of no escape. Already 
some unpleasant incidents have occurred which fortu¬ 
nately have been free from very serious issues, but they 
have served to indicate to what a terrible position travellers 
on the underground electric railways may be exposed. 
According to a Board of Trade inquiry into an outbreak of 
fire which happened on a train on the Metropolitan District 
Railway the main danger in cases of fire arises from panic 
but it is difficult to see how panic in such trying circum¬ 
stances can be averted. In the case of the Metropolitan and 
District Railways the chances of escaping from danger are 
more favourable than they are on “tube ” railways, but fires 
have occurred in the “ tubes ” also. Imagine a train in the 
“tube” packed with “strap-hangers,” in addition to seat- 
holders, stopping in a tunnel into which the carriages fit 
almost with the nicety of a plunger in a syringe, and 
that owing to a short circuit dense volumes of smoke 
from the destructive distillation of inflammable materials 
such as wood and bituminous substances make their 
appearance to render the atmosphere unbrea hable. What 
adequate means of escape is there having regard to the 
fact that there are only exits at the ends of the long 
carriages ' Assuming again that these exits are success¬ 
fully negotiated by hundreds of people, how much better 
off are they when they have gained a tunnel con¬ 
taining a live rail? We cannot help thinking that the 
“tube” railway companies should be able absolutely to 
satisfy the public on these points. If, as the Board of 
Trade states, the chief danger is that of a panic arising 
from fire, surely something ought to be done to render an 
outbreak of fire practically impossible. More than five years 
ago in these columns we directed attention to the risks of 
fire on the tnbe railways and ventured to make a few 
practical suggestions calculated to minimise the chances, 
at all events, of an extensive fire occurring. It seems to us 
that the general use of non-combustible material or materi a l 













388 The Lancet,] 


DEATH OF SIR THOMAS McOALL ANDERSON. 


[Feb. 1, 1908. 


rendered practically non combustible by the use of some 
application for all trains and tracks is imperative and the 
public have a right to expect that every possible means of 
protection against the awful risks of fire are taken. 


DEATH OF SIR THOMAS McCALL ANDERSON. 

The death took place with startling suddenness on 
Saturday night, Jan. 25th, of Sir Thomas McCall Anderson, 
professor of medicine in the University of Glasgow. He 
had been dining with the Glasgow Ayrshire Society in the 
St. Enoch Hotel and had even proposed the last toast of the 
evening. When the company broke up he was in the act 
of descending the stair from the dining-room when he was 
seen to stumble and within a few minutes he was dead. We 
shall in a later issue of The Lancet give an appreciation of 
the work of this great Scottish physician. 


THE PERCUSSION SIGNS OF EARLY APICAL 
TUBERCULOSIS OF THE LUNGS. 

We have received from Dr. Guido Rheiner of St. Gall, 
Switzerland, an interesting communication in which he 
points out the importance of careful study of the physical 
signs at the apices of the lungs in cases of doubtful pulmonary 
diseases, especially from tbe standpoint of the examiner for 
life insurance companies. He quotes the interesting observa¬ 
tion of Naegely of Zurich, who found in the course of 500 
necropsies on persons over the age of 18 years the enormous 
percentage of 97 who showed indications of previous 
tuberculous affection, and he emphasises the danger of 
these occult lesions in many persons. He refers to the 
statistics of a German life assurance company from 1857 to 
1894 in which it appears that out of 20,124.165 policy¬ 
holders 17 ■ 26 per 1000 males and 15'76 per 1000 females 
died in the course of the first year, of which 3 51 and 3 • 58 
per 1000 respectively were due to tuberculous disease of the 
lungs. As shown by Virchow the earliest deposit in the 
lnngs usually occurs in the form of miliary tubercles 
in the mucous membrane of the smallest bronchi, and 
it is not until later that inflammatory processes around 
lead to areas of consolidation. Although these may 
early give rise to a few auscultatory signs Sabli of 
Berne stated that these isolated consolidated spots even 
when supei ficial must be at least some square centi¬ 
metres in size in order to give rise to distinct dulness. Dr. 
Rheiner insists on the great importance of careful percussion 
about the apex, and especially by means of a method 
described by Krdnig of Berlin in 1889. It is well known 
that if the head be held up the extreme apex of the lung 
reaches from three to five centimetres above the clavicle, 
forming practically a small cone. Percussion of this region in 
the ordinary way simply maps out the vertical extent of this 
cone but gives no information as to its breadth or as to its 
circumference, both of which may be lessened by cicatrisa¬ 
tion. In order to determine these the examiner should stand 
beside the patient and percuss in various directions, mapping 
out the resonant area from the dulness due to the shoulder 
and surrounding parts. The line so obtained is normally 
found to extend from the inner part of the clavicle, mounting 
gradually towards the anterior margin of the trapezius muscle 
until it reaches tbe summit of the shoulder, from which 
it carves downwards to reach the vertebral column at a 
point between the second and third dorsal vertebra). In 
mapping out this line it is recommended to commence per¬ 
cussion on a dull area and percuss towards the resonant 
regions, using the third phalanx of the right middle finger 
as a pleximeter and tapping firmly on the nail with the left 
middle finger. The line is found to cross the clavicle and 
extend backwards to the end of the inner third of the spine 
of the scapula, the accurate determination of its situation 
being more difficult in this region than in front. The extent 


of this resonant area and the situation of this boundary line 
delimiting it are in normal persons identical on the two 
sides and they are capable of accurate determination, since 
if careful observers compare their results there is not as a 
rule a difference of more than half a centimetre. Dr. 
Rheiner finds that this area is contracted and the boundary 
line displaced when there is old tuberculous disease. It 
is increased in emphysema, while in eirly tuberculous 
disease although its extent is unchanged the note 
obtained in this region is altered. Although these observa¬ 
tions do not afford conclusive evidence they may often lead to 
an early lesion being discovered and its nature being 
established by other means of diagnosis. The point urged 
by Dr. Rheiner of the importance of using every means to 
render diagnosis of tuberculous apical lesions more certain in 
as early a stage as possible is one to bear in mind not only 
from the standpoint of the life insurance companies but also 
from that of the patient, since it is well established that the 
earlier the disease is recognised the more effective treat¬ 
ment is likely to be in leading to a permanent arrest. There 
is no doubt that percussion of the apices of the lungs is a 
matter of considerable difficulty and that it is often very 
incompletely carried out, so that valuable information which 
might be acquired by its aid is overlooked. Unfortunately, 
also, the personal equation in percussion is difficult to 
eliminate. Dr. Rheiner's championship of Kronig’s method i 
however, should serve to draw’ attention to it3 value. 


A GREEK MEDICAL AUTHOR OF THE SECOND 
CENTURY. 

The Berlin Academy will shortly commence the publication 
of a new complete edition of all known Greek medical works, 
produced with as much scholarly care and collation of all 
known manuscripts as have hitherto been devoted to tbe 
remains of historical and literary classic authors. In pre¬ 
paration for this great corpus of Hellenic medicine the 
German editors who are taking part in the task occasionally 
print short preliminary notes upon the subject. Thus in the 
philological journal llermei Herr Wellmann has presented a 
most interesting summary of the work of the second century 
A r>. physician Herodotus, who is praised by Galen. The 
object of Herr Wellmann s essay is to assign to this Herodotus 
the admirable, but hitherto anonymous, medical treatise 
Aidyruans srf pi tup o&utr, which is contained in two manu¬ 
scripts preserved in Paris, one of which was brought from the 
Greek Monastery on Mount Athos by Minoides Mynas. Many 
passages of this work are identical with parts of the col¬ 
lection of medical authors made by Oribasius at the request 
of the Emperor Julian. Herr Wellmann shows that the 
quotations from Herodotus are so cited as to indicate that 
he came between Soranus and Philumenus, and therefore that 
he lived in the second century, to the early part of which, as 
Galen quotes him, he must be assigned. Finally, by the 
identity of style and language between the treatise in tbe 
Paris codices and the extant quotations of Herodotus Herr 
Wellmann proves Herodotus to be the author of the work. 


THE FIRST OPERATION FOR APPENDICITIS. 

The question is often asked “ When was the first opera¬ 
tion for appendicitis performed! ” We have been asktd it this 
week almost exactly in these words. The answer must 
depend greatly on what is meant by operations for appen¬ 
dicitis. If we may include among such operations the 
evacuation of an abscess resulting from an attack of 
appendicitis we must go back a very long way indeed. 
Doubtless many such abscesses were opened ages before any 
record of such operations was made. Aretseus, who flourished 
some 50 years before the commencement of the Christian 
era, says : “I once made an incision into an abscess in the 


Thb Lancet, - ) 


THE METROPOLITAN WATER-SUPPLY. 


[Feb. 1, 1908 . 389 


colon on the right side near the liver and much pas gashed 
oat.” This may have been an appendix abscess but he goes 
on to say that mnch pus also was evacuated with the urine, 
so we cannot be sure that it was not a pyonephrosis. Here 
and there through the following centuries we find cases 
recorded which are fairly certainly examples of incision of 
an appendix abscess but it was not till 1759 that we 
meet with an operation for abscess which was definitely 
shown to be due to disease of the vermiform appendix ; 
in that year Mestivier incised an abscess on the right 
side of the abdomen near the umbilicus and much pus was 
evacuated. The wound healed but the patient died before 
long and at the necropsy a pin was found in the appendix 
with many signs of inflammation. Seven years later Lamotte 
described a large fa:cal concretion in the appendix but the 
discovery was only made post mortem. In 1848 Hancock 
reported the opening of an abscess immediately above 
Poupart’s ligament on the right side and later two he cal 
concretions came away. The incision was made early, even 
before fluctuation could be detected. In 1867 Parker pub¬ 
lished four similar cases and from that time the opening 
of abscesses in the right iliac fossa became less rare. The 
earliest suggestion to remove the appendix appears to have 
been made by Fenwick in 1884 and this operation was per¬ 
formed by Krdnlein in the same year. He opened the abdo¬ 
men of a boy aged 17 years who had general peritonitis and 
ligatured and removed the perforated appendix. Some 
temporary improvement followed but death occurred three 
days after the operation. Symonds in 1885 removed a con¬ 
cretion from an appendix without opening the peritoneal 
cavity. The first successful operation for the removal of the 
appendix was performed by Morton in 1887 and from that 
time the operation has become common. We have then 
answered the question, “ When was the first operation 
for appendicitis performed ? ” by showing that appendix 
abscesses have been opened many centuries ago; that 
Hancock in 1848 incised an appendix abscess before 
fluctuation could be felt; that Krdnlein in 1884 removed a 
perforated appendix but the patient died ; and that Morton 
in 1887 had the first successful case of appendicectomy. 

THE METROPOLITAN WATER-SUPPLY. 

The report on the condition of the metropolitan water- 
supply for last October shows that the rainfall in that month 
was 2 "70 inches above the average mean rainfall of 24 
Octobers. It will be remembered that September was an 
exceptionally dry month and in consequence the October 
rains were not able to bring the daily natural flow of the 
Thames up to its 24 years’ average, but they caused the usual 
turbidity of the water and from the 17th to the 24th it was 
more or less coloured in consequence. On the remaining 
days it was clear and in good condition. The filtered 
water from the various works contained less organic 
matter than in any preceding month last year except 
that from the West Middlesex works which contained 
the same quantity as in September. The Lea water 
is reported as of very good quality throughout the month, 
and the Kentish chalk wells were as satisfactory as usual. 
All the samples of water collected from public taps and 
examined were free from any appreciable quantity of 
suspended matter. By the colour test the Lambeth water, 
as usual, showed the deepest average tint of brown, but per 
contra, it contained the lowest average of microbes—viz., 
3'8 per cubic centimetre. The worst offender in this respect 
was the sample from the Grand Junction division of the 
southern district which showed the large number of 4625-1 
per cubic centimetre. We need hardly say that this is most 
unsatisfactory and it is liable to recur whenever the 
condition of the Thames is unfavourable or when an unusual 
strain is thrown on to the filter beds at Kew Bridge, which 


for lack of accommodation for storage and settlement are 
obliged to treat a large proportion of their water in a 
practically raw condition. A marked improvement has taken 
place in the Southwark and Vauxhall water since the 
Hampton reservoirs were brought into use and it is urgent 
that a similar measure should be adopted at Kew. The 
bacillus coli was found in 10 7 per cent, of the filtered 
samples of Thames water. 100 cubic centimetres of each being 
examined. It was found in 8 ■ 7 per cent, of similar samples 
of Lea water and 13 7 per cent, of similar samples of New 
River water respectively. Although the London water-supply 
has improved materially of late years it is obvious that there 
is still room for much more improvement, especially in this 
bacteriological respect. _ 

THE MODE OF TRANSMISSION OF TRYPANO¬ 
SOMES BY TSETSE FLIES. 

A recently published Parliamentary paper, headed 
“Miscellaneous No. 6 (1907).” contains a report prepared 
by Dr. Louis W. Sambon, the Italian delegate to the Inter¬ 
national Congress on the Sleeping Sickness held at London 
in June, 1907. The report is written in French but an 
English translation is appended, and there is a note explain¬ 
ing that the time and labour necessary for its preparation 
made it impossible for it to be included in the published 
proceedings of that conference. The subject of the report 
is the mode of transmission of sleeping sickness. Dr. 
Sambon criticises the views expressed by Colonel David 
Bruce, R.A.M.O., and Professor Minchin, and while 

he admits that it is possible that both nagana and 
sleeping sickness may be transmitted by tsetse flies 

in a purely mechanical way he is convinced that under 

natural conditions this is not the usual mode. He 

maintains that in each case the fly acts as a true alter¬ 
native host and that the respective parasites go through a 
peculiar cycle of development and multiplication within the 
body of the insect before they are returned to fresh 
vertebrate hosts. He criticises the experiments described 
by Colonel Bruce and other observers in support of the 
“mechanical” theory, which is in brief that the infection 
of the disease is conveyed by the proboscis of the tsetse fly 
in much the same manner that the vaccinating needle carries 
the infection of vaccinia from child to child. The general 
principle of these experiments is that of allowing tsetse flies 
to feed upon an infected animal and subsequently upon a 
normal one. One of the chief objections which he raises is 
that in these experiments the tset6e flies used have been 
caught in infected localities and may therefore have harboured 
trypanosomes in their salivary secretion at the time when they 
were caught. He also objects that if the mode of transmission 
of trypanosoma Gambiense or trypanosoma Brucei is purely 
mechanical it is difficult to understand why the diseases 
caused by these two parasites should be so strictly confined to 
the localities where certain species of the tsetse fly are found 
and why other blood-sucking diptera should not be able 
to carry them and to infect animals in the same mechanical 
manner. He further claims as strong presumptive evidence 
in favour of some further development of the parasites in 
their invertebrate hosts, the fact that trypanosomes taken 
from the gut of the tsetse fly and injected into vertebrates 
do not produce the disease, although they are living, the 
suggestion being that they belong to a sporogonic cycle in 
the life of the trypanosome incapable of multiplication in 
the blood of a vertebrate host. Unlike the diptera of the 
families culicidre, simulidm, and tabanidae, in which the 
females alone are blood-suckers, in the glossinre both sexes 
have this property, and Dr. Sambon suggests that it is possible 
that the further growth of the trypanosome in the fly may 
only be capable of occurring in the female ; he therefore 
suggests that in future experiments the sex of the flies 
used shall be carefully determined and recorded. He affirms 





390 The Lancet,] 


CHELSEA AND THE NOTIFICATION OF BIRTHS ACT, 1907. 


[Feb. 1, 1908. 


that male tsetse flies are far more commonly captured than 
females and believes that this fact may account for the 
failure of observers to trace the sporogony of the trypanosomes 
of mammals. It has been shown by Lfiger and Brumpt that 
the trypanosomes of Ashes undergo a true sporogony within 
the body of leeches. Although Dr. Sam bon cannot be said to 
have brought forward direct evidence establishing his con¬ 
tention, yet there would appear to be presumptive evidence 
that some further development of the trypanosome does occur 
in the insect, and this indicates the necessity for more ex¬ 
tended observation upon the life-history of these parasites out¬ 
side their vertebrate hosts. The matter is one of practical im¬ 
portance, for Dr. Sambon states that the transmission of 
both nagana and sleeping sickness may take place through 
the progeny of infected female tsetse flies—in other words, 
that the infection may be transmitted in these flies heredi¬ 
tarily. The importance of destroying the tsetse flies is 
emphasised by the success which attended the destruction of 
mosquitoes in malaria-infected districts, and Dr. Sambon 
believes that when all the life habits of tsetse flies are known 
it should be easier to destroy them than mosquitoes. His 
report is a suggestive contribution to the important subject 
of which it treats. 


CHELSEA AND THE NOTIFICATION OF BIRTHS 
ACT, 1907. 

During the session of 1907 an Act was passed known 
as the Notification of Births Act. The chief pro¬ 
vision of the Act is devoted to making it compulsory 
for the father of any child, if he be residing actually 
in the house at the time of the birth, to give written 
notice of such birth within 36 hours to the medical officer 
of health of the district. Also, any person in attendance 
upon the mother at the time of the birth or within six 
hours after the birth has to give notice as well. Penalties 
are provided by the Act for omitting notification. But a 
person shall not be liable to a penalty if he satisfies the 
court that he had reasonable grounds to believe that notice 
had been duly given by some other person. During the 
passage of the Bill through the House of Commons it was 
pointed out that the Bill threw a new duty npon medical 
men and that not only would they get no fee but 
they wonld be liable to a penalty for omitting to comply 
with the provisions of the Bill. An understanding was 
come to between Lord R. Cecil, Sir J. B. Tuke, Sir Henry 
Craib, and Mr. G. J. Cooper, M.R.C.S., on the one hand, 
and the President of the Local Government Board on the 
other, that the medical man should be exempted from the 
compulsory clauses. On this understanding the opposing 
motions of which Sir J. B. Tuke and Mr. Cooper had given 
notice were withdrawn. Eventually, however, the Bill 
passed, apparently because Mr. Cooper expressed his willing¬ 
ness that it should. 1 This preamble is necessary for the 
understanding of a debate which was held at the meeting of 
the Chelsea Borough Council on Jan. 22nd as to the 
question of adoption of the Act. The public health com. 
mittee reported that it was not satisfied that the Act would 
prove workable and recommended that the motion to 
adopt the Act should not be carried. After various 
speeches, notably one from Dr. L. Parkes, who pointed 
out that the medical profession was strongly against 
the provisions of the Act as it stands, the recom¬ 
mendation of the public health committee was carried. 
We have upon a previous occasion said that we consider the 
principle of notification to be good and of value to the body 
politic. But we strongly object to a duty being laid upon 
medical men to notify, not merely because no fee is pro¬ 
vided, for the members of the medical profession are quite 
accustomed to that treatment from the State, but because a 

1 The Lahcet, Sept. 7th, 1907, p. 742-743. 


penalty is laid upon them if they do not carry out the pro¬ 
visions of the Act. If one important borough considers that 
the Act will be unworkable others may do so too, although 
many have already adopted it. It must be remembered that 
Clause 3 gives power to the Local Government Board to 
declare the Act in force in any area in which it might 
have been adopted, although the local authority has not 
adopted it. _ 

THE BRITISH SHIP SURGEONS' ASSOCIATION. 

On Monday evening last, Jan. 27th, a meeting of past 
and present ship surgeons was held at the Medical 
Graduates’ College and Polyclinic, Gower-Btreet, London, 
for the purpose of discussing the unsatisfactory status 
and conditions of employment of ship surgeons and 
considering the best means of effecting the necessary reform. 
Mr. G. Metcalfe Sharpe of Middlesmoor, Leeds, was in the 
chair and it was unanimously decided to form a British Ship 
Surgeons’ Association. A provisional committee, comprising 
Mr. Sharpe and Mr. H. W. Bayly of 25, New Cavendish- 
street, London, W., with Mr. J. Arthur Batley, solicitor, of 
East Parade, Leeds, waB appointed to take the necessary 
preliminary steps. Communications on the subject may be 
addressed to any of the gentlemen named. 


PROFESSOR MARAGLIANO’S ANTI-TUBERCULOUS 
SERUM. 

We have received a communication from Messrs. Oppen- 
heimer. Son, and Co., Limited, 179, Queen Victoria-street, 
London, E.C., stating that they have been appointed 
agents for the “ Istituto per lo Studio e la Cura della 
Tubercolosi e di altre Malattie Infettive” in Genoa. 
This firm also informs us that the Istituto would be 
willing to forward a supply of Professor Maragliano’s 
anti-tuberculous serum to any institution especially arranged 
for the treatment of tuberculosis free of charge so as 
to enable the medical Btaff “to confirm the results 
already obtained.” Professor Maragliano’s views have for a 
considerable period been before the profession. In regard to 
the effect of the anti-tuberculous serum on pulmonary 
tuberculosis he maintains that complete and permanent arrest 
can be obtained in cases in which the first and second barriers 
of organic defence are still intact—that is, in cases in which 
the pulmonary tissues prevent the extension of the disease 
from the foci in which it first develops or in those cases in 
which the lesion is well localised in the lungs and in which 
toxsemic phenomena have not developed. On the other 
hand, such successful results cannot be obtained when 
"inflammatory centres” have been produced. Even 
in those cases, however, a beneficial influence may be 
exerted if there is an absence of those local physical 
phenomena which characterised these lesions. A trial of 
Professor Maragliano’s serum has been made in the Henry 
Phipps Institute in Philadelphia. Dr. M. P. Ravenel had 
studied in Professor Maragliano's laboratory for the purpose 
of learning the methods there adopted, so that he was in a 
position to make the serum strictly in accordance with the 
rules and practices of Professor Maragliano himself. The 
work which was accomplished at the institute with this 
serum was not encouraging. The conclusion must not 
be arrived at, however, that it has no value in the 
treatment of tuberculosis. In the third annual report 
of the institute it is stated that all that can be said is that 
it is of no practical value according to the method of using 
it in that institution. Certain facts, suggestive of good, 
appeared and indicated better ways of employing the serum. 
It has been determined that the workers at the institute will 
continue with the trial of the remedy. We publish the 
above announcement so that those observers who wish to 




The Lancet,] BRITISH MEDICAL BENEVOLENT FUND.—THE SERVICES.—VITAL STATISTICS. [Feb. 1,1908. 391 







392 The Lancet,] THE TREATMENT OF PULMONARY TUBERCULOSIS BY GRADUATED LABOUR. [Feb. 1, 1908. 


the two preceding weeks ; of these, 154 resulted from whoop¬ 
ing-cough, 99 from measles, 57 from diphtheria, 39 from 
scarlet fever, 38 from diarrhoea, 22 from “ fever ” (prin¬ 
cipally enteric), but not one from small-pox. The deaths 
from these epidemic diseases in the 76 towns were equal to 
an annual rate of 1 • 3 per 1000, the rate from the same 
diseases in London being only 11. No death from any of 
these epidemic diseases was registered last week in Brighton, 
Walthamstow, Stockport, Hornsey, or in five other smaller 
towns; the annual death-rates from these diseases ranged 
upwards, however, in the other towns to 2'8 in Ipswich 
and in Gateshead, 3'0 in Willesden, 31 in Salford, 
and 3' 7 in Aston Manor. The fatal cases of whooping- 
cough in the 76 towns, which had been 92, 127, and 
164 in the three preceding weeks, declined last week to 
154 ; the highest annual rates from this disease last week 
were 1 • 5 in Handsworth, 1 7 in Newcastle-on-Tyne, 2'2 in 
Warrington, and 3 • 7 in Aston Manor. The 99 deaths from 
measles showed a further decline from the numbers in the 
two previous weeks ; this disease, however, caused a death- 
rate of 1-3 in Preston and Southampton, 1-4 in Ipswich, 
1'7 in Salford, and 2 6 in Willesden. The fatal cases of 
diphtheria also showed a further decline from recent weekly 
numbers, but included 22 in London, six in Manchester and 
Salford, two in South Shields, and three in Gateshead, 
the latter being equal to an annual rate of 1-2 per 
1000. The 38 deaths attributed to diarrhoea showed a 
marked decline, as did the 39 fatal cases of scarlet fever, 
which included 19 in London, four in Liverpool, three 
in Manchester and Salford, and two in West Ham. The 
22 deaths referred to “fever" also showed a decline, in¬ 
cluding four in London and three in Manchester. The 
number of scarlet fever patients under treatment in the 
Metropolitan Asylums and London Fever Hospitals, which 
had steadily declined in the seven preceding weeks from 
5581 to 4325, had further fallen to 4044 on Jan. 25th, 
and during the week ending on that day 380 new cases 
were admitted to those hospitals, against 469 in each of the 
two previous weeks. The deaths in London referred to 
pneumonia and other diseases of the respiratory organs, 
which had been 333, 460, and 498 in the three preceding 
weeks, declined again last week to 455, but exceeded by 
36 the corrected average number in the corresponding 
week of the five years 1903-07. The causes of 59, 
or 10 per cent., of the deaths registered in the 76 towns 
last week were not certified either by a registered medical 
praciitioner or by a coroner. All the causes of death were 
duly certified in Leeds, Bristol, West Ham, Bradford, 
and in 48 of the other smaller towns ; and the causes of 
all but one of the 1651 deaths in London were duly certified. 
No fewer than 13 of the causes of death in Liverpool were, 
however, uncertified, and 10 uncertified deaths were registered 
in Birmingham, five in Sheffield, four in Sunderland, and 
three in Bootle and in St. Helens. 


HEALTH OF SCOTCH TOWNS. 

The annual rate of mortality in eight of the principal 
Scotch towns, which had been equal to 24 • 3 per 1000 
in each of the two preceding weeks declined to 22 2 in 
the week ending Jan. 25th, but exceeded by 3 7 the mean 
rate during the same week in the 76 English towns. Among 
the eight Scotch towns the death-rates ranged from 17*7 
and 17 9 in E linburgh and Aberdeen, to 25'4 in Glasgow 
and 26 1 7 in Perth. The 782 deaths in these eight towns 
showed a decline of 75 from the number in the previous 
week, and included 142 which were referred to the principal 
epidemic diseases, against numbers increasing from 109 
to 158 in the four preceding weeks ; of these, 81 
resulted from measles, 25 from whooping-cough, 16 
from diarrhoea, nine from “fever,” eight from diphtheria, 
three from scarlet fever, but not one from small-pox. 
These 142 deaths were equal to an annual rate of 
4'0 per 1000, which exceeded by no less than 
2 • 7 the mean rate last week from the same diseases 
in the 76 Eaglish towns. The fatal cases of measles 
in the eight Scotch towns, which had been 53, 65, 84, 

and 92 in the four preceding weeks, declined again to 
81 in the week under notice, of which 70 occurred in 
Glasgow, four in Paisley and in Greenock, and three in 
Aberdeen. The 25 deaths from whooping-cough also showed a 
decline from the number in the previous week ; seven were, 
however, returned both in Glasgow and in Leith, four in 
Perth, and two in Edinburgh and in Aberdeen. Of the 16 


deaths attributed to diarrhoea, 11 occurred in Glasgow 
and two in Edinburgh and in Leith. The nine deaths 
referred to “fever” included six in Glasgow, two in Edin- 
burgh, and one in Dundee ; one of the six fatal cases in 
Glasgow and those returned in Edinburgh and Dundee were 
certified as cerebro-spinal meningitis, the remaining five 
fatal cases in Glasgow being due to enteric fever. Four of 
the eight deaths from diphtheria and two of the three from 
scarlet fever were returned in Glasgow. The deaths referred 
to diseases of the respiratory organs in these eight towns, 
which had been 205 and 199 in the two preceding weeks, 
furtherdeclined to 178 in the week under notice, but exceeded 
by 42 the number from the same diseases in the corresponding 
week of last year. The causes of 22, or 2'8 per cent., of 
the deaths in these towns last week were not certified or 
not stated ; in the 76 English towns the proportion of these 
uncertified deaths last week did not exceed 1 • 0 per cent. 

HEALTH OF DUBLIN. 

The annual rate of mortality in Dublin, which had been 
equal to 25'5, 26 • 0, and 31 • 2 per 1000 in the three 
preceding weeks, declined again to 29 5 in the week ending 
Jan. 25th. During the first four weeks of the current 
quarter the death-rate in the city has averaged 28 - 1 per 
1000; the rate during the same period did not exceed 
18'2 in London and 18 1 in Edinburgh. The 223 
deaths of Dublin residents registered last week showed 
a decline of 13 from the high number in the 
previous week, and included nine which were referred 
to the principal epidemic diseases, against but four 
and three in the two preceding weeks ; these nine deaths 
included five from whooping-cough, two from “fever,” one 
from measles, one from diarrhoea, but not one either from 
scarlet fever, diphtheria, or small-pox. These nine deaths 
from epidemic diseases were equal to an annual rate of 
1 ’ 2 per 1000, the death-rate from the same diseases last 
week being 1 • 1 in London and 0 9 in Edinburgh. The 
fatal cases of whooping-cough in Dublin showed an increase 
upon recent weekly numbers. The 223 deaths in the city 
last week from all causes included 29 of infants under one 
year of age and 73 of persons aged upwards of 60 years; 
the deaths of elderly persons were again exceptionally high. 
Two inquest cases and two deaths from violence were 
registered, and 88, or 39 5 per cent., of the deaths occurred 
in public Institutions. The causes of five, or 2 ■ 2 per cent., 
of the deaths in the city )a-t week were not certified; 
in London all but one of the 1651 deaths were duly certified, 
while in Edinburgh the causes ot 3 • 4 per cent, of the deaths 
were uncertified. 


Comspanbrnc. 


"Audi alteram partem.” 


THE TREATMENT OF PULMONARY 
TUBERCULOSIS BY GRADUATED 
LABOUR. 

To the Editor of The Lancet. 

Sir,—T o one who has devoted much time during the past 
few years to elaborating methods and teaching the value of 
graduated work as a therapeutic agent in pulmonary tuber¬ 
culosis, it is gratifying to learn from Dr. M. S. Paterson’s 
paper in The Lancet of Jan. 25th, p. 216, that the principle 
of graduated labour has been adopted, and thanks to his zeal 
and energy put into effective practice in the sanatorium 
recently opened in connexion with Brompton Hospital. He 
is to be congratulated on the efficiency of the simple scheme 
he has proposed. It is, of course, not necessary, or even 
desirable, to insist on the particular gradations of carrying, 
spade work, and pick-axe. There is great variety possible in 
the practical application of the principle. 

While offering my congratulations to Dr. Paterson on so 
excellent an illustration of the great principle, I find it less 
easy to follow him when he speaks of it as a novel idea and 
cites once more a, priori objections which from time to time 
have been urged against it and as often answered. I had 
supposed that the significance of graduated work in the 
treatment of pulmonary tuberculosis was now freely admitted 
by those who had looked into the matter. The principle was 





The Lancet,] 


THE TREATMENT OE GRAVES'S DISEASE. 


[Feb. 1, 1908. 393 


advocated, admittedly in less detailed fashion, almost 70 
years ago by Dr. Bodington. Indeed, the very title of his 
essay suggests his view—namely, “An Essay on the Treat¬ 
ment and Core of Pulmonary Consumption on Principles 
Natural, Rational, and Successful: with Suggestions fur an 
Improved Plan of Treatment of the Disease among the 
Doner Classes of Society. ” l In the text of the esBay Dr. 
Bodington dwells on the significance of exercise of various 
kinds, more especially “ walking, as much as the strength 
will allow, gradually 1 increasing the length of the 
walk, until it can be maintained easily for several 
hours every day.” In his extraordinarily clear pre¬ 
vision of the need for sanatoriums, Dr. Bodington goes on 
to speak of the need for “country houses in proper situations, 
well ventilated, and provided ‘ with all appliances and means 
to boot,’ where patients should be strictly watched and 
regulated in all respects as regards exercise, air, diet, &c.” 
More particularly “ with respect to the consumptive poor 
patients, those who cannot afford to pay for a proper treat¬ 
ment of this sort,” be goes on to say, “ hospitals should be 
established in the vicinity of large towns, in fit situations, 
and properly appointed in all respects for their reception and 

treatment. In those there should be provision made for. 

gardening, and farming occupations for the convalescent. 
The common hospital in a large town is the most unfit place 
imaginable for consumptive patients and the treatment 
generally employed there very inefficient, arising from the 

inadequacy of the means at command.Connected with 

such an hospital provision should be made for the employ¬ 
ment of the convalescent and cured patients.” In later 
times. Brehmer advocated consistently the significance of 
graduated walking exercise. This has been continued by 
many of his disciples. 

Personally, I have long held and taught the view that care¬ 
fully graduated activity in some form is a therapeutic agent 
of first importance in relation to pulmonary tuberculosis. 
In seeking to elaborate means of treatment for the poorer 
classes I have always dwelt much on the significance of 
directed activity. The great plea for such directed effort 
or labour is to be found in its economic value both to the 
individual as a preparation for future work after discharge 
and to the institution in which he is presently resident 
and to the maintenance of which he is thus enabled to 
contribute what he can. The significance of graduated 
labour, both therapeutically and economically, in relation to 
tuberculosis among the poorer classes, as based on prolonged 
experience, has formed part of one’s regular teaching to 
students for a good many years. The senior students in the 
medical school are frequently invited to come and judge for 
themselves of the beneficial effects of the system. The 
method has been carried out in more or less elaborate fashion 
in different institutions elsewhere. I sincerely hope that the 
object-lesson which Dr. Paterson’s paper affords may be the 
means of still further extending its application. At the 
Royal Victoria Hospital for Consumpton in the neighbour¬ 
hood of this city it is routine practice to consider the case of 
every patient within a month or so after admission, or at 
least so soon as the temperature record has been approxi¬ 
mately normal for a week or two. The patient is first of 
all tested with simple graduated exercise. Shortly thereafter 
this takes the form of definite work. The kind of work 
and its amount is determined exactly in the same way as is 
other therapeutic procedure. My constant injunction both 
to assistants and students is that it must be selected and 
measured just like any drug. An accurate record of its 
effects is kept from day to day. The results of increase in 
work are scrutinised as carefully as those from any modifica¬ 
tion of drug treatment. The amount is increased or 
diminished as the temperature-chart, pulse-rate, and other 
indications may suggest. Thus, at the present time out of 
some 80 patients approximately two-thirds are engaged in 
such graduated labour. Some of them work a couple of 
hours a day, others four, others six, others for the whole day, 
as joiners, engineers, gardeners, painters, wood-cutters, 
cleaners, inspectors of shelters, &c. We have a considerable 
collection of photographs illustrative of the kinds of work. 
Indeed, the annual report of the hospital for several years 
has contained illustrations showing the patients at work. 

I mention these facts to show that the method of treat¬ 
ment need in no sense be spoken of as an experimental one. 

It has already been amply tested. I venture to say that no 
one who has made sound and prolonged trial of it has 


1 The Italics are mine. 


failed to obtain good result. Like every other thera¬ 
peutic measure it requires thought and care in the selec¬ 
tion and adjustment of the particular work. Each case 
must be judged per sc and the work strictly accommodated, 
both in respect of nature and amount, to the possibilities, 
psychical as well as physical, of the individual. It would 
be the greatest mistake in the world were the method 
to become rule-of-thumb and cease to be regulated by 
consideration of the individual. This is perhaps a danger 
which is more apt to occur when patients are grouped in 
squads, the work of the squad beiDg seriously disturbed by 
failure on the part of any one. There is always some risk of 
over-effort on the part of a physically weak, though perhaps 
willing, patient The danger is, of course, largely obviated 
if medical surveillance be carried out in the exact and 
efficient way which has been recommended. Speaking of 
psychical conditions, it is quite remarkable how quickly im¬ 
provement may be noted in the spirit as well as in the muscle 
of the patient after the adoption of productive forms of 
graduated activity, where the patient is able to appreciate 
and enjoy the result of his effort. 

As to the other aspect of the question -namely, the ex¬ 
planation of the effect produced by graduated exercise—I am 
tempted to write at some length. This would exceed the 
limits of your correspondence column. I must therefore 
defer this for the present. Prolonged observation renders 
me doubtful regarding the suggestion that the benefit of 
gradually increased physical effort results entirely, or even 
in largest part, from repeated auto-inoculation. The theory 
is interesting and attractive. Although a firm believer in 
the value on the one hand of physical activity, and on the 
other hand of the direct application of tuberculin in suit¬ 
able cases, the facts at my disposal make me sceptical as 
to the validity of the explanation which has been sug¬ 
gested of the indubitable benefit conferred on convalescent 
patients by a carefully supervised system of giaduated 
labour. I am, Sir, yours faithfully, 

Edinburgh, Jan. 25th, 1908. R. W. PHILIP. 


THE TREATMENT OF GRAVES’S DISEASE. 

To the Editor of The Lancet. 

Sib, —In The Lancet of Jan. 25th Mr. Waller Edmunds 
has recorded three cases of Graves’s disease treated 
with the milk of thyroidless goats. As nearly nine years 
have elapsed since Lanz first treated cases of this disease 
by this method and recorded benefit resulting there¬ 
from, I presume it is because of the inherent difficulties in 
carrying out the treatment that it has not been more ex¬ 
tensively employed. The obstacles at any rate have been 
sufficient to prevent my giving the method a trial myself, 
anxious enough as I have been to put it to the test. Mr. 
Edmunds is to be congratulated on having himself successfully 
surmounted the difficulties and in thus obtaining a sufficient 
supply of the milk for some of his patients. I trust that his 
example will be followed by others. 

For the encouragement of those who cannot obtain the 
fresh milk I may say that I believe that the same good 
effects as are produced by the milk are to be obtained by the 
use of rodagen. Rodagen, as is now well known, is a sub¬ 
stance prepared from the milk of thyroidectomised goats by 
a process elaborated by Dr. Burgliardt and Dr. Blumenthal. 
It is described as containing 50 per cent of the active con¬ 
stituent of the milk with 50 per cent, of sugar of milk added 
to preserve it. Although Mr. Edmunds says of two of his 
patients who were benefited by the milk that previously 
they had taken rodagen for several weeks without benefit, it 
is perhaps hardly fair to compare the effect of two drachms 
per diem of rodagen with that of a pint and a half of the 
special milk. It is quite possible that if Mr. Edmunds had 
given larger doses of rodagen he would have been able to 
observe real improvement under its use such as followed the 
milk treatment. I have used rodagen very largely in the 
treatment of Graves’s disease and my belief is that if good 
results are to be obtained from it, it must be given in con¬ 
siderably larger doses than are generally thought to be 
necessary and than 1 myself gave at one time. The dose 
indeed, I think, has to be greater the more severe the 
symptoms. 

I have at the present time under my care at St. Thomas's 
Hospital a patient who is a very striking illustration of the 
value of rodagen in the treatment of severe cases. The 
patient was admitted in a condition of great prostration; 






394 The Lancet,] 


LIQUID AIR AND CANCER. 


[Feb. 1, 1908. 


extremely emaciated, weighing less than 4 stones ; pulse-rate 
usually about 160 ; temperature pyrexial; mental condition 
one of delirium at night and obfuscation during the day ; 
and all the usual symptoms of the most severe type of 
Graves’s disease were present. Although under good condi¬ 
tions at her home she had been steadily getting worse and 
bad been altogether confined to bed for several weeks. I 
had every reason to consider the prognosis as extremely 
grave indeed. I have not hitherto seen a case of Graves's 
disease in that stage end otherwise than fatally. I ordered 
her to have an ounce of rodagen daily. The improvement of 
her condition which soon took place was most striking. The 
acute symptoms all subsided, her mind became clear, her 
temperature dropped to normal, the heart’s action consider¬ 
ably slowed down, the tremors ceased, and in a few weeks 
she gained a stone in weight. In spite of the fact that her 
recovery has been interrupted by one attack of influenza and 
another of quinsy she has done remarkably well. 

If I had the choice of giving rodagen or the fresh milk of 
a thyroidectomised goat I should not hesitate to select the 
latter from which rodagen is derived. But I consider it is a 
great matter that it is possible to prepare from the milk a 
substance like rodagen which possesses similar beneficial 
properties to those of the milk itself. Rodagen is readily 
obtainable at a price, but the fresh milk of a thyroidectomised 
goat is not to be had by most of our patients for either love 
or money. The main drawback, indeed, to rodagen is the 
usual disproportion between its cost and the purse of our 
patient. It is one of those remedies which, as I have'said 
before, few except hospital patients can afford to use. It is 
its high price which makes us inclined to dole it out even to 
our hospital patients when we should otherwise give it freely. 
Wholesale it at present costs between 3r. and 4 1 . an ounce. 
The only other drawbacks are its somewhat unpleasant 
cheesy smell and taste and an occasional tendency to purga¬ 
tive action. But some might raise the same objection to the 
use of goat’s milk. 

I may say 1 have not given more than an ounce a day in 
any case, but I believe smaller doses than this are not of 
much use in the presence of severe symptoms. I have pre¬ 
viously stated that although I have made an extensive trial 
of Merck’s antithyroid serum, which is prepared from 
thyroidless rams, I was not convinced that it exerted any 
beneficial influence. It is quite possible that if I had tried 
it in larger doses than I did I might have obtained some 
good results. All I can say about it is that in the doses 
ordinarily prescribed it seemed to me inert. I did not go 
beyond a dose of five cubic centimetres daily. This remedy 
is also expensive, ten cubic centimetres costing about 5s. 

I should like to add to what I have said about rodagen 
that in cases of Graves’s disease lately I have not been giving 
ordinary milk except in such small quantities as are 
usually taken with tea or coffee. If, as present observa¬ 
tions indicate, there be a virtue in the milk of a thyroidless 
animal, and in the rodagen obtained from it, by means of 
which the toxin of Graves's disease is neutralised, this is 
likely to be counteracted if at the same time we gave in any 
considerable quantity the milk of an animal whose thyroid 
was in full functional activity. Recently I have been 
allowing cot only little milk but also little meat to my 
patients with active Graves's disease and I believe this has 
been of benefit to them. In conclusion I should like to 
suggest that it might be possible to put up in tins con¬ 
densed milk made from the milk of thyroidectomised goats, 
but I am afraid the remedy, however prepared, will continue 
to be expensive.—I am, Sir, yours faithfully, 

Hectoi! Mackenzie, M.D. Cantab., 

Jan. 27th, 1908. Physician to St. Thomas's Hospital. 


LIQUID AIR AND CANCER. 

To the Editor of The Lancet. 

Sib, —In The Lancet of Jan. 25th Professor J. E. Salvin- 
Moore and Mr. C. E. Walker relate some observations they 
have made on the effect of exposing the cells of a oarcinoma 
to the temperature of liquid air for 20 to 30 minutes. In the 
same issue the importance of these observations is emphasised 
by a second communication, in which they are confirmed by 
Professor Salvin-Moore and Dr. J. O. Wakelin Barratt for 
another carcinoma. The authors express surprise that the sub¬ 
stance of tumours so treated gave rise to growths when im¬ 
planted into healthy animals. The conclusion that the pro¬ 
liferation of the parenchyma cells implanted is responsible for 
the parenchyma of the daughter tumours would seem, in the 


opinion of the authors, to be laid open to doubt as the result 
of their application of what, in the absence of any reference 
to the literature on the subject, has the semblance of an 
experimental method new in cancer research. 

That cancer cells may retain their vitality after long 
exposure to low temperatures has long formed part of the 
common stock of knowledge of those engaged in experimental 
cancer research. Two years ago Ehrlich obtained continued 
growth after an exposure to —10° C. lasting two years, and 
also after an exposure to the temperature of liquid air 144 
times as long as that employed by the authors of the two 
communications referred to. MichaeliB has obtained con¬ 
tinued growth after the cells had been exposed to the tem¬ 
perature of liquid air for half an hour three years before the 
repetition of a similar experiment has yielded a result so 
surprising to Professor Salvin-Moore and his two colleagues. 

There are many other references to the effects of thermal 
agencies in the literature of experimental cancer research, 
to which I need not refer in detail, since the two authors 
cited dealt specifically with the temperature of liquid air, and 
support the views advanced by Jensen, Murray, and 
myself on the processes at the site of the implantation of 
cancerous tissue. It will suffice to point out that exposure 
to thermal agencies is a routine laboratory method used to 
diminish the vitality of the cells of malignant new growths, 
and that with the extinction of the life of the cancer cells 
inoculation ceases to be successful. Although exposure to 
thermal agencies is a valuable method for studying the vita 
propria of the cancer cell, it is, for the reason just stated, 
unsuited to settle whether or not there be a virus in the 
tumour substance. The results of the cytological study of 
the site of inoculation in conjunction with this method have 
been found to be in entire agreement with the view that the 
artificial propagation of cancer is an actual transplantation 
of living cells which are merely nourished by a succession of 
new hosts. I am, Sir, yours faithfully, 

Jau. 27th, 1908. E. F. BaSHFORD. 


SUFFOCATION BY COMPRESSION OF THE 
CHEST: THE BARNSLEY DISASTER. 

To the Editor of The Lancet. 

Sir, —The sad accident at Barnsley whereby some 16 
children lost their lives presents some features in common 
with the one at Sunderland in 1883 when nearly 200 lost their 
lives. In the present instance a large number of children 
were endeavouring to force their way into the gallery of the 
public hall to witness a cinematographic entertainment. On 
the gallery being completely filled the children on the stairs 
were turned back by the attendant and told to make their 
way to other parts of the house. A stampede then occurred 
on the staircase, several of the little ones fell at a turn in the 
stairs and others fell upon them, the whole being kept from 
regaining their footing by the pressure of the children 
behind. Before they could be extricated 14 children of an 
average age of six years lost their lives and two more died 
very shortly afterwards in hospital. Those who recovered 
seemed to have sustained surprisingly little injury. Out of 
the 16 killed and 17 slightly injured, attended to at the 
Beckett Hospital, only one sustained a fracture—viz., a 
fractured humerus. This, of course, may be accounted for by 
the greater flexibility of children’s bones, especially the ribs. 
The children seen immediately after death presented practi¬ 
cally the same features as described by Dr. Lambert in 1883 
in his report on the disaster at Sunderland. 1 In varying 
degree their faces were congested and puffy, the vessels of 
the neck much swollen, the eyelids closed, the eyeballs pro¬ 
truding, the pupils widely dilated, and froth surrounding the 
mouth and nostrils. 1 n nearly all the cases urine had been 
voided and in a few cases fseces expelled. 

By order of the coroner a careful and individual examina¬ 
tion of the whole of the bodies was made 24 hours after 
death and in the case of two bodies post-mortem examina¬ 
tions were made by Dr. Hall and Mr. V. K. Blackburn. The 
external examination presented the following features. Rigor 
mortis (probably influenced by the cold) and post-mortem 
staining were well marked in all cases. With one or two 
exceptions the countenance was placid as if in sleep, the 
eyeballs were not protruding nor the pupils widely dilated. 
In three cases the face was markedly congested, the re¬ 
mainder varying from slight frontal suffusion to slight 
general congestion. The ears in all cases were much darker 


1 Biit. Med. Jour., vol. 1., 1883. 



The Lancet,] 


THE ORGANISATION OF THE PROFESSION. 


[Feb. 1, 1908. 395 


and the necks more swollen than is usually seen after death. 
Bruising was general but not extensive in area, being more 
marked on the face and lower limbs, slight abrasions being 
seen in a few cases. There was a total absence of fractures 
and wounds as disclosed hy external examination. In one 
case in which a post-mortem examination was made there 
was a trace of blood in the left ear but no fracture of the 
skull was found. In nine cases the tongue was not protruded, 
in six but slightly, and in one case well protruded. In 12 
of the cases there was well-marked oedema over the front of 
the chest and in two of these it extended over the abdomen 
and thighs. The two post-mortem examinations presented 
practically the same features. Two of the more markedly 
congested cases were selected with a view to getting more 
definite results. The following are the brief particulars 

Head. —Coverings, meninges, surface and substance of 
brain congested but healthy. 

Chett. —No fractured ribs. Lungs congested and air 
passages clear. Heart, right side contained a small quantity 
of dark fluid blood. 

Abdomen. —Liver and kidneys, slight congestion. Intestines, 
pale. Spleen, not congested but pale. 

It is to be noted that there were no haemorrhages in either 
case on the lungs or heart as is'often found in cases of death 
by suffocation.—We are, Sir, yours faithfully, 

J. Hall, M.D., 

Jan. 26th, 1908. H. F. HORNE, M.B., B.C. 

THE NEED OP FEMALE MEDICAL 
MISSIONARIES. 

To the Editor of The Lancet. 

Sir, —You have from time to time been good enough to 
make special missionary needs known through your columns. 
Will you now give publicity to the urgent need for more 
women doctors in the foreign field .’ Pioneer work waits to 
be begun in at least two districts of India ; an overworked 
doctor in China needs a colleague; and now the grievous news 
of the death in January of Dr. Marie Hayes at Delhi makes 
the reinforcement of the staff of that mission a matter of 
urgent necessity. In a letter dated four weeks ago she said 
herself, “We desperately need another doctor.” In two 
years from now there will, as we hope, be doctors qualified 
who are now going through the medical Bchools with this 
end in view. But these needs are immediate. We appeal 
earnestly for two medical women already qualified and able 
to undertake responsible work who would offer at once for 
this work, especially for Delhi. For particulars apply to the 
C.W.W. Candidates secretary, S.P.G. House, 19, Delahay- 
street, Westminster, 8.W. 

I am, Sir, yours faithfully, 

Jan. 20th, 1908. H. H. MONTGOMERY (Bishop). 

SUNSHINE IN 1907. 

To the Editor of The Lancet. 

SIR,—May I be allowed to state that the records of the 
Meteorological Office for 1907 show that the island of 
Guernsey enjoyed the maximum of sunshine of any place in 
the British Isles—viz., 1859 -7 hours. This, however, is 
considerably below its average for the last 14 years, which 
is 1916'2 hours.—I am, Sir, yours faithfully, 

Hy. Draper Bishop, 

Medical Officer of Health, States of Guernsey. 
Health Office, Guernsey, Jan. 25th, 1908. 

THE DESTINY OP CASE-BOOKS. 

To the Editor of The Lancet. 

Sir,— Referring to your leader on the disposal of case¬ 
books I send you the following facts for which I can vouch. 
You are at liberty to make what use you like of them but 
please suppress names as one of the ladies is still living. A 
medical relative of mine died some 20 years ago, leaving as his 
nearest relatives a group of ladies and a nephew not a medical 
man. He had resided long in his house which was situated 
in a populous neighbourhood and was likely to be a good 
investment for a suitable successor. The ladies managed 
the transfer of the practice and of the lease of the house. 
Soon after a gentleman called on me and asked if I was the 
late physician’s executor, and went on to state how annoyed 
he had been to see that gentleman’s case-books giving full 
reports of cases, including those of the complainant’s wife, 


for sale on a bookseller’s counter. So strongly do I feel on 
the subject that I have destroyed all my case-books except 
the one I am using. 

I am. Sir, yours faithfully, 

Jan. 21st, 1908. M.R.C.S. 


THE ORGANISATION OP THE PRO¬ 
FESSION. 

(From our Special Commissioner.) 


Attitude of the Honorary Staffs of the Liverpool 
Hospitals in Regard to Paying and Insured 
Patients. 

Liverpool, Dec. 8th, 1907. 

In so far as the organisation of the medical profession is 
concerned Liverpool cannot in any way be considered a 
model town. Perhaps for want of proper leadership certain 
it is that there has been very little cohesion among the 
members of the profession. The fear also of doing anything 
that might in the remotest degree be likened to trade 
unionism greatly exercises the minds of some of the older 
and more prominent members of the profession. Nevertheless, 
there is to-day a very strong feeling of unrest and this has 
led at least to some attempts at organisation. Of late it is 
the honorary staffs of the hospitals who have been bestirring 
themselves and are actually seeking to form a union. It is 
not quite easy at first sight to determine whether this move¬ 
ment will make for the union or disunion of the profession at 
large. Some of the observations made in answer to my 
inquiries were not altogether encouraging. For instance, 
one of the most active leaders in this new move¬ 
ment argued that there were two classes of medical 
men, members of the hospital staffs and the general practi¬ 
tioners. Now each class accuses the other of being mainly 
responsible for the prevalence of hospital abuse. The 
general practitioner says that the competition of the hos¬ 
pitals robs him of his chance of earning a decent livelihood. 
On the other hand, I was assured that at the Liverpool 
Children’s Hospital, when an inquiry was made into the 
matter, it was found that the general practitioner was the 
principal culprit. Then at the Southern Hospital a special 
superintendent had been appointed to investigate whether 
there was abuse. It was found that medical practitioners 
were themselves often responsible for abuse. When they were 
tired of a patient they would send him to the hospital. A 
case was described to me of a drunken and very dirty woman 
who was sent to the hospital with pneumonia and died 
in two days. She was fully able to pay. Then another case 
was that of a man who had nothing really the matter but 
was probably a club patient and generally a nuisance. 
Though there is undoubtedly something to be said on both 
sides there can be nevertheless no doubt that the general 
practitioner in Liverpool, as in most other towns, has si ffered 
considerable loss through the facility with which patients 
who could pay fees have obtained gratuitous treatment at 
hospitals. Obviously the true remedy rests in uniting the 
members of the hospital staffs with the general practitioners 
in one single society where all would meet on equal terms and 
discuss their grievances in a friendly manner. 

The nearest approach to such an organisation is the 
Liverpool division of the British Medical Association and the 
local secretary thinks that there is more cohesion among the 
members of the profession at Liverpool since the adoption of 
the association’s new constitution. Nevertheless, it does not 
seem to me that the position is very promising because, if I 
am correctly informed, though the division has 67 members 
only about twelve or so attend the meetings. This is but a 
small number for so large a town as Liverpool. But 
what seems more significant is the fact that when a 
considerable number of the honorary Btaffs of the hospitals 
felt that they had grievances and it was necessary to take 
action, they formed a new society instead of bringing the 
matter before the local division of the British Medical 
Association. Then, again, the lay committees managing the 
principal hospitals have also joined together and are 
attempting to constitute themselves into a joint body so as 
to take common action. It is said that their principal 
purpose is to check abuse and to employ a uniform method 
to prevent persons who can pay fees obtaining medical 
relief. In this respect they are evidently greatly impressed 
by the Manchester example. When at Manchester inquiries 




396 Thb Lanobt,] 


THE ORGANISATION OP THE PROFESSION. 


[Ff.b. 1, 1908. 


were first systematically made it was found that 42 per j 
cent, of the applicants at the hospitals were ineligible, 
while now only 4 per cent, are rejected. This shows what 
strict inquiry will do and how it will keep away those 
who could pay for medical attendance. But while the 
lay managing committees of the different Liverpool medical 
charities might come to a common agreement on this point 
and also in regard to the overlapping of the various charities, 
there are other matters on which disagreement is more than 
probable. Perhaps the most difficult of these is the 
admission of paying patients into some of the hospitals. 
Then, even if the lay committees did agree on this grave 
question, it is very likely that the medical staffs would not 
take the same view of the subject. In the meanwhile, I 
found a disposition to make a mystery of their pro¬ 
ceedings, and it seemed to me as if the lay committees 
viewed the prospect of criticism with some apprehension. It 
appears to me, however, that if the medical profession were 
united in a strong, compact body the lay committees of the 
hospitals would be less prone to hold private consultations. 
They would proceed to the headquarters of the profession 
and there discuss with those who do the principal work at 
the hospitals how the various difficulties of management 
could best be overcome. 

Unfortunately, instead of harmony and cooperation 
between the lay managing committees and the medical staffs 
of the hospitals some serious disputes may arise. This is 
the likely consequence of the radical change which new 
customs and new laws are bringing about. Hospitals 
are no longer what they used to be. What might be 
quite right and proper 50 years ago no longer applies 
to present conditions. There is a tendency to make work¬ 
men more and more responsible for their ordinary ailments 
now that they have compensation. On the other hand, 
there is such increase in the major surgical operations per¬ 
formed in a hospital that there is less and less room remaining 
for minor cases such as, for instance, simple fractures. It is 
true that some general practitioners may prefer to send a 
case of fracture to a hospital rather than to run the risk of 
an action for damages should anything go wrong. Still the 
compensation to which all classes of workers are now entitled 
should give the general practitioner a better chance. 
However this may be, the argument now brought forward 
is that the honorary staffs of hospitals undertook to 
attend the sick poor and not insured servants and 
workmen. The question as to what the insurance offices are 
going to do becomes very important. Are they entitled to 
send persons for whom they are responsible to hospitals 7 
If the insurance company receives the premium then it ought 
to pay for the patient. At Hamburg ladies in good positions 
voluntarily pay 1*. per month to the hospitals so as to have 
the right to send their servants there should they fall ill. Are 
the insurance companies in England contemplating some 
similar course. But, if bo, it changes entirely the character 
of the hospitals and the hospital patients ; and in that case 
what corresponding change should be effected in regard to 
the medical and surgical staffs of the hospitals. 

In Liverpool the hospitals have on their committees of 
management the same men who manage the great ocean 
liners. These men have wide business experience and great 
organising capacities. On the whole, also, they pull together 
fairly well. By their side and on these committees of 
management sit the elected representatives of the workmen’s 
Saturday hospital fund. The workman who pays regularly 
1 d. a week for the hospitals thinks that he is insured. He 
therefore goes to the hospital not as an applicant for charity 
but to claim that for which he has paid. Then, again, at 
the Stanley Hospital, for Instance, patients who live outside 
the Liverpool radius are taken in at a charge of 10s. 
per week. Many come from Wales or the Isle of 
Man and the excuse made is that some of these cases 
are useful for teaching purposes. This, however, may 
overcrowd the hospital and keep local and really poor 
patients out. Therefore some of the hospitals will not 
make any such charge and on this a serious difference of 
opinion exists between the lay managing committees of the 
different Liverpool hospitals. The Royal Infirmary in six 
months admitted 345 patients from outside the Liverpool 
radius. Then there are a number of patients who are not poor 
patients but pay £2 2*. a week for their treatment and this 
brought in the goodly sum of £13,270 in 1905. Such pay¬ 
ments seem to be increasing. 

In the face of all these new facts the honorary staffs 
of the various hospitals are striving to form an association 


so as to take united action and to demand a quid pro quo. 
If the hospitals remain pure charities they have nothing 
to say ; but if hospitals, managed by eminent business men, 
are to be made paying business concerns, the honorary 
medical staffs will claim their share in the profits. As for 
the honorary staffs obtaining indirect advantage this is not 
always the case ; besides, the field for private praotice is 
being gradually restricted as well-to-do people go more and 
more frequently to the paying wards of the hospitals. The 
unfairness of the present situation is admirably illustrated in 
regard to the building of the Manchester Ship Canal. On 
that occasion a staff of medical men were employed and 
paid. They followed the works and attended to all 
cases of accidents, &c. But to-day there is the Mersey 
Dock and Harbour Board which employs at the Liver¬ 
pool docks a large amount of labour. When an accident 
happens the victim is sent to the nearest hospital and no 
payment is made. The case is attended by the medical staff 
of the hospital but the medical profession receives nothing 
at all. If the medical profession was paid when an accident 
occurred at the works of the Manchester Ship Canal why 
should it not be paid when an accident occurs in the Liver¬ 
pool Docks 1 The only reason is a topographical reason. 
There was no hospital near enough to the Ship Canal. 

Another argument was brought forward by several medical 
men and seemed to weigh heavily in their minds. They 
thought that as people were made to insure their servants they 
would subscribe less or not at all to the hospitals. Then again, 
there was an impression that the very wealthy, the multi¬ 
millionaires, had ceased to give to hospitals. These institu¬ 
tions the millionaires argued should be supported by the 
community, and they preferred to give their money for 
special chemical or biological research in which the general 
public took less interest. Thus if the wealthy no longer give 
so much to the hospitals, if an ever-increasing number of 
people enter the hospitals as paying patients, and if the 
treatment of working people and servants is covered by a 
general system of insurance, the whole basis is changing. 
The hospitals may cease to be medical charities and become 
business concerns. Then the incomes of the hospitals being 
in a large measure derived from the patients, a portion of 
this income should be devoted to the payment of their 
medical attendants. As for medical schools, there still 
remain the workhouse infirmaries which have not been 
utilised. Indeed, it is a question whether these infirmaries 
should not be entirely detached from the workhouses. Under 
the Poor-law people who go to the workhouse infirmary are, 
if possible, made to pay, but if they pay why should they be 
treated as paupers. The true pauper is sometimes to be found 
in the hospital. Such considerations led up, in more than one 
conversation, to the suggestion that if the hospitals were 
not ultimately converted into municipal institutions they 
should at least be rate-aided. One leading member of a 
hospital staff declared that out of about 800,000 people living 
at Liverpool some 700,000 did not give anything whatsoever 
towards the hospitals. Why should a small minority have 
to bear the burden, and why should the medical men work 
for nothing 7 Through the rate everyone might be made 
to contribute and there would then be money enough to pay 
the medical staff. As compared with other countries the 
State in England gives very little for the benefit of science ; 
all the more reason, therefore, for the corporations to 
act, and they can reach those who do not give voluntarily. 
Actually the municipality of Liverpool does sub-idise the 
University of Liverpool and this to the extent of £10,000 a 
year. 

The question of the municipalisation of hospitals has 
lately received more attention from members of the 
medical profession. In 1896, when I made extensive in¬ 
quiries at Liverpool, the subject was barely mentioned 1 ; 
to-day I found it a matter of very general discussion. 
Yet, on the other hand, the growth of insurance does not 
necessarily make for municipalisation, unless it be in the 
sense of abolishing hospitals as charities and converting them 
into paying concerns, each patient paying because he is in¬ 
sured. Then the workhouse infirmaries, which are already 
municipal hospitals, would be the only hospitals remaining 
where the patients did not pay. From such conversations it 
would seem as if the days of charity are numbered and volun¬ 
tary subscriptions destined to be replaced by compulsory 
insurance or compulsory taxation, or more probably a mixture 


i See articles on Hospital Abuse in Tux Lancet of Nov. 14th 
(p. 1421) and 21at (p. 1494;, and Dec. 12th (p. 1720), 1896. 




Thb Lancet,] 


LIVERPOOL.—IRELAND.—PARIS. 


[Feb. 1, 1908. 39V 


of both taxation and insurance. Nevertheless, the actual 
facts do not as yet betoken any such revolution. The idea 
that compulsory compensation with the consequent 
general insurances taken out by employers for the 
employed would reduce the voluntary subscriptions paid 
to hospitals has not so far become manifest at Liverpool. 
Perhaps it is too soon for this recent legislation to take 
effect. In any case the subscriptions to the hospitals of 
Liverpool amounted in 1896 to £17,467 and in 1905 to 
£21,961, or an increase of 25 per cent, in ten years. The 
average legacies and donations for the last ten years were 
£30 585 ; the minimum sum being £21,714 in 1898, while in 
1905 the average was greatly exceeded, the sum being 
£38,287. During the last eight years the average annual 
legacies amounted to £6860. The interest on invested 
funds has increased during the recent ten years from £12.882 
to £16,434 in 1905. The payments made by patients and 
the fees paid by patients are put together under the head of 
earnings and these have increased in ten years from £18,353 
to £22.800 in 1905. The total income from all sources of 
the 20 principal medical charities of Liverpool amounted in 
1896 to £92,100 and in 1905 to £102,000. To this it may 
reasonably be objected that the income of the hospitals 
was bound to increase as the population had largely in¬ 
creased. Consequently I went to the Municipal Buildings 
and inquired what proportionate increase there had been in 
the ten years in question and was told that the borough of 
Liverpool had taken in two districts and the population had 
increased just a little over 11 per cent. In the districts 
outside the actual boundaries of the borough of Liverpool 
the proportionate increase of population would be still 
greater. It will be seen, therefore, that though the income 
of the hospitals has been well maintained it has only just 
kept on a level with the increase of popnlation and that 
the figures are not sufficiently recent to show the effect 
which the new law on compensation to workmen, domestic 
servants, &c., may produce. It would appear that there is 
an economic change taking place in regard to the condi¬ 
tions of the hospitals generally and it is well that these newt 
developments should be carefully studied by the members 
of the profession. 


LIVERPOOL. 

(From our own Correspondent.) 

Presentation of Portrait and Complimentary Dinner to 
Dr. William Carter. 

Dr. William Carter, late honorary physician to the Royal 
Southern Hospital, and professor of materia medica at the 
University of Liverpool, was on .Tan. 18th entertained to 
dinner at the Adelphi Hotel as a token of esteem by his pro¬ 
fessional brethren and friends on the occasion of his retiring 
from practice and leaving Liverpool for Deganwy. The 
Lord Mayor (Dr. Richard Caton) presided. Highly eulogistic 
speeches were delivered by the Lord Mayor, Sir Alfred .Tones, 
and his late colleagues, and Dr. Carter was presented with 
his portrait painted in oils. 

Presentation of the Royal Humane Sooiety Bronze Mtdal to 
Dr. B. A. Peters. 

The Lord Mayor, on Jan. 21st, presented the bronze 
medal and certificate voted by the Royal Humane Society to 
Dr. Benjamin Alfred Peters, one of the house surgeons at the 
Royal Southern Hospital, for the gallant rescue of a young 
lady from drowning off the coast of Anglesey in August last 
Dr. Peters recently graduated .as M.B., B.Ch., at the Uni¬ 
versity of Cambridge. The Lord Mayor complimented Dr. 
Peters on the gallantry which he displayed on the anxious 
occasion. 

Jan. 28 tb. 


IRELAND. 

(From our own Correspondents.) 

Death of Mr. William John Taggart , B.A., M.D. R.U.T., 
L. R. C. A’, kdin. 

On Jan. 23rd Dr. W. J. Taggart, whose health fcr some 
time had been failing, died at his residence, Cloneven, 
Antrim, aged 74 years. Born at Thornhill, Randalstown, 
on Oct. 8th, 1833, he was educated at first for the 
ministry. He graduated B.A. of the old Queen’s University 


of Ireland in 1865 and was ordained after completing his 
theological studies. He preached in Skipton and after¬ 
wards at Melbourne but resigned owing to ill-health, and 
returning to Ireland he studied medicine and graduated 
M.D. in 1863 and obtained the diploma of L.R.C.8. of Edin¬ 
burgh in 1864. Settling down in Antrim, he began practice 
there aDd for many years was officer of health of the Antrim 
dispensary district and certifying factory and railway 
surgeon. Of a well-cultured mind and extensively read in 
general literature. Dr. Taggart kept up his medical studies. 
He had travelled a great deal and being a good observer and 
writer he could give a very clear account of what be saw 
and read. For many years he enjoyed a good practice. Dr. 
Taggart was buried in New Cemetery, Antrim, on Jan. 25th. 

The Temperance Cause. 

Under the auspices of the Belfast Women’s Temperance 
Association Sir Victor Horsley spi ke on Jan. 23rd at Belfast 
on “ The Proper Use of Alcohol in Health and Disease,” 
while in the evening he lectured in the Ulster Hall on “The 
Temperance Movement and its Bearings on the National Life.” 
Dr. W. Calwell (president of the Belfast branch of the 
British Medical Temperance Association) and subsequently 
Professor T. Sinclair occupied the chair, and a vote of 
thanks was, at the conclusion of his address, passed to Sir 
Victor Horsley, on the motion of Dr. A. H. H. McMurtry, 
seconded by Sir John Byers. 

Jan. 28th. _ 


PARIS. 

(From our own Correspondent.) 

The Treatment of Ilebra’s Prurigo by Fresh Liver Bouillon. 

A new treatment for Hebra's prurigo has been introduced 
by M Audrin who read a paper on the subject before the 
French Society of Dermatology and Syphilography on 
Jan. 9th. Every two days 100 grammes of fresh liver were 
taken and pulped ; then a glass of boiling water was poured 
on to the pulp and the whole was allowed to digest for three 
hours. The bouillon after having been filtered through fine 
linen was divided into three or four doses and administered 
to the patient, a child. On the third day the itching had 
disappeared and the child slept quietly. After ten days’ 
treatment the marks of scratching disappeared but the 
skin was still harsh. The quantity of bouillon was then 
reduced to one dose a day. Six weeks later no trace of 
the disease remained. 

The Ophthalmic Reaction of Tuberculin. 

At a meeting of the Academy of Medicine held on 
Jan. 14th M. Calmette read a paper upon the ophthalmic re¬ 
action of tuberculin, which he said gave a trustworthy 
diagnosis of tuberculosis. Its use was quite inoffensive and 
its value superior to the subcutaneous injection of tuberculin 
or to the outi-reaction of von Pirqnet. The reaction which 
it produces was purely local and It was of great value In the 
diagnosis of all forms of tuberculosis in their very early 
stages when the diagnosis of the condition is extremely 
difficult. 

Anti-diphtheritic Serum in Affection* of the Eye. 

At the same meeting of the Academy of Medicine 
M. Darier read a paper in which he claimed that in 
infectious ulcers of the cornea, in infective penetrating 
wounds of the eye, in the complications which sometimes 
follow the operations for cataract, in certain forms of in¬ 
fective iritis, and in ophthalmic zona, he had obtained by 
means of two or three injections of Roux’s serum a rapid 
arrest of the infection. The pain then ceased and a prompt 
recovery resulted, with a far more complete conservation of 
the vision than had been obtained hitherto by any other 
form of serum therapy. Simple serum acts ten times less 
powerfully than anti-diphtheritic serum. M. Darier, con¬ 
sidering that anti-diphtheritic serum is useful not alone 
in ocular infection but in all forms of infection which 
have not at present a specific serum, recommends a more 
extended use of the remedy. 

Nomination of a Professor. 

The chair of experimental pathology, formerly held by 
Professor Charrin, which became vacant upon his death, has 
been transformed into a chair of general biology. By 25 
votes out of 30 the professors of the College of F’ranee have 
recommended to the Minister as first choice for the new 
chair Dr. Gley, agrfge of the Paris Faculty of Medicine. 




398 The Lancet,] 


BERLIN.—ITALY. 


[Feb. 1,1908. 


The Purification of Sewage. 

For some time past the sanitary authorities of the large 
towns have been seeking for some simple and rapid method 
of sewage disposal and the ordinary sewage farms have been 
a great disappointment to their upholders. They have not 
been able to treat more than from 10 to 15 litres per square 
metre per diem. Coke filter beds, which are more active, can 
only deal with, and that very imperfectly, from 500 to 1000 
litres. At a meeting of the Academy of Sciences held on 
Jan. 12th M. Muntz gave a very interesting account of some 
work which he had carried out in collaboration with M. Lainfi 
in connexion with the method of purification by peat. A 
layer of peat, 1 • 6 metres thick, will deal with 4 cubic 
metres of sewage per square metre. The pathogenic bacteria 
are destroyed by nitrifying organisms and the number of 
organisms in a sample of sewage which before treatment 
was 3,000,000 is reduced after treatment to 300. Peat 
purification, besides being a valuable source of nitrogen, 
answers all the required provisions. There is reason to 
believe that it will very shortly be applied for the use of the 
large towns. 

Absorption of the Upper Jam in a Case of Syphilitic Tabes. 

At a meeting of the Hospitals Medical Society held on 
Jan. 10th M. Danlos showed a long-standing case of syphilitic 
tabes complicated with perforating ulcer of the foot, in which 
some months ago all the teeth of the upper jaw had fallen 
out. Shortly afterwards the whole of the right side of the 
superior maxilla became absorbed and an ulceration appeared 
at the border of the gum ; on the left side a spreading mass 
appeared which looked exactly like an epithelioma. 

The Strike of Medical Men. 

In a recent letter 1 I mentioned that the medical men of 
the department of the Somme had struck against some new 
regulations of the Assistance Pubiique. Under the auspices 
of the Syndicate of Medical Men of the department a meeting 
was held at the Hotel de Ville of Amiens and it was decided 
to take no official part in the working of the Assistance in 
so far as regards medical practice after Jan. 1st, although it 
wa9 agreed to attend the poor unofficially up to May 1st. 
The members of the committee of the Syndicate are now to 
be prosecuted for putting obstacles in the way of a depart¬ 
ment for public service. 

Jan. 28th. 


BERLIN. 

(From our own Correspondent.) 

Statistics of the Medical Profession in Oerma/ny. 

According to the Medical Directory of the German Empire 
(Reicbsmedizinal-kalender), edited hy Professor Julius 
Schwalbe and summarised in the Deutsche Medizinische 
Wochenschrift by Dr. Prinzing, the number of medical men 
in Germany at the end of the year 1907 was 31,416, showing 
an increase of 485 as compared with the previous year. This 
comparatively slight increase will apparently be soon con¬ 
verted into a large increase, because the number of medical 
students, which declined sharply some years ago, once more 
begins to rise. In the summer session of 1905 there were 
6032 matriculated medical students, but the corresponding 
figures for the same period in 1907 were 7574, being an in¬ 
crease of 1500 within two years. It is obvious, therefore, 
that in four or five years, when these young men 
become qualified and engage in practice, the profes¬ 
sion will again be overcrowded. Of the total number 
of medical men 18,985 resided in Prussia, 3459 in Bavaria, 
2293 in Saxony, 1050 in Wiirtemberg, 1253 in Baden, 900 in 
Alsace-Lorraine, 692 in Hamburg, and the remainder in the 
smaller States of the Empire. It is interesting to learn from 
the statistical tables that in the great towns of more than 
100,000 inhabitants there are 10 medical men per 10,000 
inhabitants, 9 1 per 10,000 in towns having from 50,000 to 
100,000 inhabitants, 7'Oper 10,000 in towns having from 
10,000 to 50,000 inhabitants, and 2‘ 9 per 10.000 in towns 
and villages haviDg fewer than 10,000 inhabitants. The 
distribution of the profession throughout the Empire shows 
considerable inequalities and some curious instances of a 
deficiency of medical help are mentioned. For instance, 
the town of Bogetschiitz in Upper Silesia, with a population 
of 19,942, has only one medioal man, and this record Dumber 
is nearly reached by Biskupitz in the same district with one 
medical man for 12,477 inhabitants In Westphalia also there 

1 The Lancet, Jan. 13th, 1903, p. 199. 


are two places of more than 12,000 inhabitants each with 
one medical man only. Other places with 14,000 and 13,000 
inhabitants in Saxony have two medical men, and so on. All 
these places are situated in the mining districts where the 
population is comparatively poor. Most of the inhabitants 
belong to sick clubs and are at work away from home all 
day long, but nevertheless it is scarcely comprehensible how 
one medical man can suffice for nearly 20,000 people. On 
the other band, Wiesbaden has 25 ■ 4 medical men 
per 10,000 inhabitants, Munich has 15'9, Strasburg has 
14'2, Frankfort has 12'1, and Berlin has 11‘4. It 
is noteworthy that specialists are assuming a posi¬ 
tion of growing importance within the profession as in 
1906 there were in the whole Empire 6259 specialists, being 
20'2 per cent, of the profession, of whom 4004— i.e., two- 
thirds—lived in towns having more than 100,000 inhabitants. 
The great majority of specialists were gynaecologists, after 
whom there followed in numerical order ophthalmologists, 
otologists, rhinologists, laryngologists, and then the sur¬ 
geons. In 1907 the number of specialists practising in the 
great towns above indicated rose to 4160, being an increase 
of 156. I a Dresden 44 6 per cent., and in Berlin 31 5 per 
cent., of the profession were specialists. Among the prac- 
tioners in Vienna the specialists form only 14 per cent, of 
the whole, a proportion greatly below that of any large town 
in the German Empire. This comparison with the capital of 
Austria shows that in Germany something is obviously wrong 
in this development of specialism which has far exceeded 
the real wants of the population. Influential men who were 
associated with the compiler of the directory are of opinion 
that legislative measures are necessary for modifying the 
present condition of allairs. 

Death of Professor von Mering. 

The death is announced of Professor Josef von Mering of 
Halle, one of the most celebrated pathologists of Germany. 
He was born in 1849 at Cologne and after becoming qualified 
he was made an assistant to the celebrated Professor von 
Jfrerichs in Berlin. In 1878 he removed to Strasburg, where 
he was recognised as privat-docent and became extraordinary 
professor in 1886. In 1890 he was appointed chief of the 
medical polyclinic at Halle and in 1894 ordinary professor 
aDd chief of the medical clinic of the university in that city. 
The late Professor von Mering worked at physiological 
chemistry even while a student and afterwards made many 
important discoveries in that branch of medical science, 
especially in reference to diabetes. He discovered that 
diabetes might be produced in animals by phloridziu and by 
the removal of the pancreas. Other phenomena discovered 
by him related to the production of glycogen within the 
liver ; and he introduced some new medicinal compounds, 
such as amylene hydrate aDd lipaniu. He was the author 
of some text-books and wrote the chapter on diabetes in the 
great handbook of special therapy edited by Professor 
Penzold and Professor Stinzing. 

Jan. 28th. _ 


ITALY. 

(From our own Correspondent.) 

The Health of the Pope. 

During the last two decades of the life of the late Pope 
there scarcely passed a month without a sensational para¬ 
graph in the lay press announcing a svenimento (fainting fit) 
or a deliqnio (swoon) as portending the speedy demise of the 
Holy Father. He lived to be 94, the only ponriff with the 
exception of his immediate predecessor Pius IX. who “saw 
the years of Peter ”—that is, the quarter of a century duriDg 
which the first of the Apostles is said to have filled the See 
of Rome. The reigning Pope is spared the experience (shall 
I say the amusement?) of inspiring so many paragraphs in 
non-medical journals as to his health—paragraphs which, in 
the case of Leo XIII., tempted an American monsignore to say: 
“ Without the Holy Father’s bodily condition to write about, 
what would the continental quidnuncs do for a livelihood ? ” 
Still, even Pius X. does not quite escape the solicitude of 
the lay journalist—the day now passing having witnessed a 
whole “ flight” of announcements as to his having had a 
violent gouty seizure daring the night which con lined him 
to his apartment and caused the suspension of business, 
including the receptions already arranged. Inquiry, how¬ 
ever, at the only tru-tworthy quarter—the consulting room 
of the Commendatore Petacci, His Holiness’s body physician 
—reduced the report to its true dimensions, to wit, the 




The lancet,] 


BUDAPEST—OBITUARY. 


[Feb. 1,1908. 399' 


recurrence of a slight attack of the gout to which be is 
subject in midwinter, and this, by Dr. Petacci’s orders, made 
him defer one or two minor “ ricevimenti,” while giviDg due 
attention to business of more immediate urgency. Later in 
the day I learn on the same authority that His Holiness is 
<]oite himself again. 

Four Cates of Poisoning from Solution of Cod-liver Oil with 
Phosphorus. 

Milan has jnst witnessed a deplorable incident, now under 
judicial investigation—the poisoning of four little children 
after the iDgestion of solution of cod-liver oil with phos¬ 
phorus. So far as the facts are already known, it would seem 
that the oil was not prescribed by a medical practitioner but 
that the father of the children, thinking that they required 
“something of the sort,” procured it from a friend who, 
being a pharmacist, was able to get it in considerable 
quantity at a discount. So obtained, without the inter¬ 
vention (as stated) of a medical man, it was administered 
in a dose of one teaspoonfnl to each of the four children by 
their father, who did not know what the duly qualified 
physician would have told him, that the oil, thus procured 
from the manufacturing firm, had again to be diluted before 
administration—diluted in pure cod-liver oil in such quantity 
as to reduce the phosphorus to the proportion of 1 in 
10,000. The unfortunate children, it would seem, were thus 
made to take a dose of the oil containing phosphorus 19 times 
in excess of the proportion required. The results were as 
immediate as disastrous. The little victims at once gave 
signs of violent internal disturbance—“ nefrite fulminea,” it 
was called by the physician who was summoned to treat 
them, or “explosive nephritis.” Three died in a few hours 
in the hospital to which they had been removed, and the 
fourth is not likely to recover. As I hare said, these are the 
facts now under judicial investigation; meanwhile they add 
another to the many “loud warnings” addressed to the 
Italian public against playing with such “ edged tools,” as 
medicines always are, unless professionally prescribed and 
exhibited. “ Cross-counter therapeutics ” has already 
numbered many victims in Italy—particularly in the southern 
provinces where the honourable traditions of the pharma¬ 
ceutical calling are liable to be infringed by the setting up as 
“pharmacists” of adventurers who regard their business as 
little more than that of a retail dealer in groceries and who 
give “advice” and “prescribe” preparations in exchange 
for a fee to any customer who may enter their shop. The 
Government, I am glad to see, is being memorialised by the 
duly qualified pharmacists to put a stop to such invasion of 
their rightful province and it is to be hoped that legislation 
in the matter will take effect without the delays seemingly 
inseparable from Italian procedure. 

A Hospital at Mogadiscio. 

Italy has suffered in Somaliland a reverse almost identical 
with that which befell her arms 20 years ago at Dogali—a 
defeat which cost her the life of a gallant officer, the wound¬ 
ing of others, and the demoralisation of her native troops. 
Lack of equipment—that of field telegraphy in particular— 
is one cause of the disaster; in fact, but for the 
“compiacenza del filo inglese ”—the courteous help of the 
English wire—she would not, any more than at Dogali, have 
known what bad happened till many weeks afterwards. A 
movement to commemorate the fallen has been set on foot 
and will take the form of a hospital to be erected at 
Mogadiscio, the sea-port of Somalia Meridionale. This is a 
good beginning, to be followed, it is hoped, by other 
accessions to her resources in a colony lamentably deficient 
in the machinery required by such possessions. 

Jan. 17th, _ 


BUDAPEST. 

(From our own Correspondent.) 

The Treatment of Uterine Gonorrhea. 

Dr. F. ParAdi of Kolozsi fir states that the prospects of 
successful treatment of uterine gonorrhoea are not so un¬ 
favourable as has generally been believed. His conclusions 
are based on 244 cases treated in Kolozsvfir. In the clinic of 
this city the chief object of treatment is the uterus itself 
and the cavity is treated actively from the commencement of 
the disease as long as gonococci are found in the cervix. 
The method adopted is to inject about two cubic centimetres 
of a medicated solution into the cavity of the uterus under 
rtrict antiseptic prec utions, the cervix being dilated if 
thought necessary. For the past few years a 6 per cent. 


solution of sodium lygosinate, recommended by Dr. Fabinyi, 
professor of gynaecology, has been used and the injections 
have generally been given twice weekly. The preparation is 
a condensation product of salicylaldehyde and acetone and 
it possesses the advantage that, although strongly germi¬ 
cidal as regards the gonococcus, it has no irritating pro¬ 
perties and does not in any way injure the tissues. Success 
or non-success was determined by bacteriological examina¬ 
tion of the secretions. Of 128 cases treated with sodium 
lygosinate, 111 terminated in recovery, the usual number of 
applications being 10, and of the remaining 17, 10 were 
successfully treated by other means, so that only [seven 
remained unrelieved. 

The Treatment of Chancre. 

Dr. Adolf Erdos of Naqyvfirad advises the following treat¬ 
ment for syphilitic chancre. If the chancre is of recent date 
and situated on the free edge of the prepuce or of the labium 
as the case may be excision, followed by aseptic suture, is to 
be recommended. If the sore is ulcerated and of long dura¬ 
tion, two months, for instance, and if excision is impossible, 
a few drops of a soluble salt of mercury, such as the 
benzoate, the biniodide, or the bichloride, may be injected 
around the chancre. Having washed the parts with a solu¬ 
tion of sulphate of copper or nitrate of silver of strength 1 in 
50 an ointment should be applied consisting of one gramme 
of white precipitate, half a gramme of resorcin, 30 grammes 
of simple ointment, and 10 grammes of lanoline. The same 
ointment can be used for the normal chancre. The internal 
treatment should consist as much as possible in mercurial 
injections. If these are not permitted the ordinary inunction 
treatment should be followed. 

Wet Weather and In flammation of the lonriis. 

The uncommonly wet weather which is prevailing during 
this winter in Hungary has caused an unusual number of 
cases of tonsillitis, most of which set in acutely and are 
well characterised. In several instances it was found that 
the inflammation extended to the nose and gave rise to sup¬ 
puration of the accessory cavities. In disease of the middle 
ear the tonsils might require to be treated. Dr. Bauragarten 
has recently described bis experiences regarding tonsillitis in 
a medical journal. He says that in cases of recurrent 
rheumatism when the palatal tonsils were not diseased he 
had repeatedly found inflammation of the pharyngeal tonsils 
and when these were removed the recurrence ceased. The 
pharyngeal tonsils seemed to be very important as regards 
the development of tuberculosis. From them the tubercle 
bacillus made its way into the lymph stream and was 
deposited in the glands, and when these became developed at 
the period of puberty the bacilli might set up tuberculosis. 
The treatment of acute inflammations of the pharyngeal 
tonsils consisted in insufflations, removal of the secretions, 
and gargling. Operation was only indicated when there were 
ear complications. For the prevention of recurrences 
extirpation must be performed and this ought to be 
radical. 

Jan. 25th. _ 



NICHOLAS SENN, M.D. Munich., 

PROFESSOR OF SURGERY IS CHICAGO. 

We regret to announce the death of Dr. Nicholas Senn, the 
well-known surgeon, who died at his home in Chicago on 
Jan. 2nd from dilatation of the heart, aged 63 years. 
Dr. Senn was born in Switzerland on Oct. 31st, 1844, and 
went with his parents to the United States in 1852 
and settled in Wisconsin. After a short experience as a 
school teacher he received some preliminary training in 
medicine from a medical practitioner in Wisconsin and in 
1865 entered Chicago Medical College where he graduated 
with first-class honours in 1868. He began practice as a 
general practitioner in the state of his adoption but in a few 
years moved to Milwaukee where he became attached to the 
staff of the general hospital. In 1877 he returned to Europe 
and after studying at the University of Munich obtained the 
degree of medicine of that university. On his return to the 
United States he continued to practise in Milwaukee up to 
1893, although he was from 1884 professor of the principles 
and practice of surgery in the College of Physicians and 
Surgeons, Chicago. In 1893 he took up his permanent resi¬ 
dence in Chicago and from 1888 he was professor of the prin¬ 
ciples of Burgery and surgical pathology in Rush Medical 



400 Thb Lancet,] 


MEDICAL NEWS.—APPOINTMENTS. 


[F*b. 1, 1908. 


College, Ohicago, and in 1891 profesBor of the practice of 
surgery and clinical surgery at the same institution. 
In addition to these posts he held the professorship of 
surgery in the Chicago Polyclinic and was professor of 
military surgery in the University of Chicago. From 1888 
onwards he was the best known surgical lecturer in the 
United States and he used the enormous material made 
available to him by his numerous posts for the teaching of 
surgery to practitioners, the latter flocking to hear him from 
all directions. 

As an operator he excelled, especially in abdominal 
surgery. He introduced decalcified bone plates for intestinal 
anastomosis, while his experiments on the pancreas showed 
the feasibility of operating in ctrtain cases of well-defined 
lesions of that organ. As a military surgeon he took a 
prominent part in the bpanish-American war. He was 
commissioned lieutenant-colonel and chief surgeon U.S.A. 
army, and wbb commended by the Government for his 
surgical work during the Cuban campaign, as well as for 
making a valuable report upon the causes of typhoid fever 
among the troops. He was a sound writer, among the 
works from his pen which have been widely read on this side 
of the Atlantic being “Experimental Surgery,” “Intes¬ 
tinal Surgery,” “Principles of Surgery,” and “Practical 
Surgery.” 

He was a member of many and various scientific societies 
and in 1897 was President of the American Medical Associa¬ 
tion, while in 1891 he founded the Association of Military 
Surgeons of the United States, of which he was president 
for two years. This brief record shows that Dr. Senn was 
not only an exceedingly able man but had an extraordinary 
capacity for work. He rose from an obscure position in a 
foreign land to become professor of surgery in Chicago, 
the second city of that land, with a world-wide 
reputetion. And he was one of the distinguished men 
who deserve success on every ground, for he was 
universally and rightly esteemed for his rectitude and 
generosity. His public gifts were many. He endowed two 
rooms at St. Joseph’s Hospital, Ohicago, presented to Bush 
Medical College the Senn Clinical Building and to the 
medical department of the Crerar Library a valuable collec¬ 
tion of medical books and monographs, including the entire 
library of the late Dr. William Baum, professor of surgery in 
the University of Gottingen, and that of Dubois-Keymond. 
We sympathise with our American colleagues in their loss of 
a real leader. 


Utefckal JjUfos. 


Society of Apothecaries of London.— At 

examinations held recently the following candidates passed 
in the subjects indicated :— 

Surgery. —T. Campl>ell (Section II.), Liverpool; A. B. Ilardy, 
(Sections I.nnd II.), Manchester; and S. Speelman (Section I.), 
Amsterdam. 

Medicine. —P. H. W. Brewer (Section II.), St- Bartholomew’s Hos¬ 
pital; J. Brierley (Section II.), St. Thomas’s Hospital; A. R. 
Hardy (Section II.), Manchester; W. P. Binder (Sections I. and 
II.). Lee'is; and N. C. Wallis (Section I.), London Hospital. 
Forensic Medicine. —E. C. Banks, Manchester; H A. Parker, Sfc. 
Thomas's Hospital; W. P. Pinder, Leeds; and A. D. Bees, Charing 
Cross Hospital. 

Midwifery.— M. Fisher, Royal Free Hospital; C. P. B. Harvey and 
G. F. C. Harvey, London Hospital; J. A. Laughton and A. D. 
Rees. Charing Cross Hospital; G. W. Simpson, Loudon Hospital; 
and S. Speelman, Amsterdam. 

The diploma of the Society was granted to the following candidates, 
entitling them to practise medicine, surgery, and midwifery:—A. R. 
Hardy and W. P. Pindor. 

Foreign University Intelligence.— 

Heidelberg: Dr. Kiimmel, Extraordinary Professor and 
Director of the Institute of Otology, lias been promoted to 
the rank of Honorary Ordinary Professor.— Lille: Dr. 
Gaudier, ngrSge, has been appointed to the chair of Clinical 
Surgery of Children and Orthopedics.— Munich: Dr. Ernst 
Weinland, privat-doeent of Pbysiology, and Dr. Albert 
Jodlbauer, prieat decent of Pharmacology, have been granted 
the title and rank of Extraordinary Professors.— Tomsk: Dr. 
Mysh, Extraordinary Professor of Theoretical Surgery, and 
Dr. Tikhoff. Extraordinary Professor of Clinical Surirery, have 
been promoted to Ordinary Professorships.— Wurzburg : Dr. 
Jakob Riedinger, prirat docent of Orthopedics, has been 
granted the title and rank of Extraordinary Professor. 


Among the names of gentlemen called to the 
Bar at the Middle Temple last week is that of Mr. Edwin 
Smith, M.D. Lond., M.R.C.S. Eng., L.R.C.P. Lond. 

University of Durham : Faculty of Medicine. 
—Alteration of Dates of Professional Examinations. 
—The attention of candidates is directed to the fact that the 
examinations in medicine, surgery, and hygiene will in 
future be held in March and July, instead of April and 
September as hitherto. For particulars as to dates of forth¬ 
coming examinations our advertisement columns may be 
consulted. 

Three Cases of Carbonic Oxide Poisoning in 

a Workhouse. —On Thursday last week an inquest was held 
in the board-room of the Leighton Buzzard workhouse upon 
the bodies of two inmates who had been found dead on the 
morning of the previous Tuesday. A third occupant of the 
room who was found unconscious recovered under treatment. 
The jury found that the unfortunate women met their death 
from carbon monoxide poisoning which had been caused by 
structural defects in the ward. 

The Responsibility of Plumbers.— At the 

Technical College, West Hartlepool, on Jan. 17th, Dr. 
F. H. Morison, medical officer of health, gave a lecture 
to a large gathering of plumbers and representatives 
of health and water authorities. The Mayor of West 
Hartlepool took the chair. In the course of an 
interesting lecture he emphasised the great responsibility 
resting upon the plumber for the faithful execution of his 
work. He also referred in terms of eulogy to the work 
of the national registration of plumbers as helping to unite 
the craftsmen and citizens of large towns in enhancing 
the efficiency of the important industry on which all so 
largely relied for health and all dependent upon it. 
Alderman Macfarlane spoke of the interest shown by those 
in the trade in its general improvement. He referred to the 
desire of others also interested that legislation should be 
obtained as a protection against the unprincipled and 
incompetent. On the proposition of the Rev. Canon Cosgrave, 
seconded by Mr. R. I). Barker, a motion was unanimously 
carried declaring confidence in the existing organisation as 
offering the best means of securing registration on lines 
suited alike to the condition of the industry and the interest 
of the public and pledging the meeting to assist in pro¬ 
moting the object in view, particularly by appealing to the 
Government to initiate the necessary legislation. 


appointments. 


Successful applicants for Vacancies, Secretaries of Public Institutions , 
and others possessing information suitable for this column, are 
invited to forward to The Lancet Office , directed to the Sub - 
Editor , not later than 9 o’clock on the Thursday morning of each 
week, such information for gratuitous publication. 


Broster. A. E.. L.R.C.P. Edin., M R.C.S., has been re-appointed 
Medical Officer to the Braasiugton District of the Ashbourne Union, 
Derbyshire. 

Buby, A., L.R C.P. Edin., M.R.C.S., has been re-appointed Medical 
Officer to the Alstonefield District of the Ashbourne Union, 
Derbyshire. 

Cooper, A. J. Sisson, L.R.C.P. & S. Irel., has been appointed Medical 
Officer and Public Vaccinator for the Fontmell District by the 
Shaftesbury Board of Guardians. 

Friend, Gerald Edward. M.R.C.S., L.B.C.P. Lond., has been ap¬ 
pointed Superintendent and Resident Medical Officer at St- 
Georgo’s Hospital. 

Glknny, Edward T.. M.B., B.S. Lond., L.Ii.C P. Loud.. M.R.C.S., has 
been appointed Medical Officer to the Bristol Dispensary. 

Hall, A., M.lt C.S., has been re appointed Medical Officer to the 
Calton District of the Ashbourne Union, Derbyshire. 

McCandless, K., M B., B.Ch. R.U.I., has been appointed Certifying 
Surgeon under the Factory and Workshop Act for the Bathfriland 
District of the county of Down. 

Morris, Leonard Newsom, L.R.C.P. Lond., M.R.C.S., has been ap¬ 
pointed Medical Officer to the Bristol Dispensary. 

Mudoe, Z. B., M H C.S., L.R.C.P. Lond., has been appointed Certifying 
Surgeon under the Factory and Workshop Act for the Hayle 
District of the county of Cornwall. 

Phii.i.ips, Hugh R., M.D. Edin., has been appointed Physician to 
Margaret-street Hospital for Diseases of the Chest. 

Pinnigkr. Wilfrid James Hussey, M.B., B.S. Load., L.R.C.P. Lond., 
M.KC.S., has been appointed Medical Officer to the Bristol 
Dispensary. 

Telling, W/H. Maxwell. M.D., B.S. Lond., M.R.O.P., has been 
appointed Honorary Physician to the Cookridge Convalescent Hos¬ 
pital. near Leeds. 

Young. Edward Herbert, M.D. Durh., L.R C.P.. M.R.C.S., L.S.A., 
D P H. Lend., has been re-appointed Medical Officer of Health for 
Okehampton (Devon). 




Ths Lancet,] 


VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS. 


[Feb. 1, 1908. 401 


famries. 


For farther information regarding each vacancy reference should be 
made to the advertisement (see Index). 


Abebtillery Urban District Council, Education Committee.— 
Doctor (female). Salary at rate of £150, rising to £200 per annum. 

Bangor, Carnarvonshire and Anglesey Infirmary.— House Sur¬ 
geon. Salary £80 per annum, with board, lodging, and washing. 

Birkenhead Borough Hospital.— Senior Resident Honse Surgeon. 
Salay £100 and fees. 

Blackburn County Borough, Education Committee. —Assistant 
Medical Officer of Health. Salary £L50 perannum. 

Bolingbroke Hospital, Wandsworth Common. S.W. —Surgeon. 

Bootle, Borough of. Hospital for Infectious Diseases.— Resi¬ 
dent Medical Officer, unmarried. Salary £100 per annum, with 
board, washing, and apartments. 

Brighton, County Borough of.— Medical Officer of Health. 

Brighton, Sussf.x County Hospital. —House Physician, unmarried. 
Salary £70 per annum, with board, residence, and laundry. 

Brighton Throat and Ear Hospital, Church street, Quoen’e-road. 
—Non-resident House Surgeon for six months, renewable. Salary 
at rate of £75 per annum. 

Bristol Royal Hospital for Sick Children and Women.— House 
Surgeon. Salary £80 per annum, with board, rooms, and 
attendance. 

Bristol Royal Infirmary.— Obstetric Officer. Salary £75 per annum. 
Also Junior House Surgeon for six months. Salary at rate of £oO 
perannum. Also Casualty Officer for six months. Salary at rate 
of £50 per annum. All with board, lodging, and washing. 

Bury isd District Joint Hospital Board —Assistant Medical 
Officer for six months. Salary at rate of £50 per annum, with hoard, 
residence. &c. 

Casckh Hospital, Fulham-road, London, S.W.—House Surgeon for 
six months. Salary £70. 

City of London Lying-in Hospital, City-road, E.C.—Two Physicians. 

Croydon, County Borough of. —Female Assistant to the Medical 
Officer of Health. Salary £250 per annum. 

Detonport, Royal Albert Hospital.— Assistant Resident Medical 
Officer, unmarried, for six months. Salary at rate of £50 a year, 
with board, lodging, and laundry. 

Great Yarmouth County Borough.— Assistant Modical Officer of 
Health. Salary £200 per annum. 

Grocers’ Company's Scholarships —Two Scholarships for original 
research in Sanitary Science, value £500 a year each, with allow¬ 
ance to meet the cost of apparatus and other expenses. 

Grosyenor Hospital for Women and Children.—H onorary 
Registrar. 

Huddersfield Inf irmary.—J unior House Surgeon. Salary £60 per 
annum, with board, residence, and washing. 

Ireland, Lurgan Union Workhouse and Fever Hospital.— 
Resident Medical Officer (female). Salary £80 per annum, with 
apartments, laundry, and rations. 

King Edward VII. Sanatorium, Midhurst, Sussex.—Junior 
Assistant Medical Officer, unmarried. Salary £100 per annum, 
with board, lodging, and attendance. 

Lambeth Infirmary, Brook-street, Kennington. — Third Resident 
Assistant Medical Officer. Salary £125 per annum, rising to £150, 
with residential allowances. 

London Lock Hospital.—H ouse Surgeon in the Female Hospital. 
Salary £100 per annum, with board, lodging, and laundry. 

Oxford. Radcliffe Infirmary and Countt Hospital. — Junior 
House Surgeon for six months. Salary at rate of £40 per annum, 
with board, &c. 

Botal Dfntal Hospital and London School of Dental Surgery, 
Leicester-square, W.C.—House Surgeon for six months. Salary at 
rate of £60 per annum. 

Royal Hospital for Diseases of the Chest, City-road, E.C.— 
Assistant Phys cian. 

Boyal Navy, Mudical Department.—E xamination for not less than 
15 Commissions. 

St. Peter’s Hospital for Stone, & c ., Henrietta-6treet, Covent 
Garden, W.C.—Junior House Surgeon for six months. Salary at 
rate of £50 a year, with board, lodging, and washing. 

Seamen’s Hospital Society.—S urgeon at Branch Hospital. 

Stannington. Northumberland, Children's Sanatorium. —Resident 
Medical Officer (female). Salary £25, with board and residence. 

Stroud General Hospital.—H ouse Surgeon. Salary £100 per 
annum, with board, lodging, and washing. 


The Chief Inspector of Factories, Home Office. S.W., gives notice of 
vacancies as Certifying Surgeons under the Factory and Work¬ 
shop Act at Rathmore, in the county of Kerry; and at North 
Leeds, in the county of York. 


JItarrkfles, atte Jjeatjrs. 


BIRTHS. 

Hunt.—O n Jan.27th, at 3, Goldsmid-road, Brighton, the wife of Ernest 
Rivaz Hunt. M. A , M D. Cantab., of a daughter. 

Texling.— On Jan. 29Mi. at 29. Park-square, Leeds, the wife of W, II. 
Maxwell Telling, M.D., of a daughter. 


DEATHS. 

Marlhy.— On Jan 26th. at Mellingav, St. Issey, Cornwall, Henry 
Frederick Marley, M.R C.S., L.R C.P., aged 76 years. 

Stevenson.— On Jan. 17th, at Sandhurst Lodge,' Streatham. S.W., 
.Lady Sievenson, wife of Sir Thomas Stevenson, M.D., aged 68. 


N.B.—A fee of 5s. is charged for the insertion of Notices of Births, 
Marriages, and Deaths. 


States, j%rt Comments, aito Jnstoers 
to Correspondents. 

THE CERTIFICATES OF DEATH FOR ASSURANCE SOCIETIES. 
A medical man writes :— 

“Will you kindly express an opinion on the case stated below ? 
A B. who is insured, dies. The nearest relative applies for a 
certificate of death and at the same time tor a certificate of death 
for the assurance society. Should the relative be referred to the 
registrar for a copy of the original certificate or should another 
certificate (not on the forms supplied by the registrar) be given and a 
fee charged ? I have been informed by a registrar that an assurance 
society is liable to a penalty for accepting as evidence of death 
any certificate other than the copy given by the registrar. If this 
is bo. doeB it apply to both friendly societies and life assurance 
companies ? I believe it is the custom of the medical profession to 
give such certificates, but it is pointed out that the certificates are 
invalid, though ofte i accepted, and that the registrars are thereby 
deprived of fees which should come to them.” 

*#* In answer to our correspondent we may point out that assur¬ 
ance societies stand on a different footing from friendly societies. 
The policies of the former bodies generally contain stipulations to 
the effect that proof of death of the insured must be “satisfactory” 
to the insurers. This means that the evidence of death must be 
sufficient, for be it remembered that the onus of proof is on the 
person claiming the policy money. We are of opinion that “ a 
registrar” has misled our correspondent as to assurance societies 
being liable to a penalty if they should venture to dispense 
with the services of his brother officials. Most assurance 
societies are satisfied with the certificate of the practitioner who 
last attended the deceased, though sometimes circumstances 
require more corroborative proof. The stipulations (if any) in 
the policy must determine the method to be adopted by “A B’s” 
relative, and probably our correspondent may justly earn a fee 
for giving a certificate—preferably not an ordinary official one— 
setting out fully the facts which the society is likely to require. 
As regards friendly societies it may bo instructive to our 
correspondent and other readers to know that all the Acts relating 
to friendly societies previously in force were repealed in 1896 and a 
fresh code embodied in two new Acta which came into force on 
Jan. 1st, 1897, viz.: The Friendly Societies Act and the Collecting 
Societies and Industrial Assurance Companies Act. Section 61 of the 
former Act runs as ollows: " (1) A registered society or branch shall 
not pay any buiq of money upon the death of a member or other 
person whose death is, or ought to be, entered in any register of 
deaths except upon the production of a certificate of that death 
under the hand of the registrar of deaths or other person having 
care of the register of deaths in which that death is or ought to be 
entered. (2) This section shall not apply to deaths at sea nor to a 
death by colliery explosion or other accident where the body cannot 
be found nor to any death certified by a coroner or procurator fiscal 
to be subject of a pending inquest or Inquiry.” This section should 
adequately answer our correspondent’s query as to the wisdom of 
giving death certificates to members of friendly societies.— Ed. L. 

A WARNING. 

To the Editor of The Lancet. 

Sir,— I have just, heard that “von Hohenfeldt,” or as I believe he is 
now styling himself 11 Baron von Hohenfeldt, Is again on the war¬ 
path, and within the last few' weeks has victimised a number of 
members of the profession. His usual plan is to claim acquaint¬ 
ance, and indeed intimate friendship, with members of the profes 
sion who “just happen to be out of town when he most needs 
them.” He also alleges that he is doing, or is just about to de, 
moortant work for some of the leading medical societies. 

It is a wonder to me that medical men in such circumstances do not 
make use of their telephones; surely it would be easy to ring up the 
persons indicated and question them before falling a victim. 

I am, Sir, yours faithfully, 

Jan. 17th, 1908. Once Bitten. 

SHIP SURGEONS AND VACCINATION FEES. 

To the Editor of The Lxnckt. 

Sir,— Your correspondent “Bitten,” whose letter appeared in 
The Lancet of Jan. 25th, w’ants information as to the present rate of 
remuneration received by ship surgeons sailing to South America 
for vaccinating emigrants. I have just returned from a voyage to the 
River Plate. I had to vaccinate over 400 emigrants. I received 
nothing more than my ordinary monthly pav; not even thanks. 

I am, Sir, yours faithfully, 

Liverpool, Jan. 25th, 1S08. Bit. 

To the Editor of The Lancet. 

Sir,—I n reply to ymr correspondent “Bitten” I may say I com¬ 
pleted a voyage in December to South America and I was made 
responsible for the vaccination of 58 Spanish emigrants besides medical 





402 The Lancet,] NOTES, SHORT COMMENTS, AND ANSWERS TO CORRESPONDENTS. [Feb. 1, 1908. 


attendance upon the crew and other passengers and I was not allowed 
any extra pay. What I really had was 10*. per month less than the 
carpenter who also had extra pay for overtime. 

I am. Sir, yours faithfully, 

Jan. 25th, 1908. Gaviota. 

BUDIN’S SYSTEM. 

To the Editor of The Lancet. 

Sir,—I should be much obliged if any medical man who has tried the 
** Budin ” system of the hand-feeding of infants—i.e., using undiluted 
sterilised cow's milk with a 4 per cent, standard of cream—would give 
me the benefit of his experience.—I am. Si . yours faithfully, 

Jan. 25th, 1908. *” D vinous. 


Appendicitis will find our reply on p. 388 of this issue. 

Oracme.— 1. Yes. 2. Yes. 

Communications not noticed in our present issue will receive attention 
in our next. 


METEOROLOGICAL READINGS. 

(Taken daily at 8£0 a.m. by Steward's Instruments.) 

The Lancet Offlee, J»n. 30th, 1908. 


Date. 

Barometer j 
reduced to 
Sea Level 
and 32° F. 

Dtreo- j 
tioo : 

ol 

Wind. 

Rain¬ 

fall. 

Solar 
| Radio 
In 

Vacuo. 

Maxi- ! 
mum 
Temp. 
Shade 

Min. 

Temp 

| 

Wet 

Bulb. 

Dry 

Burt). 

Remarks. 

Jan. 24 

30 48 

S.E. i 


40 

37 

33 

36 

36 

F °8iw 

„ 25 

30 37 

S.W. 


46 

45 i 

31 

32 

32 

Overcast 

.. 26 

30-35 

S.W. 


E6 

52 ! 

32 

44 

45 

Overcast 

„ 27 

29-89 

S.W. 

0'19 

59 

55 i 

4b 

51 

51 

Overcast 

„ 28 

29 68 

W. 


71 

48 

44 

42 

44 

Cloudy 

.. 29 

29 78 

N. 

006 

! 68 

43 

37 

35 

37 

Fine 

.. 30 

3018 

N.W. 

... 

50 

40 

35 

33 

35 

Cloudy 


UJefal iliunT for tjre ensuing aatcdi. 


OPERATIONS. 

METROPOLITAN HOSPITALS. 

MONDAY (3rd).— London (2 p.m.), St. Bartholomew’s (1.30 p.m.), St. 
Thomas’s (3.30 p.m.), St. George’s (2 p.m.), St. Mary’s (2.30 p.m.), 
Middlesex (1.30 p.m.), Westminster (2 p.m.), Chelsea (2 p.m.), 
Samaritan (Gynecological, by Physicians, 2 p.m.), Soho-square 
(2 p.m.). City Orthopaedic (4 p.m.), Gt. Northern Central (2.30 p.m.), 
West London (2.30 p.m.), London Throat (9.30 a.m.). Royal Free 
(2 p.m.), Guy’s (1.30 p.m.). Children, Gt. Ormond-street (3 p.m.), 

_St. Mark’s (2.30 P.M.). 

TUESDAY (4th).—London (2 p.m.), St. Bartholomew’s (1.30 p.mA St. 
Thomas’s (3.30 p.m.), Guy’s (1.30 p.m.), Middlesex (1.30 p.m.), West¬ 
minster (2 p.m.), West London (2.30 p.m.), University College 
(2 p.m.), St. George’s (1 p.m.), St.. Mary’s (1 p.m.), St. Mark's 
(2.30 p.m.). Cancer (2 p.m.). Metropolitan (2.30 p.m.), Loudon Throat 
(9.30 a.m.), Samaritan (9.30 a.m. and 2.30 p.m.). Throat, Golden- 
square (9.30 a.m.), Soho-square (2 p.m.), Chelsea (2 p.m.), Central 
Loudon Throat and Ear (2 p.m.), Children, Gt. Ormond street 
(2 p.m., Ophthalmic, 2.15 p.m.), Tottenham (2.30 p.m.). 

WEDNESDAY (5th).—St. Bartholomew's (1.30 p m.). University College 
(2 p.m. ), Royal Free (2 p.m.), Middlesex (1.30 p.m.), Charing Cross 
(3 P.M.), St. Thomas's (2 p.m.), London (2 p.m.). King's College 
(2 p.m.;, St. George's (Ophthalmic, 1 p.m.), St. Mary’s (2 p.m.), 
National Orthopedic (10 a.m.), St. Peter's (2 p.m.), Samaritan 
(9.30 a.m. and 2.30 p.m.), Gt. Northern Central (2.30 p.m.), West¬ 
minster (2 p.m.), Metropolitan (2.30 p.m.), London Throat (9 30 a.m.), 
Cancer (2 p.m.), Throat, Golden square (9 30 a.m.), Guv’s (1.30 p.m.), 
Royal Ear (2 p.m.). Royal Orthopedic (3 p.m.). Children, Gt. 
Ormond-Btreet (9.30 a.m., Dental, 2 p.m.), Tottenham (Ophthalmic, 

_2 30 p.m.). 

THURSDAY (6th).—St. Bartholomew’s (1.30 p.m.), St. Thomas’s 
(3.30 p.m.). University College (2 p.m.), Charing Cross (3 p.m.), St. 
George’s (1 p.m.), London (2 p.m.), King’R College (2 p.m.), Middlesex 
(1.30 p.m.), St. Mary’s (2.30 p.m.), Soho-square (2 p.m.), North-West 
London (2 p.m.), Gt. Northern Central (Gynecological, 2.30 p.m.). 
Metropolitan (2 30 p.m.), London Throat (9.30 a.m.), Samaritan 
(9.30 a.m. and 2.30 p.m.). Throat, Golden square (9.30 a.m.), Guy’s 
(1.30 P.M.), Royal Orthopaedic (9 a.m.), Royal Ear (2 P.M.), Children, 
Gt. Ormond-street (2 30 p.m ). Tottenham (Gynecological. 2.30 p.m.) 

FRIDAY (?th).— London (2 p.m.), St. Bartholomew’s (1.30 p.m.), St. 
Thomas's (3.30 p.m.), Guy’s (1.30 p.m.), Middlesex (1.30 p.m.). Charing 
Cross <3 p.m.), St. George's (1 p.m.). King's College (2 p.m.), St. Mary s 
(2 p.m.). Ophthalmic (10 a.m.). Cancer (2 p.m.), Chelsea (2 p.m.), Gt. 
Northern Central (2.30 p.m.), West London (2.30 p.m.), London 
Throat (9 30 a.m.), Samaritan (9 30 a.m. and 2.30 p.m.), Throat, 
Golden-square (9.30 a.m.), City Orthopiedic (2 30 p.m.), Soho-square 
(2 p m.), Central London Throat and Ear (2 p.m.). Children, Gt. 
Ormond-street (9 a.m.. Aural, 2 p.m.), Tottenham (2 30 p.m), St. 
Peter's (2 p.m.). 

SATURDAY (8th).—Royal Free (9 a.m.), London (2 p.m.), Middlesex 
(1.30 p.m.), St. Thomas’s (2 p.m.). University College (9.15 a.m.), 
Charing Cross (2 p.m.), St. George’s (1 p.m ). St. Mary's (10 a.m.), 
Throat, Golden-square (9.30 a.m.), Guy's (1.30 p.m.), Children, Gt. 
Ormond street (9.3J a m.). 

At the Royal Rye Hospital (2 p.m.), the Royal London Ophthalmic 

S O a.m.), the Royal Westminster Ophthalmic (1.30 p.m.), and the 
entral London Ophthalmic Hospitals operations are performed daily. 


SOCIETIES. 

ROYAL SOCIETY OF MEDICINE. 20. llanover-square. W. 

Tuesday. (Pathological Section). 8.30 p.m., Miss H. Chick :;The 
Reaction Velocity of Disinfection. Dr. F. G. Bushnell: Cases 
of (1) So-called “ Leukrernia (2) Lymphocytic Leuk.rmia with 
Malignant Lymphomata; (3) Sarcoma of Cervical Glands. Dr. 
J. H. Smith : The Absorption of Serum from the Tissues; Mr. 
F. A. Bainbridge: The Relation of Bacilli of the Paratyphoid 
Group. Dr. J. A. Arkwright: On Non-virulent Diphtheria 
Bacilli. Dr. J. C. C. Ledingham : Experiments in Phagocy¬ 
tosis Dr. J. B. Loathes : (1) Note on a Case of Chylous Ascites; 
(2) Metabolism in Fever. Mr. A. J. Young The Action of 
Arsenates on the Fermentation of Glucose by Yeast juice (with 
demonstration). Dr. G. F. Petrie. Mr A. W. Robertson, Dr. 
R. D. Keith, Mr. E. A. Minchin, and Dr. A. C. Stevenson and 
Mr. J. D. Thompson: Demonstrations and Exhibitions of 
Specimens. 

Friday.— (Ijaryngological Section). 5 p.m.. Dr. W. Williams, Sir 
Felix Semon, Dr. J. Donelan, Dr. StClair Thomson and Dr. J. 
Horne: Cases and Specimens. 

MEDICAL SOCIETY OF LONDON, 11, Chandos-street, CavendiBh- 
square, W. 

Monday.—9 p.m., Mr. C. J. Symonds : Tuberculosis of the Kidney 
(illustrated by lantern slides, cases, and specimens*. (First 
Lettaomian Lecture.) 

WEST KENT MBDICO-CHIRURGICAL SOCIETY, Miller Hospital, 
Greenwich, S.E. 

Friday.— 8.45 p.m., Dr. F. B. Taylor : Uterine Hemorrhage. 

WEST LONDON MEDICO CHIRUHGICAL SOCIETY, West London 
Hospital, Hammersmith road, W. 

Friday*. —8 p.m., Pathological Meeting. Specimens will be shown. 

NORTH-EAST LONDON CLINICAL SOCIETY, Prince of Wales’s 
General Hospital, Tottenham. N. 

Thursday. —4.15 p.m.. Clinical Cases. 

SOCIETY OF ANAESTHETISTS. 20, Hanover square, W. 

Friday. —8.30 p.m.. Adjourned Discussion on Status Lymphaticus. 

PHARMACEUTICAL SOCIETY OF GREAT BRITAIN, 17, Blooms- 
bury-square, W.C. 

Tuesday.—8 p.m., Mr. E. M. Holmes: The Adulteration of Drugs 
and the MethodB of Preventing it. 

ROYAL SOCIETY OF ARTS, John-street. Adelphi, W.C. 

Friday.— 8 p.m., Mr. W. Burton : The Hygiene of the Pottery 
Trade. (Shaw Lecture on Industrial Hygiene.) 


LECTURES, ADDRESSES, DEMONSTRATIONS, &c. 

MEDICAL GRADUATES’ COLLEGE AND POLYCLINIC, 22, 
Chenies-streot, W.C. 

Monday.— 4 p.m., Dr. S. E. Dore : Clinique (Skin). 5.15 p.m.. 
Lecture:—Mr. J. W. T. Walker: The Diagnosis and Treatment 
of Malignant Disease of the Prostate. 

Tuesday.—4 p.m., Dr. B. Abrahams : Clinique (Medical). 5.15 p.m.. 
Lecture:—Dr. G. H. Savage: Mental Disorders of Adolescence. 
Wednfsday.— 4 p.m., Mr. J. Berry: Clinique (Surgical). 

5.15 p.m.. Lecture :—Mr. R. H. J. Swan: Malignant Cutaneous 
Tumours. 

Thursday. — 4 p.m., Mr. Hutchinson: Clinique (Surgical). 5.15 p.m.. 
Lecture:—Mr. R. Jones (Liverpool): The Present Position of 
Arthrodesis and Tendon Transplantation. 

Friday'.— 4 p.m.. Dr. D. Grant : Clinique (Bar). 

POST-GRADUATE COLLEGE, West London Hospital, Hammersmith, 
road, W. 

Monday*.—12 noon : Lecture :—Dr. Low: Pathological. 2 p.m.. 
Medical and Surgical Clinics. X Rays. Mr. Dunn : Diseases 
of the Eye. 2.30 p.m.. Operations. 5 p.m., Lecture Mr. 
Dunn : Cases of Eje Diseases. 

Tuesday.— 10 a.m., Dr. Moullin: Gynaecological Operations. 
12 noon : Lecture :—Dr. Pritchard: Practical Medicine. 2 p.m.. 
Medical and Surgical Clinics. X Rays. Dr. Bali: Diseases of 
the Throat, Nose, and Ear. 2.30 p.m.. Operations. Dr. Abraham: 
Diseases of the Skin. 5 p.m., Lecture:—Mr. Bidwell: Clinical. 
Wednesday*. - 10 a.m.. Dr. Ball: Diseases of the Throat. Nose, and 
Ear. Dr. SaunderB: Disoises of Children. 2 p.m.. Medical and 
Surgical Clinics. X Rays. Dr. Scott: Diseases of the Eye. 
2.30 p.m., Operations. 5 p.m., Lecture:—Dr. Beddard : Practical 
Medicine. 

Thursday. —12 noon. Lecture:—Dr. Pritchard: Practical Medicine. 
2 p.m., Medical and Surgical Clinics. X Rays. Mr. Dunn: 
Diseases oi the Eye. 2.30 p.m., Operations. 5 p.m., Lecture :— 
Mr. Keetley: Clinical 

Friday*.—10 a.m.. Dr. M. MoulUn : Gynaecological Operations. 
2 p.m., Medical and Surgical Clinics. X Rays. Dr. Ball: 
Diseases of the Throat, Nose, and Ear. 2.30 p.m., Operations. 
Dr. Abraham : Diseases of the Skin. 5 P.M., Lecture:—Dr. 
Abraham -. Cases of Skin Disease. 

Saturday.— 10 a.m.. Dr. Ball: Diseases of the Throat. Nose, and 
Ear. Dr. Saunders: Diseases of Children. 2 p.m.. Medical and 
Surgical Clinics X Rays. Dr. Scott: Diseases of the Eye. 
2.30 P.M., Operations. 

NORTH EAST LONDON POST-GRADUATE COLLEGE, Prince of 
Wales’s General Hospital, Tottenham, N. 

Monday.— Cliniques:-10 a.m.. Surgical Out-patient (Mr. Hi 
Evans). 2.;0 p.m., Medical Out patient. (Dr. T. R. Wbipham): 
Throat. None, and Ear (Mr. 11. W. Carson); X Ray (Dr. A. H. 
Pirie). 4.30 p.m., Medical In-patient. (Dr. A. J. Whiting). 
Tuesday*.— Clinique:—10.30 a.m., Medical Out-patient (Dr. A. G. 
Auld). 2.30 p.m.. Surgical Operations (Mr. Carson). Cliniques:— 
Surgical Out-patient (Mr. Edmunds); Gynaecological (Dr. A. E. 
Giles). 4.30 p.m.. Pathological Demonstration:—Recent Cases 
from the Post-mortem Department. 




The Lancet,] 


DIARY.—EDITORIAL NOTICES.—MANAGER’S NOTICES. 


[Feb. 1, 1908. 403 


Wednesday. —Cliniques:— 2.30 p.m., Medical Out-patient (Dr. 
Wbipham); Dermatological (Dr. G. N. Me&chen); Ophthalmo- 
logical (Mr. K. P. Brooks). 

Thursday.— 2.30 P.M., Gynaecological Operations. (Dr. Giles). 
CliniquesMedical Out-patient (Dr. Whiting); Surgical Out¬ 
patient (Mr. Carson); X Kay (Dr. Pirie). 3 p.m.. Medical 
In-patient (Dr. G. P. Cbappel). 4.30 p.m., Throat Operations 
iMr. Carson). 

.Friday.— 10 a.m., CliniqueSurgical Out-patient (Mr. H. Evans). 
2.30 p.m., Surgical Operations (Mr. Edmunds). Cliniques: — 
Medical Out-palient (Dr. Auld); Eye (Mr. Brooke). 3 p.m., 
Medical In-patient (Dr. M. Leslie). 

AON DON SCHOOL OF CLINICAL MEDICINE, Dreadnought 
Hoe pita l, Greenwich. * s 


Letters, whether intended for insertion or for private informa¬ 
tion, must he authenticated by the names and addresses of 
their ivriters—not necessarily for publication. 

We cannot prescribe or recommend practitioners. 

Local papers containing reports or ne?rs paragraphs should be 
marked and addressed “ To the Sub-Editor .” 

Letters relating to the publication, sale and advertising 
departments of The Lancet should be addressed “ To the 
Manager .” 

We cannot undertalie to return MSS. not used. 


Monday.— 2.15 p.m., Sir Dyce Duckworth: Medicine. 2.30 p.m., 
Operations. 3.15 p.m., Mr. W. Turner : Surgery. 4 p.m., Dr. 
StClair Thomson : Ear and Throat. Out-patient Demonstra¬ 
tions . 10a.m., Surgical and Medical. 12 noon. Ear and Throat. 
315 p.m., Special Lecture:—Mr. W. Turner: The Treatment of 
Syphilis 

Tuesday.—2.15 p.m., Dr. H. T. Hewlett: Medicine. 2.30 p.m., 
Operations. 3.15 p.m., Mr. CarlesS: Surgery. 4 p.m., Mr. M. 
Morris : Diseases ot the Skin. Out-patient Demonstrations :— 
10 a.m.. Surgical and Medical. 12 noon, Skin. 

Wednesday. —2.15 p.m., Dr. F. Taylor: Medicine. 2.30 p.m., 
Operations. 3.30 p.m., Mr. Cargill: Ophthalmology. Out¬ 
patient Demonstrations 10 a.m., Surgical and Medical, 
11a.m.. Eye. 2.15 p.m., Special Lecture:—Dr. F. Taylor: Intra- 
thoracic Growths. 

Thursday. —2.15 p.m., Dr. G. Rankin : Medicine. 2.30 p.m., Opera¬ 
tions. 3.15 p.m., Sir W. Bennett: Surgery. 4 p.m., Mr. M. 
Davidson : Radiography. Out-patient Demonstrations 
10 a.m. , burgical and Medical 12 noon, Ear and Throat. 

Friday.- 2.15 p.m., Dr. R. Bradford: Medicine. 2.30 p.m., 
Operations. 3.15 p.m., Mr. McGavin -. Surgery. Out-patient 
Demonstrations10 a.m.. Surgical and Medical. 12 noon, 
Skin. 3.15 p.m., Special Lecture:—Mr. McGavin: Acute 
Perforative Peritonitis. 

Saturday. — 2.30 p.m.. Operations. Out-patient Demonstrations 
10 a.m.. Surgical and Medical. 11 a.m., Eye. 


GREAT NORTHERN CENTRAL HOSPITAL, Hollo way-road, N. 

Monday.—9 a.m., Operations (Mr. White). 2.30 p.m., In-patients— 
Medical (I)r. Beevor); Out-patients—Medical (Dr. Willcox), 
Surgical (Mr. Low), Eye (Mr. Morton and Mr. Coats). 

Tuesday.-2.30 p.m., In-patients Medical (Dr. Beale), Throat and 
Ear (Mr. Waggeft); Outpatients-Surgical (Mr. Edmunds). 
Throat and Ear (Mr. French); Operations (Mr. Beale). 

Wednesday.— 2.30 p.m.. In-patients - Surgical (Mr. Stabb); Out¬ 
patients— Medical (Dr. Border), Gynaecological (Dr. Lockyer) 
Skin (Dr. WhiMield), Teeth (Mr. Baly); Operations (Mr. Stabb). 

Thursday.-2.30 p.m.. In-patients—Medical (Dr. Morison). 

3-30 P-M., lecture:—Dr. C. £. Beevor: Diagnosis and 
Treatment of Hemiplegia. 


NATIONAL HOSPITAL FOR THE PARALYSED AND EPILEPTIC 
Queen-square, Bloomsbury, W.C. 

Tuesday.— 3.30 p.m.. Lecture Dr. J. Taylor: Degenerative Dis¬ 
eases of tbe Spinal Cord. 

Fhiday.-3.30 p.m., Lecture:—Dr. A. Turner: Epilepsy. 


ST. JOHN'S HOSPITAL FOR DISEASES OF THE SKIN 
Leicester-square, W.C. ’ 


Thursday.—6 p.m.. Lecture:— Dr. 
(I-, Miliary; II., Lenticular; 
Pustular and Tuberculous. 


M. Dockrell : Syphilis: Papular 
III., Squamous; IV., Moist) 


CHARING CROSS HOSPITAL. 

Thursday.—3 p.m., Demonstration:-Dr. Galloway and Dr. 
MacLeod : Diseases of the Skin. 4 p.m., Demonstration — 
Dr. Eden : Gynaecological. (Post Graduate Course). 

H in>mJtOT F ° K CON3UMPT10N AND DISBASBS OF THE CHEST, 

Wednusdat.— 4 p.m. lecture:—Dr. J. M. Bruce: Congenital 
Heart Disease. & 


UfE ASSURANCE MEDICAL OFFIOBR3’ ASSOCIATION 20 
lUnover-aquare. W. 


Wednksday.— 8 p.m., Council Meeting. 
Lyon: Presidential Address. 


8.30 p.m.. Dr. T. Glover 


EDITORIAL NOTICES. 

It is most important that communications relating to the 
Witorial business of The Lancet should be addressed 
ncUnttly “To THE Editor,” and not in any case to any 
pmtleman who may be supposed to be connected with the 
^litorial staff. It is urgently necessary that attention should 
* given to this notice. 


It is especially requested that early intelligence of local events 
wring a medical interest, or which it is desirable to bring 
under the notice of the profession, may be sent direct to 
thu office. 

lectures, original articles, and reports should be written on 
me tide of the paper only, and when accompanied 
BY BIAICKS IT IS REQUESTED THAT THE NAME OF THE 
AUTHOR, AND IF POSSIBLE OF THE ARTICLE, SHOULD 
BE WRITTEN ON THE BLOCKS TO FACILITATE IDENTI¬ 
FICATION. 


MANAGER’S NOTICES. 

THE INDEX TO THE LANCET. 

The Index and Title-page to Vol. II. of 1907, which was 
completed with the issue of Dec. 28th, were given in 
The Lancet of Jan. 4th, 1908. 


VOLUMES AND CASES. 

Volumes for the second half of the year 1907 are now 
ready. Bound in cloth, gilt lettered, price 18s., carriage 
extra. 

Cases for binding the half year's numbers are also ready. 
Cloth, gilt lettered, price 2s., by post 2s. 3d. 

To be obtained on application to the Manager, accompanied 
by remittance. 


TO SUBSCRIBERS. 

Will Subscribers please note that only those subscriptions 
which are sent direct to the Proprietors of The Lancet at 
their Offices, 423, Strand, London, W.C., are dealt with by 
them ? Subscriptions paid to London or to local newsagents 
(with none of whom have the Proprietors any connexion what¬ 
ever) do not reach The Lancet Offices, and consequently 
inquiries concerning missing copies, &o., should be sent to 
the Agent to whom the subscription is paid, and not to 
The Lancet Offices. 

Subscribers, hy sending their subscriptions direct to 
The Lancet Offioes, will insure regularity in the despatch 
of their Journals and an earlier delivery than the majority 
of Agents are able to effect. 

The Colonial and Foreign Edition (printed on thin 
paper) is published in time to catch the weekly Friday mails 
to all parts of the world. 

The rates of snbscriptions, post free, either from 
The Lancet Offices or from Agents, are :— 


For the United Kingdom. 

One Year .£1 12 6 

Six Months. 0 IS 3 

Three Months .. 0 8 2 


To the Colonies and Abroad. 

Oue Year .£1 14 8 

Six Months. 0 17 4 

Three Months . 0 8 8 


Subscriptions (which may commence at any time) are 
payable in advance. Cheques and Post Office Orders (crossed 
“London and Westminster Bank, Westminster Branch”) 
should be made payable to the Manager, Mr. Charles Good, 
The Lancet Offices, 423, Strand, London, W.C. 


TO COLONIAL AND FOREIGN SUBSCRIBERS. 

Subscribers abroad are particularly requested 

TO NOTE THE RATES OF SUBSCRIPTIONS GIVEN ABOVE. It 
has come to the knowledge of the Manager that in some 
cases higher rates are being charged, on the plea that the 
heavy weight of The Lancet necessitates additional 
postage above the ordinary rate allowed for in the terms of 
subscriptions. Any demand for increased rates, on this or on 
any other ground, should be resisted. The Proprietors of 
The Lancet have for many years paid, and continue to pay, 
the whole of the heavy cost of postage on overweight foreign 
issues; and Agents are authorised to collect, and generally 
do so collect, from the Proprietors the cost of such extra 
postage. 

The Manager will be pleased to forward copies direct from 
the Offices to places abroad at the above rates, whatever be 
the weight of any of the copies so supplied. Address— 
The Manager, The Lancet Offices, 423, Strand, 
London, England. 


During the week marked copies of the following newspapers 
nave been received —Manchester Chronicle. Daily News, Reading 
Mercury and Ox/ord Gazelle, Nottingham Evening .Veins. South Wales 
Daily Rows. Sanitary Record, Standard, Yorkshire Daily Post, 
Newcastle Chronicle. Dublin Evening Telegraph, Liverpool Courier, 
hereford Times, Yorkshire Daily Observer , Nottingham Press, 
Wimbledon Gazette, Broad Ar r ow, See. 



404 Thb Lanokt,] 


ACKNOWLEDGMENTS OF LETTERS, ETC., RECEIVED, 


[Feb. 1, 1908. 


Communications, Letters, &c., have been 
received from— 


A. — Dr. I. W. Anderson, Lond.; 
Dr. H. Alston. West Kirby; 
Messrs. Aked and Aked, Lond,; 
Abertillery Education Commit¬ 
tee. Secretary of; Dr. T M. 
Allison, Newcastle - on - Tyne; 
Dr. W. S. Anderson, Chapel- 
en - le • Frith ; Dr. Thos. F. 
Agino, Lond. 

B. —Mr. J. A. Barth, Leipzig; 
Dr. A. T. Brand, Driffield; 
Mr. P. S. Bridgeford, Lond.; 
Mr. J. A. Batley, Leeds; 
Mr. T. B. Browne, Lond.; MesBrB. 
Burroughs, Wellcome, and Co., 
Lond.; Bristol Royal Hospital for 
Sick Children, Secretary of; 
Dr. A. B. Brindley, Bury; 
Bristol Royal Infirmary, Secre¬ 
tary of; Messrs. Brady and 
Martin, Newcastle - on - Tyne; 
Messrs. S. and E. Banks. Lond.; 
Dr. W. Beedie, Kimbolton, New 
Zealand; Lieutenant - Colonel 
E H. Brown, I.M.S., Lond.; 
Fleet-Surgeon Reginald Bankart, 

B. N., Portsmouth; British Medi¬ 
cal Benevolent Fund, Lond., 
Hon. Secretary of; Brighton 
Society and Guardian Press, 
Manager of; Bayer Co., Lond.; 
Dr. A. G. Bateman. Lond.; 
Dr. H. J. D. Birkett, Southsea ; 
Sir James Barr, Liverpool; 
Dr. Clark Bell, New York; 
Birkenhead Borough Hospital, 
Secretary of, Bayard Chemical 
Co., Paris; Barnstaple and North 
Devon Dispensary, Hon. Secre¬ 
tary of; Mr. Victor Bonney, 
Lond.; Bradford MedicoChirur- 
gical Society. 

C. —Dr. George Carpenter, Lond.; 
Charing Cross Hospital Local 
Maintenance Association. Lond.. 
President of; Chelsea Hospital 
for Women, Secretary of; Messrs. 
Cal lard and Bowser, Lond.; 
Mr. Harrison Cripps, Lond.; 
Messrs. Cassell and C<», Lond.; 
Mr. F. W. Clarke, Chorlton-cum- 
Hardy; Mr. J. Calvert. Lurgan ; 
Dr. O. Clayton-Jones, Silverton; 
Professor John Chiene, Edin¬ 
burgh. 

J).— Mr. Alexander Duke, Lond.; 
Mr. E. Darke, Lond.; Den tel 
Manufacturing Co , Lond., Mana¬ 
ger of; Dr. A. Duncan, Lond. 
B.—Dr. Wm. Ewart, Lond.; Dr. J. 
Bvre, Lond. 

P.— The Fine Art Society. Lond. 
d,_Mr. H. M W. Gray, Aberdeen ; 
Mr J. H. P. Graham, Wallasey ; 
Mr. M. Greenwood, jun., Lough- 
ton. 

H.—Mr. R. W. Hill, Bombay; 
Mr. F. H. Humphris, Ilkley-in- 
Wharfedale; MIbs Homersham, 
Lond.; Mr. W Sampson Handley, 
Lond.; Dr. K C. Hort, Lond.; 
Mr. R. Ernest Humphry, Stone; 
Dr. John Hay, Liverpool; The 
Harveian Society, Lond., Hon. 
Secretary of; H. P-; Messrs. 

C. J. Hewlett and Son, Lond.; 
Mr. T. Hawkaley, Lond.; Dr. H. 
Newton Heineman, Bad Nau¬ 
heim; Dr Harold F. Horne, 
Barnsley; Mr. J. Hatton, Bux¬ 
ton; JJ'et Vadtrland , ’s-Graven- 
hage, Holland; Helouan. 

L— Income-Tax Reduction, Lond.; 
Incorporated Institute of Hy¬ 
giene, Lond. 

J— Dr. F. F. Jay, Faversham; 
'Dr. W. Watkiss Jones, Leicester; 
Mr. J. Hervey Jones, Dinas 
Mawddwy. 

K.—Mr. Edward Knight, Lond.; 


Messrs. Kilner Bros., Lond.; 
Messrs. S. Kutnow and Co., 
Lond.; Kreochvle Co., Lond; 
King Edward Vll. Sanatorium, 
Lond., Hon. Secretary of; 
Mr. B. Kuhn, Frankfort, Ger¬ 
many; Dr. H. Cameron Kidd, 
Bromsgrove; Dr. James Kirk¬ 
land. Lond.; Dr. Henry Koplik, 
New York; Messre. R. A. Knight 
and Co., Lond. 

L. Mr. H. K. Lewis, Lond.; 
Mr. Thomas Laffan, Cashel; 
Mr. Hugh Lett, Lond.; Life 
Assurance Medical Officers’ Asso¬ 
ciation, Lond., Hon. Secretary of; 
London and County Motor Co., 
Lond., Manager of; L M . Erith; 
Mr F. W. Lowndes, Liverpool; 
Messrs. Lauthton and Co., Lond. 
M—Mr. Robert Maccoll. Glasgow; 
Miss Dora Maconochie, Bexley; 
Messrs. W. K. Morton and Sons, 
Lincoln; Dr. N. E. Mackey, 
Halifax, Nova Scotia; M. D; 
Dr. C. J. Morton, Loud.: Mr. 
Neil Maclay. Wallsend-on-Tyi e; 
Miol Manufacturing Co.. Lond.; 
Professor Robert Muir, Glasgow; 
Dr. J. A. C. Macewen. Glasgow; 
Dr. Hector Mackenzie. Lond.; 
Dr. S G. Moore. Huddersfield; 
The Mission to Lepers in India 
and the East, Lond., Superin¬ 
tendent of; Messrs. Meister, 
Lucius, and Bruning, Lond.; 
Dr. A. McDougall, Warford; 
Male and Female Nurses’ Co¬ 
operation, Lond. 

N. —Dr. Alexander Nicoll, New 
York; The Nutrolactis Co., New 
York; Mr. J. C. Needes, Lond.; 
Mr H. Neefies, Lond. 

O. —Baron Oliveira. Lond.; Orient. 

P. —Mr. W. H. Payne, Lond.; 
Dr A Pfau, Lemberg, Austria; 
Peckham House, Lond., Secre¬ 
tary of; Mr. J. M. Pearson, 
Vancouver, British Columbia; 
Mr. R Spencer Pearson, Leigh¬ 
ton Buzzard; Messrs. Parke, 
Davis, and Oo., Lond.; Dr. J. J. 
Perkins, Lond.; Dr. R. W. 
Philip, Edinburgh; P. A. F.; 
Messrs. Peacock and Hadley, 
Lond. 

Q. — Queensland, Department of 
Public Health, Brisbane, Secre¬ 
tary of; Queensland Govern¬ 
ment Statistician, Brisbane. 

R. —Mr. J. B. Roberts, Horsell; 
Dr. H. K. Ramsden, Lond.; 
Dr. W. Ford Robertson, Edin¬ 
burgh; Rebman, Ltd., Lond.; 
Royal College of Surgeons of 
England, Lond., Secretary of; 
Royal Society of Medicine. Lond., 
Secretary of; Radcliffe In¬ 
firmary, Oxford, Secretary of; 
Mr. A. Rau, Frankfurt; Royal 
Sanitary Institute, Lond., Secre¬ 
tary of ; Mr. David D. Robert¬ 
son, Lond.; Royal Maternity 
Charity of London, Secretary of; 
Royal "Society of Arts, Lond., 
Secretary of. 

S. —Mr. S. R. Soneji, Lond.; 
Mr. Sydney Stephenson, Lond.; 
Messrs. T. and W and W. 
Southall, Lond.; A Sympathiser; 
Dr. G. Scheltema, Groningen; 
Seamen’s Hospital Society, 
Lond., Dean of; Messrs. Salt 
and Co., Birmingham; Society 
of Apothecaries of London. Secre¬ 
tary of; Dr. T. P. Anderson 
Stuart, Sydney; Mr. W. S. 
Stevenson, Lenzerheide, Switzer¬ 
land; Scholastic, Clerical, Ac., 
Association, Lond. 


T. -Mr. P. G. Temple, Lond.; 
Dr. J. G. Taylor, Chester; T. 8.; 
Triumph Cycle Co.. Coventry; 
Mr. B. D. Telford, Manchester; 
Trades Commissioner for the 
Cape of Good Hope, Lond. 

U. —University of Liverpool, Regis¬ 
trar of. 

V. -Mr. A. E. Vindeu, Lond.; 
Dr. C. Wilfred Vinlng, Lond. 


W.—Dr. Andrew Wylie. Lond.; 
Mr. Ernest L. Waiford, Lond.; 
Mr. K. H. Worth, Lond.; Mrs. 
L- Wheeler, Lond.; Messrs. F. 
Williams and Co., Lond ; Messrs. 

R. Walker and Sons, Leicester; 
Mr. S. Wand. Leicester; West 
London Medico - Chirurgical 
Society, Secretary of. 

Y.—Dr. Meredith Young, Lond. 


Letters, each with enclosure, are also 
acknowledged from— 


A.— Mr. J. P. Atkinson, Lynton; 
Ardath Tobacco Co., Lond.; 
Aberdeen Free Press, Manager 
of ; A. J. D.; Dr. F. H. Alderson, 
Bournemouth; Anglo American 
Pharmaceutical Co.. Lond.; 
Aston Manor Corporation, Trea¬ 
surer to the: Messrs Appleyard 
and Sons, Middlesbrough. 

B Dr J. T. Brett, Melbourne; 
Messrs. Bedford and Co., Lond.; 
Mr G. P. Butcher. Plymouth ; 
Messrs. Butterworth and Co., 
Lond.; Mr. A. Bonner, Bradford ; 
Messrs. Broadbent and Co, 
Huddersfield ; Beta. Devonport; 
Mr. W. H. Bush. Stamford 
Bridge; Miss B.; Mr. R. A. 
Bickersteth, Liverpool; Mr. 

S. N. Babington, Tilehurst; Dr. 
H F. Bassano, Ventnor, Isle of 
Wight; Biikenhead and Wirral 
Children's Hospital, Secretary of. 

C. Mr. J. Coffey, Preston; C. B.; 
Messrs. Carnick and Co.. Lond.; 
Mr E. Croft. Plymouth; Car¬ 
narvonshire Infirmary, Bangor, 
Secretary of; Mr. E P. 
Court, Horsmonden; Chelten¬ 
ham General Hospital, Secre¬ 
tary of; Mr. Corkey, Gwmbach; 
Messrs. J. and A. Carter, Lond.; 
Messrs. Cox and Co., Brighton; 
Dr. H. H. Clarke, Liverpool; 
Cambay (India), Chief Medical 
Officer of. 

D. Mr. J. T. Davenport, Lond.: 
Captain Dykes, I.M.S., Rai 
Bareli, India; Dr. A. C. Dixon, 
Antofagasta, Chili; Mr. R. A. 
Dickson, Newcastle, Stafford 
shire; Professor S. Delepine, 
Manchester; Mr. P. H. Day, 
Poulton-le Pylde; Dr. W. T. 
Dougal, Piltenweem; Dorset 
County Hospital, Dorchester, 
Secretary of. 

B.—Messrs. Eason and Son. Dublin; 

E. M. T.; Mr. F. Eve, Lond.; 
Mr. H. S. Blworthy, Ebbw Vale, 
E. E. 8.; K. A.; Miss Turle 
Evans, Lond.; Mr. W. Edmunds, 
Lond. 

P. Mr. G. Finch, Meon Stoke; 
Dr. J. A. C. Forsyth, Lond.; 
Messrs. Fannin and Co., Dublin; 
Dr. C. Fraser, Alnwick. 

Q. —Dr. C. C. Gibbs, Lond. ; 
Mr. G. H. Gemmell, Edinburgh; 
Dr. V. R Gorakshakar, Hyder¬ 
abad; Captain J. H. P. Graham, 
R A.M.C., Wallasey. 

H.— Mr. C. B. Howse, Lond.; 
Dr. E R. Hunt, Brighton; 
Messrs. Holland and Son, Lond.; 
Dr. J. Hay, Liverpool; H. P.; 
Mr. J. Hoole, Parwich; Mr. 

J. J. Hicks, Lond.; 

J. -Dr. W. M. Jones. Torquay; 
Mr. G. H. Jones, Deddingtou; 
John Street 8urgical Nursing 
Corps, Lond., Secretary of; J. G.; 
J. k.; J. D. K.; Dr. P. S. Jakins, 
Lond. 

K, Mr. R. C. B. Kerin, Lond.; 
Kent and Canterbury Hospital, 
Secretary of ; King Edward VII. 
Sanatorium, Mid hurst. Secre¬ 
tary of; Kumbakonam Municipal 
Council. India. Chairman of; 
Dr. W. Kirkpatrick, Stourbridge; 


Dr. G. S. Keeling, Attleborough; 

Dr. Keys, Hainhill. A 

L.—Mr. L. F. Leslie, Evesham; 
Locum Tenons. Leicester; Dr. 

J. Shaw Lyttle, Cilfynydd; ** 
Messrs. Lee and Nightingale, 
Liverpool; L. D. O.; Messrs. W. 

Le Lacheur and Son. Lond.; 

Mr. W. W. Linnev, Croydon; , 

Liverpool Royal Infirmary, Secre¬ 
tary of; Leslies, Ltd., Lond.; 

Lady Superintendent, Streat- g 

ham; London Association of 
Nurses, Superintendent of; Mr. 

G. L. Luksumanaswami, Banga¬ 
lore. 

M —Mr. J. H. Morgan, Lond.; 

Mr. H. C. Mac Bryan, Box; 

Mr. C. Mansell Mouflin, Lond.. 

Mr. R. Mosse, Berlin; Maltine 
Manufacturing Co., Lond.; 

Dr. W. R. Marnier, Stockport; 

Dr. W. Moyers, BUndford; 

Mr. R. C. B. MaunBoll, Dublin; 
Medical Society of London, j 

Registrar of; M. U.; Mr. J. E. 
May, Lond.; Mr. E. Merck, 
Lond.; Mr. W. McKay, Grey- 
mouth, New Zealand; Messrs. 

J. F. Mac far lan and Co., Lond.; 

Dr. C. J. Macalister, Liverpool; 

Dr. J. F. Macdonald, Govau; 

M.B., Evesham. 

N. -National Dental Hospital, 
Lond., Secretary of; North 
British Advertising Ageucy, 31 

Lond. 

P.—Dr. L. W. Pole. Edinburgh; 

Dr. W. F. Peacock, Croydon; 

Messrs. C. Pool and Co., Lond.; * 
Poplar Guardians, Clerk to the; 
Miss Peacocke, Lond. 


R.-Miss Ringwood, Haslemere; 
Messrs. Reynolds and Branson, 
Leeds; Mrs. Robinson, Lond.; 
Messrs. Roberts and Co., Lond.; 
Dr. W. Rice, Fermoy; Dr. II. 
Lawton Roberts, Ruabon; Dr. 
A. Routh, Lond.; Miss R. 

8 . —Dr.A. Sheh&di. Faggala, Egypt; 
Dr. H. E. Symee-Thompson, 
Lond.; Stroud General Hospital, 
Secretary of; Sanitas Electrical 
Co., Lond., Secretary of; Mr. 
D. Sen, Midnapore, India; 
Mr. G. F. Smith, Watford; 
Messrs. G. Street and Co., Lond.; 
Messrs. Spiers and Pond, Lond.; 
Staffordshire Education Com¬ 
mittee, Stafford, Director of. 

T.—Messrs. Toler Bros., Lond.; 
Tower House, Leicester, Super¬ 
intendent of; T. M. R., Lond.; 
Messrs. Tribes haw and Edwards, 
Lond.; Mr. F. Topic, Prague; 
Dr. W. H. M. Telling, Leeds; 
Mr. J. Thin, Edinburgh. 

W.— Mr. T. F. Wyse, Dalkey; 
Dr. W. L. Walker, Milford 
Haven; Wye House. Buxton, 
Superintendent of; Mr. W. T. 
Williamson, Hereford; Mr. C. 
Hamilton Whiteford, Plymouth; 
West Riding County "Council, 
Wakefield, Treasurer to the; 
Mr. T. H. Waller, Chelmsford 5 ; 
WonfordHouse Hospital, Exeter, 
Clerk to the; Mr. W. :F. A. 
Walker, Dinas Mawddwy; Messrs. 
H. Wilson and Son, Lond. 


EVERY FRIDAY. 

SUBSCRIPTION, 

Fob the Ukited Kingdom. 

One Year .£1 12 8 

Six Month*... ... ... 0 16 3 
Three Months ... ... 0 8 2 


THE LANCET. PBIOE BEVENPENOE. 


POST FREE. 

To thk Colonies and An road. 

One Year ... ..£1 14 8 

Six Months.. ... 0 17 4 

w —.. . Three Month* ... ... 0 8 8 

Subscription* (which may oommence at any time) are payable in 
advance. 


ADVERTISING. 

Book* and Publication* ... 8even Line* and under £0 
Official and General Announcements Ditto 0 

Trade and Miscellaneous Advertisement* I 
and Situation* Vacant . f 


... , 0 4 6 

Every additional Line 0 0 6 
Situation* wanted: First 30 words, 2*. 6d.; per additional 8 word*, 6<i 
Quarter Page, £110«. Half a Page, £216«. An Entire Page, £5 5a. 





THE LANCET, February 8, 1908, 


% Jwto« 

ON 

SLEEP AND SLEEPLESSNESS. 

Delivered at the Great Northern Central Hospital on 
Deo . 13th, 1907 , 

By ALEXANDER MORISON, M.D. Edin., 
F.R.C.P. Lond. and Edin., 

PHYSICIAN TO THE HOSPITAL. 


Gentlemen, —A human being does not cease to be man 
-when he becomes a patient. He remains snch whether the 
host of a tapeworm or streptococcus or the subject of any 
other malady. This incontestable fact would not require 
mention were it not that it appears at times to be lost Bight 
of when attention is directed too exclusively, as may happen, 
to the invading disease. Whether in health or in illness the 
mind plays an Important part by the influence it exerts upon 
the body. This is more noteworthy in the case of the 
disorder of some organs than of others, and in none perhaps 
is it more so than in that of the cardio-vascular system which 
is not under the control of the will but is very sensitive to 
the influence of the emotions. It is obvious, therefore, that 
interference with the periodic repose of the organ of mind 
has a practical importance which justifies its particular study 
by the physician. A man may die exhausted “from the 
top ” when other physical dangers threatening him have been 
successfully overcome. 

While the hospital patient is often the victim of 
insomnia the satisfactory study of sleeplessness is best 
made in private practice, and I feel in addressing this 
audience on this subject that I am speaking to many 
who must have had a large experience of this con¬ 
dition. It is, moreover, one which requires a considerable 
experience both of disease and of life to discuss with advant¬ 
age. It is probably because defective sleep is associated 
with so many states that text-books of medicine, notwith¬ 
standing its importance as a symptom of disturbance and 
cause of still further exhaustion, do not treat it fully under 
one heading. Like dropsy, it is referred to, if mentioned at 
all, in connexion with its causal conditions, and if this were 
done more systematically there would be no serious ground 
of complaint, but this is not the case. Comprehensive mono¬ 
graphs and instructive paperB have, however, been published 
from time to time on the subject and will repay perusal. Of 
these, it will suffice if I mention the monographs of Cappie 
and Hacfarlane and the practical papers of Sir James 
Sawyer and Sir William Broadbent. In connexion with the 
purely scientific investigation of the subject the names of 
Durham and Donders deserve mention as early investigators, 
and since their time other physiologists and physicians have 
recurred to a subject which is always of interest. 

In the present lecture I propose discussing so far as I can 
the factors which underlie sleep and wakefulness, the dis¬ 
crimination of one type of insomnia from another, the 
significance and prognosis of different varieties of sleepless¬ 
ness, and the rational treatment of the condition. In short, 
I desire to discuss as briefly as possible, but with adequate 
fulness, the principles, so far as we can explain them, which 
underlie the etiology and treatment of insomnia. 

Sleep and sleeplessness are synonymous with unconscious¬ 
ness and consciousness. Intermediate degrees of these states 
are, in various proportion, conditions of partial unconscious¬ 
ness or of partial consciousness—the dream state. Conscious¬ 
ness, whatever its psychological analysis or definition, is a 
property of the nervous system and of the highest plane of it 
—namely, of the grey matter of the cerebral cortex. Reflex 
actions we know may be provoked in decapitated animals 
and apparently even purposive movements manifested by 
them. The decapitated frog may raise its foot to all seeming 
in order to brush away a stimulation of the surface of the 
trunk, and the beheaded turtle may snap its jaws for a length 
of time after the severed head has lain far from its body. 
But the “ spinal soul,” if it exist at all, is peculiar to lower 
types of animal life, with which the physician has no imme¬ 
diate concern, and physiology teaches us that as the cortex 
is removed in layers unconsciousness deepens, although the 
functions of visceral life may continue little impaired. We 
may therefore conclude that, whatever the actual seat of 

No. 4406. 


consciousness, it stands in close relation to the oells of the 
oerebral cortex. Its manifestation among the higher animals 
is not possible without the agency of some cells in the brain 
any more than is the function of any other viscus without 
that of the cells proper to it. 

Recent methods of investigating the anatomy of the 
cerebral cell have shown how lar reaching are its afferent 
sensory parts or receptive roots and their collateral tentacles 
or gemmules, and also how directly its efferent or executive 
processes transmit the nervous influence to the nerves or to 
the next in a series of cells conveying the motor impulse. 
In a sense the receptive radicles of a motor cell may be 
regarded as its sensory or afferent portion. This view of the 
relation of radicles or dendrites to cell-body and efferent 
fibres Is regarded by those who accept this theory of the 
transmission of nervous influences as illustrative of what 
has been called the “law of dynamic polarisation ”—that is, 
that nerve force entering at the receptive pole of a cell 
issues from the other, the axonic end, according to some by 
passing through the cell unaltered, and in the view of others 
modified by the action of the transmitting cell itself. 
Modern research has also shown the cell body to have a 
very complex organisation. Staining methods reveal con¬ 
stituents which hold and others which refuse the stain—the 
so-called chromatic and achromatic portions of the cell. 
Moreover, some of these constituents stain differently from 
others under the varying conditions of rest and activity. 
Thus some stain with certain reagents when the cell is 
exhausted and others with other stains when the cell is 
refreshed by functional repose. To these points I shall 
have occasion to refer again. 

But consciousness, we also know, may be lost when 
animals are deprived of blood and restored with a renewal 
of the circulation. It follows, therefore, that the quantity 
of blood and character of the circulation have an influence 
upon the condition of the cells which manifest consciousness 
or unconsciousness as the case may be, and that whether 
unconsciousness be the result of a swoon or of sleep. We 
know further that substances introduced into the circulation 
may render an animal soporific or unconscious or, on the 
other hand, delirious and excited The quality of the blood 
also has, therefore, an influence in the maintenance of con¬ 
sciousness or in the production of uncomcioueness. 

That the physical conditions obtaining within a closed 
chamber such as the skull, capable of resisting the atmo¬ 
spheric pressure in great measure, if not altogether, have an 
influence upon the character of the circulation within the 
skull may be granted. That the intracranial circulation, that 
is, differs in a measure from that in portions of the body 
not so protected, may be admitted. But the invariability of 
the intracranial blood content, which the doctrine of Monro 
assumed and on which some theories of Bleep-production 
have been based, can no longer be regarded as a fact. That 
doctrine lived long and died hard, if, indeed, it be yet quite 
dead ; so long indeed did it last that support for it was until 
recently sought in the assumed absence of innervation of the 
intracranial blood-vessels, because the innervation of these 
vessels had cot been demonstrated. In a series of lectures 
which I delivered in Edinburgh ten years ago on the rela¬ 
tion of the nervous system to visceral disease I was able, 
however, to show from specimens I stained in the laboratory 
of this hospital that the intracranial vessels were richly 
endowed with nerves, and, cot only so, but that these 
nerves bore peripheral ganglionic cells. I afterwards 
learned that Obersteiner had previously stained these nerves 
and others also have done so since. My preparations were 
from vessels in the pia mater, but Ford Robertson figures an 
innervation of vessels in the cerebral cortex both of quad¬ 
rupeds and men. 1 We therefore know now that intracranial 
vascular Innervation is general and indubitable. 

Some physiologists, notably Leonard Hill, have contended 
that, these facts notwithstanding, these nerves cannot be 
made experimentally to vary the calibre of the vessels they 
innervate, and for Hill the key to the intracranial lies in the 
splanchnic circulation. 2 It is manifest that this conclusion 
is difficult to accept, as nature is as averse to distributing 
fnnctionless structures as Bhe is to loving vacua. Observers 
have, moreover, Bhown that there is ; s direct a relation 
between oerebral activity and blood-supply as Ihere is between 
the activity of any other group of functionally active cells 
and their blood supply. This relation even Hill admits, 


1 Pathology of Mental Diseases, p. 163. 

* Schafer’s Physiology, p. 146, Edinburgh and London, 1S00. 
F 





406 The Lancet,] 


DR. ALEXANDER MORISON: SLEEP AND SLEEPLESSNESS. 


[Feb. 8, 1908. 


although he ascribes it to variations in the splanchnic and 
somatio circulation. 

What then is sleep? As night succeeds day and the 
parched and dusty earth is steeped in the cool and refreshing 
moisture of the sunless interval ; as rest succeeds toil, and 
the strain of exertion stretches itself out in the grateful 
relaxation of mental and bodily effort; so sleep, in normal 
circumstances, wraps in the oblivion of unconsciousness the 
whole being exhausted by a term of conscious activity. The 
machinery of,life cools down in sleep, the temperature falling 
slightly. The pulse on the whole becomes slower and it may 
be somewhat irregular. The depth of respiration is increased 
and its frequency diminished, as anyone may note who has 
the misfortune to hear another snoring. The eyes close and 
exclude all light. The pupils contract in proportion to the 
profoundness of sleep. The activity of all secretions is 
lessened. The work of life is carried on with a minimum 
of friction. 

In this series of phenomena a difference is to be observed 
between the behaviour of the organs of voluntary motion and 
the involuntary organs. The voluntary muscular system is 
relaxed ; its reflex irritability is lessened and its centres of 
motor activity are placed in abeyance. On the other hand, 
taking the pupil as a type of involuntary organic action, for 
we may leave out of consideration its accommodative 
faculty, we And that with the loss of eight and the closure 
of the eyelids the pupils contract as if still further to 
exclude any chance of sensory stimulation by light. During 
consciousness the exclusion of light, as we know, is 
associated with dilatation of the pupil. Now we also 
know that this contraction of the pupil, so characteristic 
of normally recurring unconsciousness, that is of sleep, is 
not necessarily associated with abnormal unconsciousness 
or the stupor attending certain diseased states. In many 
euch conditions the pupil is widely dilated or varies in 
the degree of dilatation in one eye as compared with the 
other. 

On the other hand, from lesions in certain parts of the 
brain and as the effect of certain drugs, unconsciousness 
is associated with an equal contraction of both the pupils, 
indistinguishable from that which attends normal sleep. 
The pupillary changes in sleep therefore are unlike the 
flaccidity of voluntary muscle in the same state, for the 
withdrawal of light from the reflex arc of optic nerve, 
pontic centre, and oculo-motor result, are not those one 
would expect as a result of such withdrawal of stimulus. 
Nor can the contraction of the pupil in sleep be attributed 
to a relaxation of the motor-sympathetic innervation of the 
radiating fibres of the iris, as there is evidence of the 
potential and actual activity of the sympathetic in the vaso¬ 
constriction of the cerebral vessels which has been noted 
by Durham, Donders, and others. There has been no 
adequate explanation of this marked difference in the 
behaviour of the pupil as compared with voluntary muscle, 
but the conclusion may legitimately be drawn that sleep is 
the resting period of consciousness and of all voluntary 
actions and only indirectly refreshes the ever-labouring heart 
and other organs whose perpetual activity is necessary to 
life. The unconsciousness of death and of apparent death, 
such as that associated with profound syncope, is coupled 
with a widely-dilated pupil and the complete loss of 
irritability of all organs, voluntary and involuntary. 

The essential or primary element in the mechanism of con¬ 
sciousness is the brain cell—not its afferent channels of 
stimulation, not its blood-supply, but the cell itself. Not 
that the cell itself as apart from these could manifest con¬ 
sciousness, but it is evident that it is only in relation to the 
cell that the latter have importance. The condition of the 
peptic cell in the stomach during fasting and digestion, of 
the urinary cell in the kidney, of the essential cell of every 
other organ during activity and rest respectively, supports 
this argument. In sleep blood still irrigates the brain cell, 
and its processes are presumably still in connexion with it 
and with the rest of the body. 

I have said that the primary element in the mechanism of 
consciousness is the brain cell, but behind all the factors 
named is the mystery of life. It might more truly perhaps 
be asserted, that consciousness is life manifest in certain 
brain cells, just as the exercised function of any other organ 
is life manifest in the cells proper to it; the brain or neTve 
cell, however, governs every other functionally active cell in 
the body in a way in which the latter do not govern it; nervous 
influenoe is as universally distributed as the blood. Sines the 
discovery of the far-reaohing processes of the nerve cell, as 


revealed by modern staining methods, it has been suggested 
that sleep may be due to the withdrawal cellwards or 
modification of these processes or of portions of them, and 
their loss of touch, in consequence, with afferent sources of 
stimulation. But of this there is no proof. Even assuming, 
however, such a hypothesis to be possibly correct, such a 
withdrawal would be a consequence, not a cause, of changes 
in the brain cell itself, and the fact that the sleeper may be 
wakened by sensory stimulation in greater or less degree pro¬ 
portionate to the profoundness of sleep rather argues that the 
afferent channels of sensibility still have touch of the 
external world, although the centre, the cells on which they 
converge, may not respond to stimuli falling upon them. It 
is also noteworthy that noises or stimuli which the mind has 
interpreted when awake frequently act rather as a lullaby 
than as a disturbance to sleep, while much lesser noises, not 
so interpreted and to which the individual has not become 
accustomed, serve frequently to rouse the sleeper to con¬ 
sciousness. The conclusion therefore seems to be warranted 
that a change in the cell itself is the primary cause of sleep, 
and that vascular and neural changes associated with 
sleep are effects, not causes, of the condition. What 
the essential cause of these intracellular changes is is 
unknown, but that they exist is indubitable. In the absence 
of more precise knowledge they can only be termed chemico- 
vital. 

Normally a measure of exhaustion of the nerve cell from 
the exercise of function appears to be the essential cause of 
sleep. With this there may also be exhaustion of other 
organs, and more especially of the voluntary muscular 
system. But however the latter may participate in sleep- 
production the primary cause is the need for rest on the part 
of the brain cell itself, and its essential nature that chemico- 
vital change in it of which this need is the expression—a 
change of which we know no more at present than we do of 
the essential nature of life itself. Moreover, some interesting 
observations have been made on the appearance of nerve 
cells in conditions of functional activity and repoBe, and 
which can only, I think, be regarded as evidence that the 
cell creates as well as transmits energy. These visible changes 
in the bodies of cells respectively normally active and 
exhausted or at rest have been studied by many observers, 
and Ford Robertson thus summarises the general result 
of these investigations; “During normal activity the 
chromophile substance is utilised by the cell and slowly 
diminishes in quantity. At the same time the fuchsinophile 
granules of Levi increase considerably in numbers. The 
nucleus undergoes an increase in volume and the particles of 
chromatin adherent to it tend to become elongated. During rest 
the chromophile substance gradually accumulates again, the 
fuchsinophile granules diminish in numbers, and the nucleolus 
(nucleus ?) assumes a smaller volume. When the energy of 
the cell is exhausted by prolonged or excessive activity, the 
cell-body and the nucleus are distinctly diminished in 
volume; the chromophile substance of the cytoplasm is 
small in amount and appears diffusely granular instead of 
forming local aggregations.” 3 These observations are surely 
sufficient to indicate that the organ of consciousness is the 
brain cell, or rather certain brain cells, in touch, on the one 
hand, with afferent influences by their receptive radicles 
and, on the other, putting forth the products of their 
activity by efferent channels, the whole being sustained in 
action by the blood, the nutrient fluid which bathes the organ 
of consciousness and source of mind. 

But before passing from this subject we must remember 
that notable distinction between the results of mental 
cellular action and the action of unthinking cells, such as 
those of the stomach, liver, kidney, and spinal cord, or even 
of such cerebral cellB as those the function of which is not 
emotional perception and ratiocination—namely, that the 
products of the organ of consciousness are more or less 
permanent, while those of unthinking cells are repeatedly 
produced, but each crop or series is itself transient and 
eliminated from the system. This permanent product of the 
organ of consciousness interests us on the present occasion 
because it may in its turn become a source of stimulation of 
the thinking cells. Itself an efferent product of their 
energy it may become in its turn an afferent source of 
stimulation. Memory, like thought, is cumulative. It has 
a beginning; much of it probably has an ending; some of 
it possibly is unending ; but to inquire as to this is beyond 
our present purpose. These thoughts lead us to a short 

3 Pathology of Monts! Diseases, p. 226; Edinburgh, 1900. 


/ 




The Lancet,] 


DB. ALEXANDER MORISON: SLEEP AND SLEEPLESSNESS. 


[Feu 8, 1908. 407 


consideration of some psychological points bearing upon our 
present theme. 

Perhaps no subject has exercised more the ingenuity of 
the thoughtful than the nature and actions of mind, and 
classifications of the different manifestations of human con¬ 
sciousness have been very numerous. The phenomena of 
consciousness appear to be subjective and objective, involun¬ 
tary and voluntary ; I had almost said passive and active, 
but passivity is properly applicable only to the reception of 
a stimulus by the organ of mind. The “ Senses and the 
Intellect,” to use the title of Bain’s well-known treatise, 
perhaps expresses this division sufficiently. Feeling and 
expression, in thought, word, and deed, embrace all phases 
of mind, for all these may be phases of an internal process 
of which there is no overt manifestation. Feeling in the 
first instance can of necessity only be appreciated by the 
individual. It is purely subjective. A thought need not be 
apparent to others, a word need not be uttered, and an act 
need not be manifested. A thought is an act, a word is an 
act, and a resolve is an act. They are all within the sphere 
of will, to be liberated or repressed, as the individual 
desires. 

To enter at length upon the field of fine distinctions in 
moral philosophical terminology is, however, scarcely 
germane to our present purpose. It will suffice if I explain 
with greater detail what I mean by subjective and objective, 
involuntary and voluntary phases of the operations of mind. 
The subjective operations of mind deal with the feelings — 
with love, self-esteem, hate, joy, grief, hope, fear, certainty, 
uncertainty, satisfaction and dissatisfaction, however they 
may be provoked, and however they may be further divisible 
in relation to the desires and appetites of our nature. 
Primarily they appear to spring from our possession of life 
and the impulse to preserve and perpetuate it. When we 
cease subjectively to feel, our mental operations become 
objective ; our feelings shape themselves towards intellectual 
effort and transpire in thought, word, and deed. Such action 
completed, we may again lapse into satisfied or dissatisfied 
subjectivity. We may feel satisfied or dissatisfied. Satisfac¬ 
tion is rest; dissatisfaction is unrest or continued stimula¬ 
tion. This may appear to some but prolix verbiage, but I 
hope to show that it has a bearing upon our theme in my 
endeavour to explain the phases of cellular action which 
underlie consciousness and which tend, according to their 
nature, to encourage or to thwart the normal advent of 
rhythmical sleep. 

Another point of importance in relation to sleep and sleep¬ 
lessness is temperament. While man may be regarded as 
essentially one in his nature—scratch anyone and he will 
bleed much like his neighbour—it is nevertheless a truism 
that no two men are precisely alike. In no respect is this 
more so than in his mental nature, in the sphere, that is, of 
his consciousness. These differences of temperament may 
be assumed to be based on physical differences which 
may escape detection by the test-tube or microscope, but 
which are unmistakeably written in the objective manifesta¬ 
tions of mind, in the conduct and bearing of the indi¬ 
vidual. A man, the intellectual side of whose nature is 
well developed, may exercise a control which imposes 
outward calm on a naturally perfervid disposition, and 
may give a surface impression of quietude which is foreign 
to his nature. This is not likely to mislead those who 
have any faculty for distinguishing the quick, energetic 
type usually associated with the possession of powers 
of rapid perception, rumination, and expression, from 
the slower, more deliberate, and less impulsive type. 
The majority of men of the former type are easily recognised 
by rapidity of speech when discussing matters which interest 
them, frequently emphasised by gesture and decorated with 
metaphor or imagery which may easily degenerate into 
extravagance of language or oratory. Their emotions are 
easily roused and they sometimes advocate with enthusiasm 
causes not necessarily sound in themselves. What is true 
of the neurotic man is true also of the neurotic woman, 
“ only more so,” to use a conventional phrase. The intel¬ 
ligent man of a naturally imperturbable disposition, on the 
other hand, is not as a rule the stuff of which poets, orators, 
and artists are made. His ratiocination is often slower, but 
often also more accurate than the neurotic’s and the results of 
his cogitation frequently more reliable, while his actions and 
expression are less explosive but often more sustained and 
effective. Dogged sometimes does it, after the rocket has 
flared into the heavens and returned as the unpicturesque 
stick. There is, of course, the contingent possibility of 


tardy worth arriving on the scene too late to be of much 
use to himself or anyone else. But that is a detail 
which probably would not disturb him to the same extent 
as it would his more impetuous fellow. Both types when 
not dullards may no doubt be raised to white heat 
on sufficient occasion, the one quickly and the other 
Blowly, but the brain-cell rest of the quick is more easily 
disturbed than that of the slow. Both, however, in virtue 
of their intelligence tend to return to the normal, for each 
creates for himself a centre of calm by cleaih insight into 
circumstances and possibilities. Neither of them, that is, 
desires long a slice of the moon if that luminary cannot 
reasonably be reached with a knife. 

When we come to a lower plane and the subjective differ¬ 
ences remain while intelligence is less marked, the phleg¬ 
matic have the advantage still more. They have a bovine 
imperturbability which is conducive to good digestion and to 
doing nothing, which is sometimes safe. The stupid neurote, 
on the other hand, is apt to be hurried into precipitate and 
often unfortunate action, not calculated to hasten his 
return to normal quietude and rhythmical sleep. Alco¬ 
holism, morphinism, and other bad habits are more easily 
acquired by the stupid neurotic than by the stupid phleg¬ 
matic person, although, unfortunately, many a brilliant and 
lovable nature has also succumbed to the same fatal 
influences to escape the torture of insomnia. 

These temperamental differences which influence cellular 
excitation, influence also disturbances of sleep due to 
afferent neural and to hsemic causes. Sleeplessness may 
therefore be placed in three groups—cellular, neural, and 
hsemic. Not that these can be altogether detached the one 
from the other any more than these factors can be separated 
in the production of normal consciousness, but inquiry will 
usually elicit in cases of insomnia which of them plays the 
predominant role in a particular case. But whatever the 
immediate cause of sleeplessness the effects of it, though 
varying in degree, are the same in kind and the opposite of 
those observed in sleep. Thus, the temperature of the body 
is slightly raised, visceral actions are quickened, and secre¬ 
tion, especially the urinary secretion, is increased, not 
diminished. The latter phenomenon is, like all the phenomena 
of sleeplessness, most evident in the. neurotic insomniac 
and is due to the higher vascular tension involved which 
causes a larger excretion of urine by the kidneys, for the 
increased output is usually of a limpid character. 

Let us now consider these varieties of sleeplessness 
seriatim. 

1. Cellular insomnia .—The majority of cases of disturbed 
sleep are referable to this class, as might a priori be 
expected ; indeed, most papers on insomnia deal solely with 
this class. We need not attach too much importance to 
statistics which are rarely based upon a sufficient number of 
oases to carry conviction to the mind of the lesson they seem 
to point. Such as they are, however, they indicate the pre¬ 
ponderance of the cases I have termed cellular. Thus, the 
late Dr. Macfarlane in his thoughtful work found that 
neurasthenia and worry were responsible for 26 per cent, of 
cases of insomnia calculated from a total of 273 cases. 
Although gout, overwork, the menopause, dyspepsia, alco¬ 
holism, and senility are among the other causes which he 
mentions it is probable that the cellular factor played a not 
insignificant part in many of these also. We must dis¬ 
tinguish, moreover, between the subjective and objective 
causes of cerebro-cellular disturbance. Of these the former, 
dealing with sensibility and emotion, are more likely to pre¬ 
ponderate than those dealing with executive overwork. 
Worry kills and keeps awake more frequently than work. 
There is relief and attainment in action which does not 
appertain to the unutilised energy of subjective or un 
expressed feeling. Action takes a man out of himself and 
thus favours repose. 

2. Neural insomnia , in the sense in which I have need the 
term, includes all those cases in which sleep is disturbed by 
afferent impulses of a more strictly physical kind. Pain and 
bodily discomfort in various degree and originating in what¬ 
ever system, be it cutaneous or pulmonary, renal or hepatic, 
gastric or intestinal, may rouse conscious activity and 
prevent its dropping into the rhythmical repose natural to 
it. This such efferent impulses may effect directly, as is the 
case in pain and local discomfort from any cause, when it is 
sufficiently pronounced to be perceived by the mind as 
such ; or indirectly when the combined influence of afferent 
stimulation and cerebral excitation raises the blood pressure. 
We must remember also that; the absence of satisfaction of 




408 The Lancet,] DR. ALEXANDER MORISON : SLEEP AND SLEEPLE88NES8. 


[Ebb. 8, 1908. 


an appetite, the hunger of desire, may be an afferent cause 
of oerebro-cellular excitation as well as its over-gratification 
or improper indulgence. The infant at its mother’s breast 
whioh obtains too little nourishment is frequently as sleep¬ 
less as the child which is overfed or has improper food. In 
both oases there is a discomfort wbioh is referred to the 
periphery, and in the case of indigestion certainly begins 
there. Moreover, what is true of the infant and its food is 
true also of the adult and of desires and appetites to which 
the infant is a stranger. 

3. Harmic iruomnia is a term whioh, I think, may legiti¬ 
mately be applied to cases in which the exciting cause of 
sleeplessness is in the blood. As in the case of the cellular 
and neural group, the hsemic cannot perhaps be stated to act 
altogether independently of the other factors. There is 
reason, indeed, to think that the hsemic group is the smallest 
of those into which cases of insomnia fall, but our experience 
of anaemia, however originated and at whatever age, teaches 
ns that defective nutrition and repair of the nervous system 
raise its sensibility and impair its stability. In the hsemic 
category we should also place cases in which the tempera¬ 
ture is raised without the development of localised disease, 
as, for example, in the continued fevers and also various 
intoxications, whether with on. without localised disease. 
The terrible insomnia, for example, of the delirious 
pneumonic, which in no small degree hastens the 
frequently fatal issue, belongs to this group. Drug 
and food agents alBO which disturb sleep may be re¬ 
garded as acting through hrcmio channels. Tobacco when 
smoked is possibly an exception to this rule, as it has a 
directly stimulating effect upon the sensory nerves of the 
oro-nasal cavities, but even in this case there is probably 
absorption in some measure into the circulation. The blood 
stream, moreover, may carry products of defective meta¬ 
bolism which act through the medium of the nervous system 
on the blood-vessels and induce a hypertonic state unfavour¬ 
able to oerebro-cellular repose, for the most perfect uncon¬ 
sciousness is that which is associated with lowered activity 
and rest in every texture. Vascular bypertonus of a spastic 
and functional type has its organic expression in the arterio¬ 
sclerotic rigidity of advancing life and old age, which is so 
often associated with defective sleep. Senile insomnia of 
this type is, indeed, exalted into a special variety by Sir 
James Sawyer in his interesting lecture on Sleeplessness.' 
Perfect normal sleep requires a normal minimum of physical 
and mental stimulation ; unrest in one part of the body 
physical tends to rouse other parts which crave repose. 

Prognotu. —The probability or otherwise of the subsidence 
of insomnia and the recurrence of normal rhythmical sleep 
depends naturally on the removeability or otherwise of the 
cause of disturbance. A good deal depends also upon the 
judiciousness with which protracted sleeplessness is handled 
by the physician and the strength of character of the patient 
whether the wakeful habit become fixed or subside. When 
insomnia is dependent upon physical lesion—ulcerative 
colitis, to chooBe a cause at random for the sake of illustra¬ 
tion—it is self-evident that unless we can cure the condition, 
reducing thereby the discomfort and temperature often asso¬ 
ciated with it, the patient is not likely to drop into sound 
sleep without the aids of drugs. Similarly, when hsemic 
causes are at work the agents producing wakefulness must be 
eliminated or withheld before we can expect their effects to 
disappear. But in the large class of cellular insomniie 
dependent upon abnormal excitation of the cells of conscious¬ 
ness, when we are face to face with a multitude of emotional 
and mental excitants, at times difficult even to discover, and 
when discovered frequently quite incapable of being removed, 
the obviation of effects as expressed in sleeplessness must 
depend largely upon the intelligence and strength of 
character of the patient. It is these cases which are so apt 
to acquire the drug habit, be it morphinism, chloralism, or 
any other “ ism,” whioh may in the first instance have been 
properly used to impose brain rest. A large proportion 
of these cases become chronic, lesB from the actual inBomna- 
bility of the cells themselves than from their being kept 
active by the stimulus of apprehension on the part of 
patients lest they may not sleep and the baneful conclusion 
reaobed, usually erroneously, that they can not Bleep without 
the aid of a hypnotic. 

But, on the whole, the prognosis of functional as apart 
from organic insomnia is good. The normal rhythm tends 
to re-establish itself when the novelty of abnormal sleepless¬ 
ness has passed off and sufferers begin to entertain the usual 


indifference towards what has become familiar. When, 
however, we are dealing with a patient whose reason is 
impaired and whose collective consciousness has lost the 
fixed points for rational arrangement, we can expect no 
normal rhythmical recurrence of sleep unless such disorder 
subside. Even in such cases, however, there is frequently 
a periodical recurrence of sleep alternating with equally 
rhythmical insomnia and excitement. Like the unconscious¬ 
ness which follows an epileptic seizure, sleep follows 
recurrent psychical unrest as manifested by incoherent 
talkativeness with or without equally incoherent active 
violence. 

Diagnotie. —Remembering what has already been remarked, 
that, whether we are dealing with the exercise of a normal 
function or with disorder of function, we cannot absolutely 
separate as independent factors the cell from its sources of 
neural stimulation or these from their indispensable blood- 
supply in the discrimination of one variety of insomnia from 
another, we have, nevertheless, to discover the preponderant 
r61e played in such cases by one or other member of this 
indissoluble functional tri-unity. 

Infancy, at which period of life the storage of mental 
products is at a minimum, simplifies our task by leaving 
neural and hsemic sources of stimulation chiefly to be 
investigated. The organism is at this time chiefly con¬ 
cerned with the intake of nourishment, the elaboration of 
blood, the evacuation of waste products, and with growth. 

A comparison of the condition of these processes in a given 
case, with an accepted standard of health, will reveal 
whether they are normally exercised or defective, whether, 
that is, the child has too little or too much food or has 
improper nourishment, whether the evacuations are effec¬ 
tively carried out, whether the condition of the blood is 
normal for the age of the restless infant, whether the hard 
and soft textures of the body are of average form, size, con¬ 
sistency, and development, and whether the hygienic 
surroundings are such as are conducive to health. Defect 
in one or more of these particulars may reasonably be 
assumed to be causal of the restlessness which is manifested. 

In the case of the adolescent and adult a similar physical 
examination will reveal facts equally capable of interpreta¬ 
tion. But now we are dealing with a more developed mental 
organisation, with a stage of life which has other require¬ 
ments, wants, desires, and attractions than the feeding- 
bottle, a warm cot, and a well-ventilated room. We have not 
even the comparatively simple task of dealing with the 
primitive savage adult but with a civilised being, girt round 
by necessity and laden with responsibility ; with a creature, 
in short, which has ideas and ideals and Is capable of being 
miserable if his ideals are not realised. At this stage, there¬ 
fore, we may find a sound body yet a disturbed or unreBtful 
mind, and by the exclusion of discoverable physical causes of 
unrest may correctly come to a conclusion as to the pre¬ 
ponderant role played in the case by what I have termed 
cellular insomnia. This disturbance may be due to the over¬ 
reception of Btimuli and consequent cogitation or to executive 
overwork either of head or hand or of both combined. In 
both instances the insomnia will probably be found to depend 
upon that exhaustion of cellular irritability which so 
frequently expresses itself in the more widespread functional 
disorders throughout the body which have been grouped 
under the term neurasthenia. The brain cells, like the plates 
of an electric battery, become exhausted by use and have to 
be raised out of the medium which generates their activity 
in order to revive. This period of recuperation is in normal 
circumstances sleep and its restitution when defective the 
task set the physician. 

The treatment of tleepletsneu. —There are some preliminary 
considerations which have a bearing upon the prevention 
and treatment of sleeplessness and which deserve mention. 
Except when insomnia is due to physical pain or discomfort, 
or to a state of the nervous system preoeding serious cerebral 
disorder, or finally, in the case of tragic moral commotion, 
when the uneducated in self-control among the poor who 
cannot striotly be regarded as insane are perhaps more apt 
than the more reserved classes in the same circumstances 
to take refuge in suicide, sleeplessness is, in my experience, 
and I think I corroborate the general impression, more rare 
among the poor than among their wealthier neighbours. 
This conclusion on my part is based upon lengthened 
observation among hospital patients and the poor generally. 
It is remarkable how rarely in the mention of their 
diverse ailments sleeplessness is referred to by them. 
Serious nervous ailments such as epilepsy and various 


* Tug Lancet, June lGth&nd 22nd, 1878. 



The Lancet,] 


DR. ALEXANDER MORISON: SLEEP AND SLEEPLESSNESS. 


[Feb. 8, 1908. 409 


psychoses are apparently, though perhaps not actually, 
<9 common among the poor as the rich. I say appa¬ 
rently, because the poor as a body so greatly outnumber 
the rich. This fact, if such it be, that insomnia is rarer 
among the poor has a certain significance. The poor 
are neither overfed, overclotbed, nor idle as a rule, except 
when unavoidably unemployed. I do not speak now of the 
submerged “ unemployable ” but of the labouring poor as a 
body, the peasantry, urban and rural, who are the source 
and foundation of a nation. No one will assert that these 
are free from anxiety or that they have not as tender a 
regard for their offspring and relations as their wealthier 
neighbours. It must therefore be that such sleeplessness as 
they suffer from must either be regarded by them as a minor 
evil or that their conditions of life are less favourable to its 
occurrence. I think the latter conclusion may be accepted 
as correct, for no human being can work hard unless he 
sleeps well, and as the poor must work hard they probably 
also sleep well. The workman’s energies are largely peri¬ 
pheral, so to speak, or executive. He is hands as a rule, not 
head. His food is moderate in quantity and plain. He is 
not superfluously clothed day or night. He is inured to 
hardship. He is little concerned in laying up for himself 
“ treasure upon earth ” possibly from lack of opportunity, 
and is inclined to believe that the evil of each day suffices 
for it. 

All these conditions of hardihood and hard work lessen as 
we pass into the so-called higher strata of society. Han 
then becomes more subjective in his mood, more fastidious 
in his appetite, “softer ” generally, and demands more as his 
right, being proportionately discontented when his expecta¬ 
tions are not realised. What he terms refinement takes the 
place of more natural and simpler conditions. Whether as a 
consequence of these altered circumstances or not, minor 
nervous disturbances bulk large in his imagination, and 
it is, I think, a fact admitted by most observers that 
insomnia not dependent upon physical pain or great moral 
distress is more common among the upper classes than 
among the lower orders. 

Now we cannot expect the nervous system, modified by 
education, easy circumstances, and hereditary influences, 
suddenly to divest itself of all these properties as a man takes 
c5 an overcoat. It takes time to make the modification ; 
time is also necessary to unmake it. But it is possible for 
the wealthy and cultured classes to lead the simple and 
strenuous life and not hopelessly to degenerate in the lap of 
luxury. To cultivate, that is, the sound body which holds the 
sound mind. To keep themselves fit —tou jours en vedette, 
and to avoid becoming blase in a life which may be made 
solidly interesting and beneficial from the dawn of 
intelligence to its close. 

When, however, we have the particular instance of a given 
insomniac in more or less easy circumstances to deal with we 
cannot expect him suddenly to assume a Spartan mode of 
life and regard his state philosophically. We have to take 
him as he is, and endeavour by degrees to make him, if 
possible, what he ought to be. The young and potentially 
vigorous must be fed plainly, advised to take regular 
exercise, increasing with their improvement of tone, and 
placed under circumstances in which, day and night, they 
have an abundance of fresh air, a cool head, and comfortable 
surface warmth. The older, and especially those with a 
measure of persistently raised blood pressure, require to be 
particularly careful as to surface warmth in bed, and 
especially warmth of the feet, which helps to reduce vascular 
tension. To secure a cool head in bed the ordinary feather 
pillow is not a good contrivance. It may certainly be so 
arranged as not to heat the head for a time but n head¬ 
rest may be constructed which is much cooler. Inflated 
pillows are usually more or less hard and uncomfortable. A 
■‘pillow” has, however, been made under my directions by 
Messrs. Krohne and Sesemann of Duke-street, London, W., 
which, in my opinion, fulfils the indications better. It is a 
lightly padded iron frame covered by a case of smooth 
webbing and open at both ends on which the head and neck 
rest comfortably, surrounded by air of the same temperature 
as that of the bedroom. This pillow, which has been called 
the “ open air-pillow," may be used under all circumstances 
in which such coolness is desirable (see Figs. 1 and 2). 
Indeed, the so-called hop pillow, consisting of a muslin bag 
filled vith the dried flowers of the hop (Hum ulus lupulut), 
probably owed any reputation it ever had to its coolness and 
the snggested purpose of its use rather than to any direct 
narcotic influence of the odour of the flowers themselves. It 


is said to have been first used to woo sleep for a merry 
monarch now departed—Bacchus on a hop-pillow, not 
crowned in boisterous mirth with the more graceful leaf of 
the vine! What a falling off was there 1 
As night is the normal period for sleep it is well when that 
function is disturbed to seoure darkness in the bedroom by 
blinds of a sombre hue. This is the more especially desirable 
because the insomniac, after tossing restlessly the greater 
part of the night, frequently falls asleep towards morning, 


Fig. 1. 



Fig. 2. 



and his slumber is more likely to be resumed, if, in a 
moment of wakefulness, he open his eyes upon darkness, 
rather than upon daylight with all its associated duties, In 
the case of nervous children, however, who dread darkness, 
it is frequently necessary to keep some shaded light in their 
rooms when first put to bed. But this luxury should be with¬ 
drawn as they grow older, to inculcate that mood which they 
will find invaluable in after life—namely, fearlessness under 
all circumstances. For the rest it need only be added that 
the insomniac should be enjoined to impose the calm of 
natural sleep on his voluntary mnscular system and to 
resist the temptation to tossing and restlessness. Voluntary 
muscular quiescence affords in itself a measure of refresh¬ 
ment. Patients have frequently been advised to pursue some 
monotonous imaginative exercise like counting sheep jumping 
over a wall, but the less voluntary exertion there is imposed 
either on brain or muscle, the sooner as a rule will sleep 
ensue. Patients should especially be impressed with the fact 
that sleep will overtake them, but they will only postpone its 
advent by endeavouring to overtake it 

When sleeplessness is due primarily to discoverable 
physical causes, acting through afferent neural channels 
directly, or to causes acting indirectly as excitants to con¬ 
sciousness by conveyance to the centre in the blood stream, 
or, again, to such effects of these causes as disturbance of 
temperature or vaso-innervation, the removal or mitigation 
of such causes of defective sleep is necessarily the first duty 
of the physician. To enter with detail into this aspect of 
the treatment of sleeplessness would manifestly be out of 
place on this occasion, as it would require many lectures to 
deal with it adequately. It is therefore only possible in this 
connexion at present to indicate the principle of the removal 
of the ostensible cause of the sleeplessness in any given case 
to secure the disappearance of the effects in most instances. 
But even when such a procedure is in progress, be it 
temperature reduction, or the reduction or increase of 
vascular tension, or the treatment of any other abnormality 
whatsoever, it may be necessary to act directly upon the 
organ of consciousness, to secure sleep in that interval which 
must necessarily elapse in many cases before the introduced 
bajmic or the peripheral cause of disturbance can be 
eliminated. For this reason medicinal agents are neces¬ 
sary and their selection is not an unimportant detail. 

Many as have been the hypnotics introduced into practice 
during recent years, when physical pain or disorders of 
visceral motion and sensibility are the active causes of 
insomnia, none of these has an efficacy in any way compar¬ 
able to that of those oldest of hypnotics, opium and its de¬ 
rivatives. No agents, however, are more apt to induce the 
drug habit. - Prescribed in the first instance for sufficient 









410 The Lancet,] 


DR. ALEXANDER MORISON: SLEEP AND SLEEPLESSNESS. 


[Feb 8, 19C8. 


reasons, and in quite a legitimate manner, they frequently 
continue to be used by the patient, openly or surreptitiously, 
after the need for their employment has gone. Their use, 
therefore, has to be constantly guarded from abuse. In the 
absence of physical pain and visceral commotion or discom¬ 
fort the majority of reliable hypnotics in use belong to the 
methane series, of which alcohol, chloroform, paraldehyde, 
eulphonal, trianal, veronal, chloral, and chloralamide may 
be mentioned as examples. Why this group should have a 
special action in abolishing consciousness is not quite 
clear, notwithstanding some ingenious suggestions as to 
their modut operandi. Cushny 3 refers to the hypothesis of 
Meyer and Overton, according to whom their special solu¬ 
bility in lecithin and cholesterin, in which brain-cells 
abound, is a possible cause of this specific action. 
But, as Cushny points out, there are other substances 
resembling these in this particular of solubility which 
have no such narcotic effect. One would a priori expect 
that if this special solubility led to a more intimate 
incorporation of these substances with the brain cells 
their effect upon the latter would be more lasting than 
experience teaches to be the case. Thus the chloral habit, 
or even the habit acquired of taking that most disagreeable 
hypnotic paraldehyde, may exist for many years without 
apparently disabling the brain cells from doing much active 
mental work. But again, one meets with cases in which the 
drug habit appears to incapacitate its victims altogether for 
continuous mental application. These differences are not 
easy to explain merely as effects of the drug. There is 
evidently a personal factor involved, a personality which is a 
synonym for character, moral and probably also physical. 
The intelligent and industrious who dread the effects of 
insomnia may, like him who eats to work, take hypnotics to 
work. Others, like those who live to eat and who also live 
to sleep and to indulge in anything else that is pleasant, take 
hypnotics to squander in sleep the time they are too selfish or 
too inert or too ignorant to employ profitably when awake. 
But sleep is necessary for all ; like rain it falls upon the just 
and upon the unjust, and, injurious as are the effects of the 
abuse of hypnotics in many cases, their actual destructive 
power is less than that of a continuous or persistent insomnia 
however caused. Regrettable as is the acquisition of the 
sleep-drug habit, there are cases, therefore, in which, as the 
lesser of two evils, the use of hypnotics for a considerable 
period seems unavoidable. 

With one or other member of the methane group bromides 
may be prescribed, alone, or with the addition of a deriva¬ 
tive of hyoscyamns or cannabis indica. The well-known 
effect of the byoscyamus group upon the peripheral motor 
nerve-endings tends to quiet muscular unrest and helps to 
induce that quietude of the extremities which favours the 
advent of sleep. Hyoscine itself is too powerful a drug for 
habitual use, but in the violent excitement of the insane may 
be invaluable as a muscular quietant. I have not in¬ 
frequently found the use of the bromides during the day 
and a separate dose of one of the methane hypnotics at bed¬ 
time an effectual means of removing the consequences of 
insomnia. 

The most difficult cases to treat among those possessed of 
reason are those in which artificially induced sleep only leads 
to an awaking in which the recognition of persistent causes 
of mental disturbance again present themselves. A certain 
proportion of such patients, usually with a congenital 
neuropathic strain, develop some form of maniacal aberra¬ 
tion, temporary or persistent. Others without such strain 
may, after continued anguish, even die from that exhaustion 
which has in figurative language been termed a ‘ ‘ broken 
heart,” and which, if, like Balzac’s callous husband who 
sent his wife’s tears to a chemist for analysis, we try to 
define it more scientifically, we shall find it compounded of 
malnutrition, aDtemia, loss of flesh, and the unresisted 
incidence of some intercnrrent affection which proves 
fatal. 

Those, however, are the cases in which the acme of dis¬ 
tress is witnessed, in which physical pain is added to mental 
torture from other than physical causes. Even such cases 
one has at times known to reach a harbour of quietude and 
relief, but sometimes only for a brief period, before they 
again cross the bar on a voyage from which no ordinary 
mortal has ever returned. This last journey is, however, not 
infrequently taken on the initiative of the miserable patient 
himself, either by the self-administration of an overdose of 


5 Text-book of Pharmacology, p. 126. 


hypnotic or by a despairing leap into space when death is 
welcomed as a friend. The suicide of the insomniac is not 
an uncommon event, even when the physical or mental 
suffering involved is not of such a degree as would tempt an 
unhinged mind to do the desperate deed. This only empha¬ 
sises the importance of the subject we are discussing. 

Yet another group of cases in this class find relief and 
recovery by learning to ignore the pressure of such persistent 
psychical excitants. These three kinds or degrees of dis¬ 
turbance belong, however, to an exceptional and aggravated 
group and tax the ingenuity of the physician not only as one 
prudently administering certain physical agents which act 
as narcotics but also as a philosopher with experience of life, 
whose undisturbed vision relatively to his patient’s may 
enable the latter to walk through the fog of his circum¬ 
stances into clearer day and with better hopes of overcoming 
his "strong enemy.” The vast majority of cases of cellular 
insomnia, however, present no such difficulties and merely 
require judicious management upon the part of both physi¬ 
cian and patient to be satisfactorily replaced by refreshing 
sleep. The prognosis, as I have said, in most cases of 
insomnia is good—a fact to be impressed upon the patient, 
fora succession of nuits hlanahet has a very depressing effect 
which naturally aggravates the condition and renders the 
task of the physician proportionately difficult. Sleep at 
night has frequently to be earned under these circumstances 
during the day. Robust and wholesome life, fully exercised 
during the day, throws itself more or less tired on to its 
couch at night to sleep soundly, in some cases the sleep of 
the just, and in others that of the unjust with a maximum 
of digestive power and a minimum of conscience. But, as a 
rule, when, from one cause or another, peripheral or central, 
or both combined, sleep has been disturbed, the return to 
refreshing slumber at night must be earned by a carefully 
regulated life during the day. 

In extreme cases, both in men and women, there is no- 
doubt a place for the “rest cure” and all its appurte¬ 
nances. By this I mean the isolation of the individual in a 
nursing home, quietude, massage, careful feeding, and a 
curfew sounded comparatively early after sundown. But in 
most cases of insomnia, and especially among men, the 
nursing home Bhonld be avoided. It stands not far under 
these circumstances from the lunatic asylum and leaves a 
memory of nerve-wreck, or even of cowardice, which doea 
not minister to self-respect. The steady performance of a 
compassable amount of work ; the avoidance of excitement 
so far as possible ; the cultivation of self-control ; the pro¬ 
duction by circumspect and wholesome conduct, physio¬ 
logical and moral, if a centre of calm into which the indi¬ 
vidual may retire, taevit tratii/uillut in undti, when external 
sources of irritation bear upon him ; the consciousness of a 
brave endeavour to perform duties which cannot be neglected 
without injury to himself or others ; the well-spent day which 
leads to the cool and quiet pillow at night—this day tleep, as 
such an attitude from its reduction of the friction of life may 
be termed, will gradually lead by recuperation of energy to 
sound night-tl'ep , often without the aid of drugs, though 
sometimes requiring their help for a time. The most annoy¬ 
ing incidents which, suddenly thrust upon a man, induce 
cellular mental activity and the vaso motor disquiet normally 
associated with that state spend themselves. Bravely 
looking the situation, whatever it be, in the face and 
translating thought into reasonable action will do more 
for the average and normally constituted man or woman who 
Buffers from insomnia than more elaborate and invalid 
methods which enhance introspective activity, sap the self- 
reliance and self-respect of the individual, and perpetuate 
that subjective sense of dissatisfaction which turns the 
useless and mis-spent day into the restless and wakeful 
night. Indeed, Sir William Broadbent’s words on the abuse 
of drugs in insomnia apply equally to the frequently un¬ 
necessary incarceration of such patients in nursing homes 
—“they diminish,” he writes, “the resistance and impair 
the manhood of the individual.” 6 

In the same category should be placed the practice of 
hypnotic suggestion as a therapeutic agent. There is a 
residuum of effete men and women in whom it is almost 
hopeless even to attempt to rouse that “heart for any fate 
which brings its own reward in steady effort and in calm 
repose, who drift at times into the hands of the practitioner 
of hypnotism to be coaxed into an oblivion not otherwise 
attainable except by drugs. But the type suitable for hie 


6 The Lancet, Jan. 27th, 1900, p. 216. 




Thb Lancet,] mb. 0 . B. LOCKWOOD: SOME OF THE SOURCES OF WOUND INFECTION. [Feb. 8, 1908. 411 


ministrations is likelj to relapse at the first serious contre¬ 
temps nnleBS lifted on to a higher level of open-eyed 
endurance, the road to which does not lie through 
hypnotism. On the therapeutic value in nervous disorders of 
indifference— insouciance— the readiness to meet with sang¬ 
froid whate'er betide, a not uninBtructive essay might be 
written. It is a mood akin to, though cot identical with, 
the grand attitude of Renunciation or Entsagung and both, 
born of strength, beget calm, and in the absence of organic 
disease, the normal consequences of that state, sound and 
refreshing sleep. 

% future 

ON 

SOME OF THE SOURCES OF WOUND 
INFECTION. 

Delivered at St. Bartholomew's Hospital on Deo. 11th, 1507, 

By C. B. LOCKWOOD, F.R.C.S. Eng., 

8UBOE0H TO THE HOSX’ITAL. 


Gentlemen, —You may have observed that twice a week 
in the operating theatre we make certain tests of the 
materials which we are using, of the hands which are 
brought into contact with the patient, and of the patient’s 
skin. It is now some years since I last referred to this 
subject, and it is rather strange that 1 have never yet told 
you the reasons for my procedures. The essential object of 
making bacteriological tests during the performance of the 
operation is to ascertain the absence of bacteria. If bacteria 
are absent we then consider that we are working 
sceptically and we call the result asepsis. I am quite 
aware that that is not the sense in whioh the word asepsis 
is always used. Some surgeons apply the term to operations 
which are conducted by means of heat and with the aid of 
salt solution and without any stronger chemicals. Whether 
their results are clinically better than the results of surgeons 
who use mild chemicals I cannot say. But their published 
records show, I believe, that their results are never germ- 
free, and that in the vicinity of the wounds the staphylo¬ 
coccus epidermidis albns (the ordinary skin coccus) is con¬ 
tinually present. The staphylococcus pyogenes aureus is not 
infrequent, and streptococci and even the colon bacillus are 
found. Now, I myself could not be contented with the 
presence of such micro-organisms in the vicinity of wounds. 
Besides, let us take what is after all a perfectly logical and 
scientific standard of excellence, the entire absence of 
bacteria, and then you know exactly where you are. At all 
events, a wound which contains no bacteria cannot be septic. 
What sepsis is I cannot tell yon. It has never been defined. 
I should suspect that some of the wounds which contain 
streptococci, staphylococcus pyogenes aureus, or the colon 
bacillus may be very septic indeed. 

The tests which we apply prove that everything which can 
be treated by heat gives perfectly aseptic results. Perhaps 
I ought to make this qualification and say that unless you 
steadfastly test—and I have been testing for more than 
15 years—curious errors creep in. I remember a while ago 
being rather surprised when informed that the needles 
infected our broth. As soon as this was ascertained and 
brought to the notice of those who performed the process of 
sterilisation the needles were sterile. So, clearly, you must 
not assume the Bterility of anything until it has been tested. 
In passing I would perhaps answer a question which has 
occurred to you, and it is this: Why might chemicals not be 
used for the disinfection of instruments ? I have often 
wondered whether instruments dipped in pure carbolic acid 
are liable to infect. I am inclined to think that they may. 
Pure carbolic acid may coagulate albumin on the instruments 
and there may be infection beneath its layers and during the 
course of the operation the layer may come off and the 
wound may be infected. Mr. B. T. Lang very kindly tried 
to ascertain whether be could disinfect instruments by means 
of strong solutions of formalin. Formalin is a very potent 
disinfectant. A disinfectant is a chemical which kills bacteria. 
So Mr. Lang applied a 25 per cent, solution of formalin to 
infected instruments for 24 hours and had to acknowledge 
that he failed. Clearly, great caution is required before 
using instruments which you have attempted to disinfect by 


means of chemicals. I have said already that the effects of 
heat are absolutely oertain. We have seen that over and 
over again. We are continually disinfecting silk by means 
of heat. It never comes into contact with any chemical 
whatever and is passed straight into broth but nothirg 
grows. I want to make this qualification. Outside this 
hospital we have a hay market, and some years ago Dr. E. 
Klein pointed out that it was difficult, in experiments per¬ 
formed upon this site, to exclude the hay bacillus. And we 
have fonnd that when any source of error has crept in the 
presence of the hay bacillus has been recorded. I need 
hardly say that the hay bacillus is a perfectly harmless 
bacterium, and one which is very easily recognised. 

A far more potent source of wound infection is the 
Bkin of the human hand. When first I began to put 
a piece of skin from my own hand into broth an 
aseptic result was almost unknown. I became quite dis¬ 
heartened and thought it impossible to achieve asepsiB. 
By making further efforts, and more especially by realising 
the value of alcohol, especially in conjunction with such 
antiseptics as the so-called biniodide of mtreury, we began 
by degrees to achieve better results. I do not think that the 
inexperienced will ever get good results at all. I have been 
working at disinfection of the bands for over 15 years and 
am only now beginning to realise how difficult the problem 
is. I need hardly say that it is impossible in the preparation 
of the hands to disinfect or to clean beneath the angles of 
the nails ; the nails must be cut off short. Next, it would 
be absolutely impossible to disinfect hands which have any 
open sore or septic place upon them. A new cut would not, 
I imagine, matter, but it would be unjustifiable to operate if 
there were any septic focus upon the bands. And, without 
going far out of my way, I could tell you of some dreadful 
disasters which have happened through the breach of this 
rule. You might think that if you had a septic sore upen 
your bands it would be justifiable to cover it up with, say, 
collodion or perhaps with a rubber finger stall or with rubber 
gloves. But I am afraid that that would not be right. 
Collodion comes off, finger stalls come off, gloves may have 
holes in them, and, further than that, gloves are often 
punctured during the course of an operation or may even be 
tom. So that a person with septic sores upon the hands 
should not perform surgical operations, or, what is equally 
important, gynaecological operations, including midwifery. 

Supposing that the hands have been prepared for dis¬ 
infection, that they have been cleansed as far as possible by 
means of soap and water, and freed from any superficial 
contamination, the next step is to disinfect the skin. Now 
that is really a most difficult problem. 1 have already told 
you that at one time we never achieved it. Then our results 
improved and we managed to disinfect perhaps once in five 
or six times. Then we have managed to improve and to 
disinfect 20 per cent, and then more. And on looking over 
the reports of the gentlemen who have so kindly taken 
cultures from my own skin I find in the last 66 tests that 
they have only caught me out once. As yon know, this test 
is made with a small piece of skin snipped off and dropped 
into broth. Presently I shall tell you about more rigorons 
tests which we applied. I knew that various observers had 
examined the skin of their hands after they had been pre¬ 
pared with salts of mercury, such as sublimate or biniodide, 
and so forth, but usually sublimate, and that they had found 
that the skin after disinfection contained an appreciable 
quantity of mercury. Haegler in his book on the Dis¬ 
infection of the Skin, which consists of 250 pages and 
four pages of figures, has made the same ebservation. 
After the hands had been prepared, treated with 
alcohol, and then Boaked in sublimate he dipped them in a 
solution of sulphide of ammonium. Hands which had been 
treated with mercury came out black, proving conclusively 
that the skin retained within it a proportion of the sublimate. 
I snipped off some particles of skin from my own bands and 
sent them to Dr. W. H. Hartley who with great kindness 
undertook to report upon their chemical properties. And he 
reported that the scraps from the freshly prepared hands 
contained an appreciable quantity of mercury. But Dr. 
Hartley did not know until I told him yesterday that I had 
not for 27 hours applied any biniodide to some of the 9kin 
which I sent to him, so that the skin of my fingers had 
retained an appreciable quantity of mercury for that 
length of time and of course during that 27 hours they 
had been washed many times in the ordinary manner. So 
it is possible to saturate the human skin with mercury. 
On thinking this matter over it occurred to me that the 




412 The Lancet,] MB. C. B. LOCKWOOD: SOME OF THE SOURCES OF WOUND INFECTION. [Feb. 8, 1908. 


process of satnration of the human skin wag an essential one 
in its disinfection and in making it antiseptic. And by 
antiseptic I mean that bacteria would refuse to live in 
it. So we have been trying of late to saturate our skin 
with biniodide of mercury. The way in which we proceed is 
this : we take the ordinary solution of spirit of biniodide of 
meroury, which is made of 75 per cent, of ordinary rectified 
spirit, and a solution of mercuric iodide in iodide of 
potassium to make it of a strength of 1 in 500. The water 
amounts to 25 per cent., and the reason for this addition is 
well known—and 1 need hardly dwell upon it—that when 
disinfectants or antiseptics are mixed with alcohol, or with 
glycerine, or with fat they become inert. A solution of dis¬ 
infectant with spirit becomes potent again after the addition 
of water, and for practical purposes we find that a dilution of 
25 per cent, suffices. Now as to the way in whioh we try to 
get the antiseptic into our skin. Biniodide suits my skin and 
it is a good antiseptic, and we have tested its effects on the 
tissues. With tissues which were washed with biniodide of 
mercury of a strength of 1 in 4000 I am unable to see the 
slightest change. Mr. A. J. Kendrew, to whom I am much 
obliged, showed me first sections of ordinary muscle and of 
ordinary fat and then afterwards some which had been 
washed with 1 in 4000 biniodide of mercury, and 1 was un¬ 
able to tell which was which. So I think we may guess that 
many of the statements which are made about the harmful 
effects of chemicals upon the tissues will not apply to 
biniodide of mercury. I think that on looking through the 
literature you will find that the statements which are made 
apply to very strong solutions of sublimate and to strong 
solutions of carbolic acid, which you know combine with 
albumin very freely. 

Now, how do we get biniodide of mercury into the skin of 
our hands 1 After the hands have been washed they are put 
in spirit and biniodide 1 in 500, and afterwards put into a 
watery solution of 1 in 500. That is repeated four times at 
least, until we get 1 in 500 watery solution absorbed into the 
depths of the skin. Dr. Hurtley has ascertained that skin 
treated in that way contains an appreciable amount of anti¬ 
septic. Also, I believe that it will bear tests which skin 
treated in other ways will not bear. Haegler tested the 
asepticity of skin by dragging across it pieces of silk 
which were afterwards dropped into broth or put on 
to the surface of a culture. And we have found that 
after these more rigorous efforts we have been able to 
drag pieces of silk through the fingers without infection. 
But this is not the most stringent test because the 
fingers are easy to disinfeot. Therefore it has been dragged 
many times through the palms of the bands, which 
you know have numerous sweat glands upon them, and a 
large proportion of that silk was not infected. We have not 
been practising this stringent test for very long, but I 
am quite within the bounds of veracity in saying that 
40 per cent, of our tests were aseptic. As a matter of fact, 
1 believe the proportion is higher. Further, if some gentle¬ 
man will apply his mind to this subject he will discover 
a better method than any of these for the disinfection of 
the human skin. 

You might say this to me: “Why, if the skin of the 
hands is so difficult to disinfect, do you not wear gloves? " 
1 have already partly answered that question. The assistants 
at operations should certainly wear gloves. I am not saying 
anything that is not quite kind or polite when I say 
that the assistants at operations cannot have had a 
very large experience in the methods of disinfecting their 
hands, and have already said that in disinfection of the 
hands experience counts for a very great deal. Why should 
not an operator wear gloves ? Many operators do. I have 
been wearing gloves for a great many years. When I was 
surgical registrar I used rubber gloves in all the post-mortem 
examinations and was conscions that I could not feel pro¬ 
perly in them. And with gloves on I could not during an 
operation put my fingers down into the depths of the pelvis 
and extract an adherent vermiform appendix or an adherent 
and suppurating Fallopian tube with any degree of con¬ 
fidence. But, for a great many operations, such as rectal 
examinations, operations for haemorrhoids, for fistula, and 
for operations on septic sinuses and so forth, surgeons ought 
to wear gloves. Surely it must be easier to disinfect hands 
which have not been contaminated than to disinfect hands 
which have. 

We come next to another matter and that is the testing of 
the skin of the patient. You probably know that the diffi¬ 
culty in disinfecting the skin of the patient depends to a 
very great extent upon the region from which it comes and 


you may say offhand that regions which have upon them hair 
and consequently deep sebaceous glands and which have 
long Bweat glands are additionally difficult to disinfect. 
This is true with regard to the scalp; the skin of the back 
is also very difficult to disinfect, so is the skin of the groin 
and the skin of the armpits. The easy skin to disinfect is 
in front of the limbs, of the abdomen, and of the chest. 
The bearing of this is obvious and you will take additional 
pains in endeavouring to saturate the more difficult regions 
with disinfectants. The difficulty which you will meet with 
is the presence of fat in the sebaceous glands of the skin. 
And you will observe that I have almost put the difficulty 
in the order of the abundance of the sebaceous glands. I 
wonder if anybody has ever succeeded in disinfecting the 
scalp. If you are aware of the difficulty your minds will 
suggest to you methods of overcoming it. And you may 
have observed that we use all sorts of materials for extract¬ 
ing sebaceous matter from the human skin. Ether is good 
but it speedily evaporates. Turpentine is good and has 
some disinfecting properties. We have tried benzol and I 
do not see why we should not try others of the petroleum 
series. We also use alcohol as part of the process of dis¬ 
infection. It is not only a disinfectant in itself but it is 
useful in the removal of grease. Again I say about dis¬ 
infection of a piece of skin wbat I have already said to you 
about disinfection of the hands. As our realisation of the 
extreme difficulty of the process has grown, so we have 
become more successful. I regret not to have had time to 
abstract all the returns which the house surgeons and patho¬ 
logical clerks have with such great kindness sent me. But 1 
believe it to be correct to say that we succeeded, taking every 
region of the body into consideration, in at least 75 per cent, 
of our attempts. I believe that is well within the truth. 
And it is comforting to think that in some of the regions 
where the effects of skin infection would be most disastrous 
it is least likely to occur. So that one feels very few qualms 
when called upon to open a knee-joint for the removal of a 
loose cartilage, as one had to do yesterday. 

With regard to the disinfection of the human skin there 
are certain further tests which can be applied. One of the 
tests which we are endeavouring to apply on every occasion 
is the removal of a stitch from the wound when it is dressed 
and placing that Btitch into broth. And here, again, with 
increasing experience and increasing trouble we are getting 
a very much higher proportion of asepsis. I ought to say 
that we are not contented with our methods of closing 
wounds. The stitch-hole often has a small red point around 
it which is objectionable. We have tried celluloid thread, 
which is better, but that often has a red point round it. I 
am not by any means certain that we may not try other 
means and shall suggest to the house surgeon that some 
of our wounds be closed with metal clips. The meaning of 
all this is—and I do not know what the house surgeon will 
think of it—that I shall not be content until we get perfec¬ 
tion. 

I now come to another point in regard to the source of 
wound infection, those which are due to the environ¬ 
ment of operations. And I had this point brought 
home to me in a very painful manner when the temporary 
theatres were opened. This hospital is ultimately to be 
equipped with proper theatres and I cannot tell you what a 
very difficult problem the arrangement of proper theatres 
will be. I have learnt a very great deal from having to 
operate in different kinds of theatres in this hospital and 
hope that either I or somebody else will ultimately evolve 
the plan of a suitable operating theatre. But to come back 
to my painful experience. I had to perform a gastro¬ 
enterostomy and also a complete removal of the breast 
and also the removal of a myxo-sarcoma from the brachial 
plexus on one day. In those times the theatre bad 
no bay in it for the audience. And that day, for some reason 
or other, there was a large audience, so that the floor of the 
theatre was full of people. The atmosphere was dreadful and 
the end was that the unfortunate patient who had gastro-enter- 
ostomy performed died from a slow form of septic peritonitis, 
although there was no leak nor any reasonable probability 
of some fault on the part of the operator. Next, the 
case of complete amputation of the breast suppurated 
freely but the patient fortunately survived. Lastly, the 
myxo-sarcoma of the brachial plexus healed by first 
intention, but by the time that operation was done most 
of the audience had departed, and the operation was a 
speedy one and did not involve exposure to a polluted atmo¬ 
sphere for over an hour. That was a sad experience. 

And now I want to discuss with you for a few minutes the 




The Lancet,] DR. TURNER: IS DEATH-RATE THE BEST MEASURE OF SEVERITY IN DISEASE ? [Feb. 8 19C8. 41 3 


source of this environment infection. First of all, the condi¬ 
tion of the atmosphere would, of course, depend upon the 
size of the room. The room we are in is a very suitable size 
for an operating theatre. It contains about 9000 cubic feet. 
Tbe small operating theatres contain from 5000 to 
7000 cubic feet, and the old operating theatre contains some 
12,000 cubic feet The new theatre at the top of the east 
block is a very good size for a theatre and contains about 9000 
cubic feet. I wonder if I am making any impression upon your 
minds. Some of you gentlemen will have to plan operating 
theatres, and this question of size will be one of extreme 
importance to you. The next thing about the atmosphere of 
an operating theatre is this. If you agree that you are 
going to have 10,000 cubic feet of space in your operating 
theatre bow often ought that air to be changed for the 
comfort of the inmates 7 It is agreed by those who are 
versed in the science of ventilation that the air ought to 
be changed at least six times in the hour. In the building 
you are in at present they have instituted a modified form of 
the Plenum system of ventilation. That system does this, 
it takes air in from the outside. And that air is filtered and 
moistened. It is then passed over water-pipes to warm it in 
winter to 65° F. and cool it in summer, and then it is passed 
to where it is wanted. The vitiated air goes out at the top. 
I may tell you that I have no prejudice in this matter. The 
proper Plenum system necessitates the closure of doors and 
windows. But the Plenum system occasionally breaks down. 
I believe it broke down the other day at the new law courts 
with very unpleasant results. Again, I am told that the 
people living where that system is in operation do 
not feel comfortable and that children who live in 
it become anaemic. These are not my own experi¬ 
ence; they are simply what I have been told. Against 
that you have to put what is known as the natural 
system. That admits air near the floor beneath radiators, 
and then it has an extractor consisting of a fan near the roof 
for the vitiated air. The theatre we are in has, in addition 
to these appliances, a Tobin’s tnbe. My experience of these 
tubes is unpleasant, because the air enters half-way up the 
room and is often cold and falls down on to the top of one’s 
head, and so is uncomfortable if yon sit near it. What I 
want to impress upon you is that you have to make up your 
minds about the size of the operating theatre in which you 
work and decide how often the air ought to be changed, and 
next the method by which it is to be changed. Besides 
odour and unpleasantness, what other tests are there of the 
condition atmospheric? There is the bacteriological test. 
I can tell you offhand that in great cities air outside the 
windows contains various sorts of bacteria which are 
derived, of course, from the animals in the streets, from the 
surface of the bodies of the people who are walking 
about in the streets, from their respiratory tracts, and 
so on. I can tell you further that in a room snch as 
this all those bacterial contaminations are increased. And 
they are increased in many ways At present, whilst I am 
speaking to you in an ordinary colloquial manner, it has been 
scientifically shown that 1 am not sending my throat or mouth 
bacteria into the atmosphere. This work was begun by 
Flugge, but in the last few years Dr. M H. Gordon has 
added most important scientific evidence and has extended 
the work by identifying the bacteria. He says that as long 
as a. person speaks in an ordinary conversational tone 
nothing is emitted from his throat into the air around. But 
as soon as he begins to speak loudly and to gesticulate, then 
bacteria are showered to a distance of 40 feet from the 
mouth. Therefore the mouth is a potent source of 
infection of the atmosphere. What happens in that 
respect when a person coughs and sneezes it is difficult 
to imagine, but if loud talking and gesticulating will send 
bacteria 40 feet, I assume that coughing and sneezing will 
send them 20 or 30 more. Another potent source of aerial 
contamination is dust and dirt brought in upon the garments 
and boots of people from the street. The carrying of bacteria 
upon the boots is not a matter of speculation. That might 
be guessed when one thinks what a horrible mixture the mud 
in the roads is, that there may be colon bacilli in it, strepto¬ 
cocci of various kinds, the tetanus bacillus, the bacillus 
septicus, tubercle bacilli, and many others. It is certain 
these may, when present, be carried into theatres on people’s 
boots, because Dr. Gordon made the following experiment. 
At the House of Commons he put down some earth which had 
been contaminated with the bacillus prodigiosus, a bacillus 
which it is very easy to identify. He then examined the dust 
which fell from beneath the gratings where the Members of 


the House of Commons trod, and he found that they carried 
the bacillus prodigiosus on their feet a distance of 576 feet. 
Yon can therefore very well imagine the dangers of this form 
of infection. How is that to be met 7 One of the great ways 
in which anything is met is not by laying down rules but by 
educating people. And no man who had ever thought of this 
would willingly carry dirt or dust into rooms or operating 
theatres, nor would he, when he got there, stamp about the' 
dust which is there. But, after all, there is a great deal of 
human nature in man, and human nature dictates that he will 
not always remember. In consequence of that steps ought to 
be taken—and we are taking them—to provide a cheap and 
efficient method of covering up dirty boots before they go 
into the theatres. But in addition a glass screen should be 
placed between the audience and the operator. The glass 
screen need not go up to the top of the theatre; it would 
become, perhaps, in such circumstances easily clouded with 
moisture and the audience would not be able to listen to the 
dnlcet tones of the operator. 

I have only mentioned some of the matters on which we 
are engaged, but have perhaps told you enough to interest 
you in what we are doing, and I hope shall encourage 
gentlemen to take these matters in hand and try to go one 
better. 


IS THE DEATH-RATE THE BEST MEASURE 
OF SEVERITY IN DISEASE ? 

By F. M. TURNER, M.D. Cantab., B.So. Lond., 

MEDICAL SUPERINTENDENT OE THE SOUTH-EASTEBH FEVER HOSPITAL, 
HEW CROSS, LONDON, 8. E. 


Long habit has made many medical men so familiar with 
the use of death-rates (or, to nse the stricter terminology, of 
case mortality rates) that they have come to regard them 
as the only possible measure of severity in disease. Others 
would not deny that other means of measuring severity 
might be used, but would emphatically deny that the latter 
could in any case give results more accurate than those 
given by mortality rates. To measure severity by any other 
criterion than recovery or death they might admit to he 
possible, but if the special method gave results opposed to 
those given by mortality rates such discrepancy would prove, 
they consider, the unreliability of the former. This exalta¬ 
tion of mortality rates into an absolute standard is quite un¬ 
justifiable. And. what is of more practical importance, a 
devotion to mortality rates as tbe chief, if not the only, 
subject worthy of study in medical statistics accounts in 
great measure for the present backward state of that branch 
of science. In tbe present paper I hope to show by very 
Bimple methods, first, that reliance on mortality rates 
can mislead; and, second, that the mortality test can 
for many problems be a very inconvenient one and 
mnch less likely to give the trne solntion than other 
methods. 

I. The mortality rate is not in all cates a reliable test 
of severity of disease .—The first thesis will be proved 
if I can show that the mortality rate can be affected 
by other circumstances than the severity of the disease. 
It is often suggested that death or recovery may depend 
upon two independent factors: (a) the severity of the 
attack and (J) the strength of the patient; and 
although many will be prepared to admit both factors 
as possibilities they have no clear idea how the effect 
of these factors could be distlnguisbed. How can we 
measure tbe vitality of onr patients 1 Some would bold that 
it is not measurable, others would argue that whether such 
patients die or recover must be tbe trne test. And how can 
we measnre the severity of attack unless we here also fall 
back on the mortality rate? The answer is very simple. 
We can in many cases measure the symptoms, and, if 
so, we have a real test of the severity of the disease. And 
even if the symptoms are not measurable we can still get 
reliable results if we divide cases into groups or classes 
according to the severity of any symptom. 

Tbe firet example which I will give is a table which I 
published in the reports of the Metropolitan Asylums Board 
for the year 1904, showing the connexion between tbe age of 
the patient and the severity of the eruption in cases of small¬ 
pox amongst the nnvaccinated. For the facts I am indebted 
to Dr. T. F. Ricketts, medical superintendent of the Metro¬ 
politan Asylums Board small-pox hospitals. 




414 TheLancet,] DR. TURNER: IS DEATH-RATE THE BEST MEASURE OF SEVERITY IN DISEASE? [Feb. 8 , 1908. 


Table I .—Showing the Severity of the Eruption and the Age 
in 183i Unvaccinatcd Cates of Small pox. 


Class. 

Age-periods—Years. 

Total. 

0-5 

5-10 

10-15 

15-20 

0-30 

30-40 

4C-50 

Over 

60 

i. 

43 

18 

12 

7 

10 

6 

4 

3 

103 

i'. 

37 

20 

32 

22 

27 

7 

3 

0 

148 

Ill. 

137 

132 

91 

73 

62 

29 

8 

5 

637 

IV. 

123 

112 

64 

30 

38 

15 

3 

i 

386 

V. 

130 

102 

57 

27 

30 

8 

0 

i 

357 

VI. 

108 

85 

44 

21 

23 

6 

1 

5 

293 

Total ... 

578 

469 

300 

180 

190 

71 

19 

17 

1824 


Class I. is htemorrhagic small pox. Classes II. and III. are confluent 
cases, the former confluent before pustulation occurs and the latter 
after. Class IV. is discrete small pox with over 500 pocks on the face. 
Class V. is discrete small pox with from 100 to 500 pocks on the face. 
Class VI. is small pox with less than 100 pocks on the face. 

It will be Been that the figures in this table show no pre¬ 
ponderance of severe eruptions at early ages or at the very 
late ages of life when the death-rate is very high. On the 
contrary, with one exception (Claes I., in infancy) the 
preponderance is slight but significant in the opposite 
direction—viz., increased number of pocks at increased 
ages. 

Table II. shows the distribution that would correspond to 
complete equality of severity at all ages, which is calculated 
thus. Take the total number of cases in the first column— 
i.e., 578—and divide them up in the same proportion as the 
grand total 1824 in the last column is divided between the 
separate classes. Repeat the process similarly for every 
column. Table III. Bhows the difference between Table II. 
and Table I. It will be noticed that the differences are not 
great, but all the positive quantities tend to collect in the 
upper right hand and lower left hand quadrants, showing 
a slight preponderance of severe cases at higher ages. 

The difference between any figure in Table I. and that 
which corresponds to it in Table II. represents the tendency 
that small-pox of a definite type has to attack persons of a 
definite age in exoess or defect of the average rate of all ages. 


Table II. 


Class. 

Age-periods—Years. 

Total. 

0-5 

5-10 

10-15 

15-20 

1 

20-30 30-40 

40-50 

Over 

50 

I. 

11-6 

26-5 

16-9 

10-2 

10-7 4-0 

IT 

1-0 

1030 

II. 

46 9 

381 

24-3 

14-6 

15 4 5 8 

15 

1-4 

148-0 

Ill. 

170-2 

138-1 

88-3 

530 

55 9 20 9 

56 

50 

537-0 

IV. 

122 3 

99-3 

63-5 

38T 

40 2 15-0 

4*0 

36 

386 0 

V. 

1131 

9T8 

587 

352 

37-2 13 9 

37 

33 

356-9 

VI. 

928 

75 3 

48 2 

28-9 

30-5 11-4 

31 

2-7 

292-8 

Total ... 

577-9 

4691 

299 9 

180 0 

189-9 71 0 

19 0 

170 

183-8 


Table III. gives these differences, a + sign denoting that the 
observed number exceeds that calculated from the average, a 
- sign that it falls short. To avoid confusion fractions are 
omitted and the nearest whole number is given. In a few 
instances the difference is less than i, bo that the nearest 
whole number is 0. The -f or - sign of the fraction is, 
however, retained. 

Table III. 


Class. 

A ge- peri od6—Y ears. 

Total. 

0-5 

1 5-10 

10-15 

15-20 

20-30 

30-40 

40-50 

Over 

50 

I. 

+ 10 

- 8 

- 6 

1 ” 3 

- 1 , 

+ 2 

+ 3 

+ 2 

0 

II. 

-10 

-18 

+ 8 

+ 7 

+12 

+ 1 

+ 1 

- 1 

0 

Ill. 

-33 

- 6 

+ 3 

+20 

+ 6 

+ 8 

+ Z , 

- 0 

0 

IV. ... ... 

+1 

+ 13 

+ 1 

- 8 

- 2 

- 0 | 

- 1 

- 3 

+1* 

V. 

+ 17 

+ 10 

- 2 

- 8 

- 7 

- 6 

- 4 

- 0 

0 

VI. 

+ 16 

+ 10 

- 4 I 

- 8 

- 8 

- 5 

- 2 

+ 2 

0 

Total ... 

0 

+ 1 * 

+ 1" 

0 

0 

0 

- 1* 

°i 

+ 1 * 


* Theee totals would liave been 0 if the actual fractional difference 
had been taken instead of the nearest whole number. 


Table IV.— Vaccinated Cases. 





Age-periods—Years. 

Total. 




0-5 

£-10 

10-15 

15-20 

20-30 

30-40 

40-50 

Over 50 

/ Actual cases . 



0 

0 

2 

5 

54 

57 

4 2 

53 

163 

I. < Calculated . 



05 

2-7 

79 

19 5 

59 2 

41 7 

20-2 

11-1 

— 

(_ Difference . 



- 0-5 

- 27 

- 5-9 

- 14 5 

- 252 

+ 15-3 

+ 21 8 

+ 11-9 

— 

C Actual c&Bes . 



0 

1 

0 

IS 

39 

49 

SO 

10 

143 

11.-I Calculated . 



0 4 

2 4 

6 9 

17 0 

51-5 

363 

17 7 

9-7 

— 

1. Difference . 



- 0-4 

- 1-4 

- 69 

- 4 

- 125 

+ 12-7 

+ 12-3 

+ 0-3 

— 

f Actual cases . 



0 

• 

5 

29 

149 

170 

81 

LI 

477 

III. •! Calculated . 



1-4 

8 0 

232 

67 3 

173 5 

122 

59 6 

32 5 

— 

t Difference . 



- 1-4 

- 60 

- 18-2 

- 283 

- 24 6 

+ 48 

+ 21 4 

+ 85 

— 

/ Actual cases . 



0 

4 

26 

6U 

256 

925 

129 

62 

756 

IV. < Calculated . 



2-2 

126 

36 8 

90-7 

274 

193 5 

946 

51-5 

— 

(Difference . 



- 2-2 

- 8-6 

- 10 8 

- 26 7 

- 18 

+ 315 

+ 34-4 

+ 0-5 

— 

j Actual cases . 


... ... 

2 

.9 

1*8 

115 

377 

285 

120 

78 

1029 

V.< Calculated . 



3-0 

17 2 

50 0 

1235 

374 

263 

129 

70-0 

— 

t Difference . 



- 1 

- 8-2 

-7 

- 85 

+ 3 

+ 22 

- 9 

+ 8 


t Actual cases . 



IS 

70 

173 

389 

1005 

521* 

239 

145 

2553 

VI. < Calculated . 



7 5 

43 

124 

307 

929 

. 654 

320 

174 

— 

(Difference . 



+ 55 

+ 27 

+ 49 

+ 82 

+ 76 

- 130 

- 81 

- 29 

— 

Total . 

15 

86 

249 

615 

1860 

1310 

64 f 

549 

5125 


The black lines divide the table into four quadrants. The top left-hand quadrant—i.e.. cases of severe small pox m young patients—and 
the bottom right hand quadrant—i.e., mild small-pox in old patients—both show deficiencies, while an excess of cases shows in the reverse condi¬ 
tions, viz., mild cases in young people and severe cases in old people. 
















This Lanciet,] DR. TURNER : IS DEATH-RATE THE BEST MEASURE OF SEVERITY IN DISEASE ? [Feb. 8,1908 . 41 5 


A stronger preponderance of severe cases among the older 
patients is Bhown if we take the vaccinated cases; though 
the effect of vaccination in infancy and the gradual dis¬ 
appearance of the protection afforded by it render the table 
lees suitable to the illustration of my thesis. To save space 
the numbers corresponding to equal severity at all ages and 
the differences between these and the actual figures have 
been entered in the same table. 

A second instance is obtained from a paper, not yet 
published, by Dr. W. Lowson and myself on the temperature 
in scarlet fever. Here we have measured the severity of 
pyrexia in each case by measuring the area included on the 
temperature charts between the record of the patient’s 
temperature and the normal line. For the precautions taken 
I shall have to refer my readers to the paper when it appears. 


Table Y. — Temperature—i e., Area on Temperature Chart. 


Years of 
age. 

Area of fever shown on chart. 


| 0-5 

5-10 

10-15 

15-20 

20-30 

30-50! 

50-100 

Over 

100 


0-1 

1 

— 

_ 

— 

1 


1 

_ 

3 

1 

15 

2 

3 

1 


3 

4 

1 

29 

2 

27 

5 

1 

1 

4 


1 

2 i 

41 

3 

25 

1 

« 

2 

2 

4 

4 

1 

43 

4 

25 

12 

3 

1 

5 

1 | 

4 | 

l ! 

52 

5 

13 

4 

3 

1 

2 

5 

1 

2 

31 

6 

18 

1 

4 

3 

2 

5 

1 ! 

— 

34 

7 

11 

1 

2 

1 

4 

i 

— ' 

— 1 

20 

8 

4 

i 1 

— 

_ i 

1 

2 1 

1 

1 

l 10 

9-10 

3 

2 

— 

— 

— I 

i 

2 

' — 

8 

10-15 

8 1 

8 

7 

5 

5 

4 

1 

1 

39 

15-20 

3 

2 

1 

— 

2 

— 1 

j 1 

— 

! 9 

Over 20 

1 

— 

— 

1 

2 

1 

1 

1 — 

6 

Total ... 

154 

39 

28 

16 

' 30 

27 

| 22 

9 

325 


Thus the top line shows that out of 325 cases of scarlet fever only 
three were under one yesr of age, and that of these one had very slight 
pyrexia, an area of less than five units-i.e., 0 5 of a square inch on the 
charts used. The other two had more severe attacks with areas of over 
two and over five square inches respectively. 

In the first example we could not calculate the mean 
severity of eruption, since our six classes were not quanti¬ 
tative, and we had to fall back upon a less familiar way of 
attacking the problem. But in this example area is a 
measurable quantity, and we can accordingly find the mean 
area (i.e., the mean severity of fever) for each age-period. 


The results 

are 

as 

follows:— 



Years of 

Age. 



Mean area of 
temperature 
chart. 

Years of 
Age. 

Mean area of 
temperature 
chart. 

0-1 . 

... 


... 34-1 

8 . 

. 347 

1 . 

... 


... 288 

9-10. 

. 26 5 

2 . 



... 14-9 

10-15. 

. 14-6 

3 . 



... 18-9 

15-20. 

. 12-7 

4 . 



... 158 

Over 20 ... 

. 316 

5 . 



... 23-9 


— 

6 . 



... 28-6 

All ages ... 

. 192 

7 . 

... 


... 10-9 




Though the numbers at different ages (litter considerably, 
it will be noticed that those means, based on considerable 
numbers of cases, cluster fairly closely round the mean of the 
whole and that the most discrepant values are based upon 
a small number of cases ; also that there is no tendency for 
high ages to be associated with low values of area. In other 
words, the differences found are probably due to chance. 
A more satisfactory calculation can be made by using 
formulae which apply to the figure as a whole—viz., those 
introduced by Bravais and Pearson. By them I have 
obtained the value of the correlation coefficient of the 
table 1 — 

r = + 0-0072 + 0-038. 

These figures may be interpreted thus: The correlation 
between age and severity of fever in the 325 cases inves¬ 
tigated is positive, showing a greater severity at greater 

1 The table given la abridged from that in' Dr. Lowson'a and my 
paper. The value given abovu was calculated from the full table. 


ages. In magnitude, however, it is extremely small, and if 
another 325 cases were examined the laws of probability 
would lead us to expect the discrepancy between the two 
series to be about five times as great. In other words the 
table shows, as clearly as can be shown with the number of 
cases investigated, complete independence of age and severity 
of fever. 

We have now two instances, one in small-pox and another 
in Bcarlet fever, of independence, or at least almost complete 
independence, of severity of symptoms with age of the 
patient. In both cases, however, the mortality-rate shows a 
very great alteration with age, as shown below:— 

Table VI. — Mortality Per Cent, at Different Ages in 
Scarlet Fever and Smallpox. 


Age-periods—Years. 



0-5 | 

K - J 10- 
5 " 10 i 15 

15- 

20 

20- | 30- 1 
30 j 40 , 

40- 

50 

Over' All 
50 ages 

Smallpox, unvacci- 

natcd cases . 

I 

48 3 

i 

18-0 23-1 

25-1 

35 5 (48-1 1 

75-0 

Jl 

55-5 33 2 

Scarlet fever . 1 

6-09 

CO 

00 

(-* 

A 

0-63 ( 

1-9C 

071 

, 3 26 

I 


If the quinquennium 0-5 be subdivided the variation with 
age becomes still more striking. The conclusion seems 
obvious that in these two diseases the great variation of 
mortality with age depends solely upon the vitality of the 
patient and is independent of the severity of the disease. 
Only one means of escape from this conclusion, which I 
confess was quite unexpected by myself when I started to 
collect the facts, seems possible; and I have no doubt that 
some critics will avail themselves of it. 

We have taken in each disease one symptom only as 
criterion of severity. Is this justifiable ? Does not the 
mortality test sum up all the phenomena of the disease in a 
perfect manner, so that the mere nse of a single symptom is 
comparatively unreliable? To this objection the proper 
answer would be to take the various symptoms in 
order and see whether the high death-rate in early 
childhood could be ascribed to any of them. In small¬ 
pox this course was not possible for me ; and in scarlet 
fever for a long time I considered that the facts could 
only be ascertained after a vast amount of labour, such 
as might take many years to carry out. For instance, the 
severity of scarlet fever rashes might be estimated by com¬ 
paring the colour of the patient’s skin with a set of standard 
shades of red and crimson. But it would take some time to 
get several observers used to working with these, and a 
further period for the collection and reduction of the obser¬ 
vations. Only recently did it occur to me that for our 
present purpose such a high standard of accuracy is not 
required. The published statistics of fever hospitals show 
year by year that the mortality of scarlet fever in patients 
under two years of age exceeds about ten times that of the 
disease at the prime of life, say from 10 to 25 years of age. 
The tables given above show that this excess mortality in 
infants iB not due to an excessive severity of fever. If it 
were due to excessive severity of rash or of throat lesion we 
must have severe throats and rashes preponderating amongst 
the younger children to an extent that would show itself in 
the notes taken by ordinarily careful clinical observers, and 
special observations ad hoc are not necessary. I accordingly 
took 100 consecutive reports of cases from the bed cards of 
the South-Eastern Hospital and wrote a special slip for each 
case, noting (1) the age; (2) the severity of the rash ; (3) 
the duration of rash, if noted ; (4) the severity of throat 
lesion ; (5) the presence of complications; (6) the duration 
of fever ; (7) the maximum height of fever; and (8) the 
result—i.e., death or recovery. From these slips it was 
possible by sorting to examine into the connexion between 
age and any of the other factors, or between any pair of the 
latter. In short, it was possible to compile 56 different 
correlation tables, out of which I publish the following as 
sufficient to show (a) that there is little or no correlation 
between age and severity of rash or throat lesion ; but (b) 
that there is moderate or high correlation between certain 
other pairs, such as throat lesion and maximum height of 
fever, and rash and maximum height. The notes as to rash 
varied a little in terminology with different observers, but 
seemed to fall most naturally into four classes—faint, 
ordinary, marked, and vivid. 

F 2 


























416 The Lancet,] DR. TURNER: IS DEATH-RATE THE BEST MEA8URE OF SEVERITY IN DISEASE? [Feb. 8,1908. 


Table VII .—Sash and Age. 


Years of age._Total. 

l'aint. Ordinary Marked, j Vivid. 


Table VIII .—Throat Lesion and Age. 



12 100 


We cannot, as in Table V., calculate the mean severity of 
rash for given ages, as our divisions are not quantitative, but 
it is possible to examine the table by working out the mean 
ages for given severity of rash, and we obtain :— 


Bash, faint ... 
„ ordinary 
„ marked 
,, vivid ... 


Mean age, 576 years. 
„ 7*23 „ 

„ 7-42 ,. 

„ 6-58 „ 


Years of age. 

Mild. 

-Total. 

Severe. 

1 

0-5 . 

36 

12 48 

6-16 . 

40 

12 52 

Total . i 

76 

24 100 





Throat. 


Years of ago. 


Dirty. 

Total. 




Clean. 

Slight. 

Moderate. 

Severe. 


0-1 

1 



3 

- 


- 

3 

2 

. 


6 

— 

1 

1 

8 

3 



6 

1 

3 

2 

12 

4 



11 

1 

1 

1 

14 

6 



8 

1 

2 

— 

11 

6 



10 

2 

1 

1 

14 

7 



9 

— 

3 

— 

12 

8 



2 

— 

3 

1 

6 

9 



5 

— 

— 

— 

5 

10 



1 

1 

— 

— 

2 

11 



2 

— 

1 

1 

4 

12 



3 

— 

1 

— 

4 

13 



1 

— 

— 

— 

1 

14 

15 

16 



1 

— 

— 

— 

1 



3 

- 

- 

- 

3 

Total . 

71 

6 

16 

7 

100 


Table VIII. a. — Throat Lesion and Age. 


YearB of age. 


A more satisfactory method is to group the whole 100 
cases in only four divisions retaining two age-periods, 0-5 
and 6-16, and two grades of rash, faint or ordinary and 
marked or vivid. We get the following:— 

Table VII.a. —Sash arid Age. 



Here inspection shows that the agreement between the 
facts and the hypothesis of complete independence of age 
and severity of rash is as close as could be expected with 
100 cases; but we can calculate the degree of dependence 
as follows: multiply the figures in opposite quadrants 
together, then take the ratio of the difference of these two 
products to their sum. This formula, called Yule's 
coefficient, 8 gives— 

40 X 12 - 36 x 12 _ 

40 X 12 + 36 X 12 - ° 062 

Pearson has given formulae for four-fold divisions, such as 
the above, which are probably more correct on theoretical 
grounds, but are much more tedious to calculate. In the 
above case Pearson’s formula; give— 
r = 0 039. 

The connexion is between high age and mild rash, but is so 
slight as to be negligible. We can examine throat severity 
in a similar way. The notes on this gave five natural classes, 
clean throats, either red or red and swollen, and dirty throats, 
with slight, moderate, or much deposit. In the following 
table only four divisions have been used. 


3 With both Yule’s and Pearson's formula? 1 would represent perfect 
correlation—i.e., that for every age there occurred only one fixed type 
of rash—and 0 would represent no correlation—i.e., that various types 
of rash occurred indiscriminately at all ages, which is practically what 
does occur. 


w , , _ . . 34x15 - 37x14 „„„„ 

Yules coefficient = = _ 0 008 

Pearson's „ = - O'006 

The correlation is thus even less than in the laBt instance. 
The negative sign means that high age is associated with 
mild throat lesion though only to an insignificant extent. 

As a contrast to Tables VII. and VIII. the following two 
show a high association between severity of throat lesion and 
rash respectively and severity of fever, and the next a 
moderate association between the two former factors. 

Table IX .—Rash and Maximum Temperature. 



In Table XI. the correlation is rather irregular, that is, 
there is a higher proportion of clean to dirty throats in the 
middle row than in either the top or bottom row. Accordingly, 
we do not fairly represent the facts by condensing either the 
two top or two bottom rows to make the division fourfold. 
A fair result can be obtained either by working out both 
methods and taking the mean or by splitting the middle row 
into two halves to get a fourfold table. By the latter 
method I have calculated Y'ule’s coefficient as -f 0 • 146. The 

















Tan Lancet,] DR. TURNER: IS DEATH-RATE THE BEST MEASURE OF SEVERITY IN DISEASE? [Fbb. 8,1908. 41 7 


Table IX. a. — Mash and Maximum Temperature . 


Maximum temperature. 

Rash. 

Total. 

Mild. 

i Severe. 

101° . 

48 

7 

55 

101° or over . 

28 

17 

45 

Total . 

76 

2d 

100 


48 X 17 - 28 X 7 

Yale s coefficient — qg x 17 + 28 X 7- = 


4- 0 612 


TABLE X. —Throat and Maximum Temperature. 


Maximum 
temperature. ! 

Throat. 

Total. 

Clean. 

Dirty. 

Red. 

Red and 
swollen. 

Slight. 

Moderate. 

Severe. , 

98° 

2 

— 

— 

_ 

1 

3 

99° 

4 

8 

— 

1 

- 

13 

100° 

8 

13 

2 

4 

— 

27 

101° 

7 

4 

— 

1 

— 

12 

102° 

5 

6 

1 

4 

2 

18 

103° 

5 

7 

3 

6 

1 1 

22 

104° 

1 

1 

— 

— 

3 

5 

Total 

32 

39 

6 

16 

7 

| IOO 


Table X.a. —Throat and Maximum Temperature. 


Maximum temperature. 

Throat. 


Clean. 

Dirty. 

lOlal. 

101° . 

46 

9 

55 

101° or over . j 

25 

20 

45 

Total . 1 

71 

29 

100 


Y'ule’s coefficient = 


46 X 20 - 25 X 9 
46 X 20 + 25 X 9 


+ 0-606. 


Table XI.— Threat and Mash. 


Rash. 

Throat. 

Total. 

Clean. 

Dirty. 

Faint.. 

22 

9 

31 

Ordinary. 

35 

10 

45 

Severe . 

14 

10 

24 

Total . 

71 

29 

100 


correlation is mncb lower than in the two preceding 
instances, and being irregular most be regarded as not very 
certain. A larger namber of cases or a more careful system 
of note-taking might, however, show it to be real. 

The foregoing examples suffice to show that high correla¬ 
tions exist between certain pairs of symptoms in scarlet 
fever but not between age and either of the three most 
obvious of the symptoms in this disease—viz., rash, throat 
lesion, and pyrexia. 

II. The inconvenience of the mortality rate as a test of 
severity. —Those who have followed the first part of this 
paper will probably have already thought of most of what I 
propose to say under the second heading. Nothing is 
commoner in medical discussions than to hear it said that 
certain problems ought to be settled by statistics, and yet 
hardly anything is rarer than to see these vexed questions 
actually argued out and Battled by an appeal to the facts— 
i.e., statistically. Various problems no doubt occur to all. 


but those I allude to may roughly be classed into the effects 
of treatment and the effects of other factors in the environ¬ 
ment. To take examples from my own specialty, medical 
meD who treat scarlet fever differ in some details of treat¬ 
ment, such as the routine time for keeping the patient 
in bed, the treatment of the throat, the amount of diet 
allowed both in the acute stage and in subsequent 
nephritis. Apart from treatment, many other questions have 
been raised, some of them of great theoretical or practical 
interest. Do fever wards get more unhealthy with continued 
use? Are such complications as post-scarlatiDal otitis and 
nephritis infectious ? Is there any evil result from over¬ 
crowding in fever wards ? What effect has poverty on 
severity of disease ? Are there differences due to difference 
of race, as between aliens and natives ? 

In the Metropolitan Asylums Board hospitals, with an 
experience of 20,000 scarlet fever cases a year, one would 
think that ample material was available for settling in the 
course of a few months, or at most in a couple of years, 
every one of the above questions. Yet very few of them 
have even been seriously attempted and the results of the 
attempts so far made have not always been as conclusive as 
could be desired. And one important cause contributing 
to this has been the very low death-rate in scarlet fever. 
In the last published volume of the Metropolitan Asylums 
Board reports the death-rate for all hospitals was 
2-94 per cent. That is to say, that in 1000 cases 
one would expect about 29 deaths. Time and opportunity 
rarely allow any careful experiment to be made on any 
much greater number than this, so we require to know what 
would be the difference from 29 deaths per 1000 which would 
convince us that our treatment had been improved or that 
any other change had really happened in the conditions. A 
knowledge of the laws of probability would teach us that 
not unless the deaths fell to 15 or 19 per 1000 should we 
have good reason for supposing that we had anything beyond 
a chance variation. A knowledge of the mathematical 
formulae appropriate to the case is not very widespread 
among medical men, but there is an equivalent deeply 
ingrained in the minds of those who are most familiar with 
statistics. Those who see scarlet fever cases by the thousand 
are well aware that any reduction in case-mortality that can 
be hoped for by improved methods of treatment will be too 
slight to be shown conclusively by working with death-rates. 
Theoretically the difficulty could be overcome by working 
out a sufficiently extensive series of cases ; in practice this 
is improbable. The difficulty of insuring uniformity of 
treatment (or other conditions) over 10,000 cases is very 
great and the time occupied in the experiment would prob¬ 
ably cause disturbance in the results from the slow altera¬ 
tion in type that goes on from year to year. On the other 
hand, if we use other criteria of severity, as in some of the 
instances given above, it is easy to find a line that divides 
the cases into two approximately eqnal divisions. Here with 
only 100 cases it might be possible in some problems to get 
a decisive result, and where 1000 cases are available a 
definite answer to any statistical problem would be almost 
assured. 

The only important argument in favour of death-rates 
and complication rates, as against criteria obtained by 
measuring the severity of symptoms, is the risk of high 
personal equations in the latter. The risk is not so great 
as most people assume. It is quite possible to choose 
criteria of severity that are little affected by it—e.g., the 
duration of fever or the area of a temperature chart. And 
even in other non-measurable characters the adoption of 
standard degrees of severity for the purpose of collecting 
observations would not be very difficult, if only observers 
were convinced that it was worth while. 

A concrete case or two will make my meaning clearer. A 
problem of considerable theoretical interest is this. “Are 
cases of scarlet fever contracted inside a fever hospital more 
severe than those contracted in the usual way ? ” Since the 
reopening of my own hospital 18 months ago 78 such cases 
have occurred with only one death. The death-rate has 
therefore been 1 • 28 per cent. The death-rate usually met 
with in my own and kindred institutions is about 3 per cent. 
The last published figure for my own hospital on 1001 cases 
was 2-62. Taking the latter figure, the death-rate amongst 
the cases caught in hospital is less than half that found 
amongst ordinary cases, yet the evidence in favour of a 
change in severity is very inconclusive. It is by no means 
uncommon to get a run of 78 cases with only one death and 
the difference in the two series might easily be due to 
chance. Mathematically calculated, the difference of the 





418 The Lancet,] MR. W. ARBUTHNOT LANK: EXCISION OF THE RECTUM FOR CARCINOMA. [Feb. 8, 1908. 


death-rates is 1 • 24 and is not much larger than the probable 
error, whioh is 0 92. Snch a difference might therefore very 
often' arise as a chance effect. The severity of the cases, 
however, lends itself to measnrement in many other ways, 
two of which I have need in attacking this problem. 
Classified according to duration of pyrexia the 78 cases 
caught in hospital were grouped as follows :— 


Duration In days. 



0 

1 

2 

3 

4 

5 ! 

6 

I 7 ! 

8 

9 

10 

11 

Number of cases . 



4 ! 

8 

10 

20 j 

9 

7 

3 

i 4 

2 j 

1 

1 

2 

Days (continued) 

... 



12 

13 

14 ! 

15 

16 

17 

18 

19 

20 1 

21 

22 

Cases (continued) 

... 



1 

2 

- 

1 

— 

1 


— 

1 i 


1 

Giving 

a total 

of 78 cases 








A series of 314 ordinary cases all 

admitted on the firat or 

second day of disease gave the 

following 

- 






Duration in days ... 

0 1 

1 

2 

3 

4 

( 5 

6 

7 

| 

8 

9 

10 

11 

12 

13 

Number of cases ... 

2 1 

10 

24 

88 

53 

34 

l_! 

24 

10 

l_ 

20 

8 

(_ 

10 

3 

6 

i 

3 

i_ 

Days (continued) ... 

14 

,15 

16 

17 

18 

1 

i 19 

!20 

! 21 

22 

23 

24 

25 

26 

I 27 

Cases (continued) ... 

5 

5 

i- 


1 

I l 

1 1 

l 

- 

1 

- 

1 

2 

1 


Giving a total of 314 cases. 

The two series, reduced to percentages in each case, are 
shown together on the annexed chart, where the vertical line 
■of figures shows the number of cases per cent, and the 
horizontal line of figures the duration of fever in days. 


The mean of the first series is 101’795 + 0’10 and of 
the second series 101 • 167 + 0 ■ 037 and the difference is 
0 63 + 0 11 degrees. Summarising the above evidence, 
cases of scarlet fever caught in hospital tend to have higher 
fever, which, however, does not last so long. The death-rate 
also appears to be less. The first two conclusions are, 
however, almost certain ; the third is well within the limits 
of chance error. 

A second problem of considerable practical importance is 
the dosage of antitoxin in diphtheria. In spite of the 
elaborate reports issued during the early years after the 
introduction of antitoxin into this country the proper scale of 
dosage remains still very uncertain ; and I think the current 
doctrine on the subject consists more of ex cathedrd state¬ 
ments than of proved facts. Quite recently the medical 
superintendents of the Metropolitan Asylums Board dis¬ 
cussed this matter and a considerable divergence of opinion 
was shown. Surely the problem is capable of solution, but 
not if we rely on the death-rate as the only fact worth 
observing. Even if two hospitals be compared, each treating 
500 or more cases a year, and one hospital employing on an 
average double the dosage of the other, I doubt if any 
differences observed in the death-rates would convince 
anybody. The advocates of the system which showed the 
higher death-rate would assume that the rival hospital got a 
larger proportion of mild cases. Our obvious duty, there¬ 
fore, is to devise some method other than the death-rate for 
measuring the severity of cases, and if clinical observers set 
themselves seriously to this task I see every reason for 
believing that almost all problems connected with the 
efficacy of treatment of common diseases could be solved, 
say, within one or two years of their being propounded. 

New Cross, S.E. 



Cases caught in hospital shown by continuous line, other cases 
by dotted line. 


The mean of the first series—i.e., cases contracted in 
hospital—is 4 05 + O’29 and of the second series is 
5 05 + 0 16. The difference in mean duration is therefore 
one day. The probable error of this difference being only 
O' 33, or one-third, it is unlikely that another series of cases 
taken in similar circumstances would give a different result. 

The cases were also grouped according to the maximum 
temperature recorded, or culminating point of the fever, 
with the following resnlts : — 


Culmination of fever 

So 

03 

99° 

100° 

101° 

102° 

103° 

104° 

Number of cases ... 

4 

5 

9 

23 

23 

11 

3 


Giving a total of 78 cases. 




A series of 679 ordinary cases 
following 

similarly grouped gave the 

Culmination of fever 

1 98° : 99° 

100° 

1 101° 

! 102° 

103° 

! 104° 

105° 

Number of cases 

162 

131 

157 

128 

90 

10 

1 


EXCISION OF THE RECTUM FOR 
CARCINOMA. 

By \V. ARBUTHNOT LANE, F.R.O.S.E.vg., 

Sl'RGEOK TO GUT’S HOSPITAL AHD SENIOR SURGEON TO THE HOSPITAL 
FOR SICK CHILDREN, GREAT ORMOND-STREET. 


The risk associated with the operation of complete 
removal of the rectum and of all infected mesenteric 
glands is so considerable that I have made many attempts 
to minimise it by modifying my operative procedures. I 
am not referring to snch measnres as that known as Kraske's 
operation which, in my opinion, is unsatisfactory for many 
reasons. The operation that I have adopted for some time 
appears to me to effect the maximum of benefit to the 
patient with a minimum of risk and discomfort. The last 
feature—namely, the absence of discomfort—is of para¬ 
mount importance inasmuch as the sufferer is already suffi¬ 
ciently depressed by the very serious nature of his malady. I 
only apply this procedure to cases in which it is not possible 
to resect a portion of the bowel to establish continuity. I 
make use of it in cases in which it is advisable to remove the 
growth and all infected tissues, and when the patient is 
prepared to accept the very trifling inconvenience of a 
colotomy in the immediate vicini'y of the middle line in the 
substance of the rectus. The youDger the patient the more 
necessary is it that a very radical operation should be per¬ 
formed. The principle involved in this operation is the 
separation of the peritoneal space contained in the true 
pelvis with the diseased portion of the intestine from the 
general peritoneal cavity. This prevents any chance of a 
general infective peritonitis when the rectum is removed 
from below and obviates the formation of adhesions involving 
the small intestines, since no raw surfaces are left in the 
pelvis to which the bowel can become attached. 

The procedure is as follows. A vertical incision is made 
three-quarters of an inch to the left of the middle line from 
the umbilicus downwards for about four inches The 
opening is formed in this situation as it affords easy access 
to the pelvis and to the sigmoid flexure. In these cases 
the Bigmoid ll-xure is almost always pinned down by 
adhesions. These are of the same nature and perform the 
same function of obliterating the loop as in obstruction due 
to constipation. A further reason is that in this situation 
a firm scar can be obtained in which the rectus muscle 
controls more or less completely the exit of material from 
the bowel. The patient beii g placed in the Trendelenhurg 
position and the pelvic caviry beieg rendered fully accessible 
by the use of suitable retractors, the growth is carefully 


Giving a total of 679 cases. 







The Lancet,] PROFESSOR J. B. HELLIER : THE METHODS OF PRIMITIVE MIDWIFERY. [Feb. 8, 1908. 419 


defined, together with any infected glands or mesentery. The 
sigmoid flexure is rendered mobile by the careful separation 
from it and from the meso-sigmoid of the acquired adhesions 
already referred to. A sufficient length of bowel having 
been drawn out of the abdomen, it is divided with the 
cautery at such a point as to leave two or three inches of the 
proximal bowel protruding from the abdominal incision 
after the edges have been approximated by sutures. The 
mesentery of the distal bowel is separated from the sacrum 
as far down as possible and a ligature is tied firmly round 
the rectum at its lowest limit above the growth, any infected 
mesentery above the level of the ligature being thoroughly 
eradicated. The rectum is divided by the cautery imme¬ 
diately above the ligature. The ligatured stump is then 
inverted into the rectum and securely buried by purse¬ 
string and other sutures. Then the peritoneum of the 
pelvis lining its wall and the bladder in the male, 
and the uterus and broad ligament in the female, 
is picked up on a catgut suture so that that portion of 
the peritoneum of the pelvis which contains the rectal 
growth is completely separated by an artificial diaphragm 
from the general peritoneal cavity, and whatever disease 
still remains lies entirely below the protecting diaphragm 
which has thus been constructed. A curved tube fitted with a 
special rubber apparatus (Fig. 1), which 1 have employed for 


FIG. 1. 



many years, is then tied into the portion of the sigmoid flexure 
left protruding from the abdominal incision, ail fouling of 
the wound or discomfort to the patient during the whole 
period of convalescence being absolutely avoided by this 
means. The two or three inches of gut projecting from the 
wound is utilised to re attach the glass tube as each section 
of bowel sloughs off with the constriction due to the ligature 
till the bowel is divided flush with the skin. This leaves 
a perfect aperture which is readily controlled by the rectus 
muscle and over which a cup and belt is worn without 
inconvenience. 

After the operation the patient is put upon continual 
saline injections subcutaneously. Two pints are introduced 
into the axilla at once while the patient is still under 
the anrcsthetic ; during the three days following the opera¬ 
tion about eight or ten pints are absorbed in this way by 
continued transfusion. To meet any risk of infection of 
the material introduced I devised an arrangement by means 
of which this can be effectually eliminated. It has also the 
advantage of occupying a very small bulk in the bag of the 
surgeon. It is made for me by Messrs. Down Bros. It 
consists of a bag made of the best rubber capable of con¬ 
taining two pints of water' (see Fig. 2). It has a metal 
orifice sufficiently large to admit of the ordinary salt 
■“ tabloids." To this is joined a rubber tube by means of a 
bayonet catch, to which a suitable needle can be attached. 
This needle is fitted with a shield which serves the double 
purpose of keeping it covered after sterilisation and pre¬ 
venting any blunting of its point A rectal nozzle is also 
supplied in the event of the surgeon wishing in certain cases 
to introduce the solution into the rectum. By using saline 
solution subcutaneously in this manner any sickness with the 


strain on the wound and the associated pain and distress is 
absolutely avoided, while the danger of shock to the patient 
from the operation is reduced to a minimum. I first 
employed this continual transfusion with the most marked 
success in cases in which I had removed the big bowel, with 
the result that the risks from the operation are very much 
reduced, while I believe the tendency to the formation of 

Fig. 2. 



gSC 



adhesions about the dilated small intestine, which is an occa¬ 
sional annoying sequence, is apparently obviated by it. The 
bag can be placed in any situation in or above the bed and 
its contents can be kept warm by placing it on a hot-water 
bottle, &c. If the solution does not run freely pressure can 
be exerted in it readily or it may be suspended at a greater 
height. To employ it the bag is filled with water after the 
salt has been introduced into it. The shield, tubing, and 
needle are then connected and the whole thing is put into 
any suitable vessel and bofied. The shield being taken off 
the needle, it is introduced between the cleansed skin and is 
fixed in position with a suitable dressing so as to assure 
asepsis at the seat of puncture. 

After a fortnight has elapsed the remainder of the rectum 
is removed from below. This is done by a careful dissection 
of the rectum from the sacrum and from the bladder or 
vagina till the portion of the peritoneal cavity which has 
been shot oil by the artificial diaphragm is encountered. 
From this peritoneal space into which the finger enters the 
remainder of the rectum is easily removed. The cavity left 
is drained in the usual manner and closes up rapidly. 

Ooe satisfactory result of this method of operating is that 
before the second step in the operation the patient gets about 
with comfort, and after the second step the sitting posture 
can be resumed after the lapse of a few days. 

Cavendish-square, W. 


THE METHODS OF PRIMITIVE MID¬ 
WIFERY. 

Bv JOHN BENJAMIN HELLIER, M.D.Lond., 

PROFESSOR OF OBSTETRICS IN THE UNIVERSITY OF LEEOS AND 
OBSTETRIC PHYSICIAN TO THE LEEDS GENERAL INFIRMARY. 


I. 

I will introduce my subject by quoting a description of 
present-day practice as observed by a member of our pro¬ 
fession who was for many years in charge of a mission 
hospital in South India, who has kindly communicated it to 
me verbally It gives an excellent illustration of the methods 
to which the reader's attention is invited. 

When a Hindu woman is in labour all her relations crowd 
into the room. In an ordinary case they may let the woman 
go on as best she can, but in any case of difficulty they call 
in a so-called "barber woman.’’ She is supposed to know 
something and claims to know a great deal, but as a matter 
of fact is completely ignorant and filthily dirty. Suppose 
the labour to be lingering or the case to be primiparous and 
that delivery does not follow as Boon as expected, then 





420 Thb Lancet,] PROFESSOR J. B. HELLIER: THE METHODS OF PRIMITIVE MIDWIFERY. [Feb. 8, 1908. 


various expedients of cruel and brutal nature are adopted. 
For instance, they may jump on the body of the woman as 
she lies upon the floor. They may try to seize any present¬ 
ing part and tear at it, perhaps even palling off the scalp 
of the child. They may tear the vulva and vagina or use 
knives in a senseless endeavour to make a way for the child. 
The woman may be made to sit over hot ashes and burning 
twigs or charcoal. When she is very far gone they may at 
last send for the medical missionary, who may And the 
patient severely burned or lacerated, bruised and bleeding. 
The bladder may be ruptured, the abdomen greatly distended, 
the patient pulseless and insensible. She may die before 
anything can be done or may expire immediately after 
delivery. If the burned cases survive the first Bhock they will 
very likely die from gangrene, or the whole of the vagina 
and bladder may slough, and tetanus is very common. After 
labour the patient is kept lying on the floor for three days 
without food or drink. The baby is given cow's milk at 
once, which upsets it. It is against their religious ideas to 
wash the child till the tenth day. A large proportion of the 
newly-born children die from tetanus. The mothers are con¬ 
sidered to be unclean until the eighth day and are often kept 
outBide of the house in a little shed, which is a dark room 
like a cupooard. After their first bath they are taken back 
into the house but if fever set in the bath of purification is 
delayed until they are well, if they do get well. If these 
women are treated rightly in childbirth their labours are as 
easy and normal as are those of women in England, probably 
more bo on the average. When labour is delayed, or they 
desire to produce abortion, a powerful and irritant poisonous 
drug is sometimes administered, the nature of which is not 
known to us. It causes severe pain and green vomit and 
seems always to be fatal. 

A second similar illustration is taken from the New York 
Medical Record for January, 1906, where Dr. W. D. Bell 
describes observations made during a residence of 13 months 
on the island of Luzon in the Philippines. He says that the 
so-called safety supposed to exist amongst savage peoples in 
childbirth was not found in these islands, for barbarous 
practices and tortures with far-reaching consequences were 
what were really observed. Ho attention waB paid to the 
sanitary surroundings of the patient. As soon as the first 
real pains manifested themselves the patient was held on the 
ground and a cloth was passed around the abdomen and the 
four ends were pulled by four persons seated on the ground 
with their feet against her body. As soon as a portion of the 
child presented it was immediately seized by a fifth assistant 
and vigorously dragged upon, regardless of consequences. 
If any delay occurred a plank was laid across the abdomen 
on which a native assistant stood, raising himself on Mb toes 
and coming forcibly down on his heels. This was usually 
snccessful except in breech presentations, when a rude attempt 
at version was made with hands innocent of any effort to 
cleanse them. Few cases escaped laceration and sometimes 
the uterus was ruptured. If the same means failed to 
expel the placenta forcible traction was made on the cord 
and very often parts of the placenta were left behind, with 
the usual consequences. Prolapse, inversion, and puerperal 
sepsis were frequent here, also chronic endometritis. Syphilis 
and gonorrhoea were also common. 

II. 

The development of obstetrics falls into three stages. 
First, there is the primitive stage. This is characterised by 
the absence of all literature and of all knowledge of anatomy 
and physiology, and by an overwhelming amount of super¬ 
stition, by the crudeness and absurdity of its ideas and the 
barbarity of its methods. It is almost without exception in 
the hands of women. Iu the second or intermediate stage 
we find the beginnings of obstetric literature and some 
attempt to describe the various positions of the foetus in the 
womb and to lay down rules for treatment. The practice of 
midwifery is almost wholly in the hands of women, but men 
are called in in very bad cases to help. The treatises are 
written by men for the guidance of midwives. Version 
and embryotomy begin to be described but not forceps. 
The third or scientific stage may be said to begin 
about the time of Ambroise Parc in the sixteenth 
century, and its history has often been written. The 
intermediate stage has its dawn in the ancient Hindu 
physicians, such as Susruta, and there may even yet 
be recovered some of the lost literature of Egypt which will 
show more obstetric knowledge than we at present credit to 
those times. An account of their obstetric knowledge will 


be found in ila-kiy’s “Ancient Gynseovlogy.” Literature 
practically begins for ns with the writings of Hippocrates 
and his followers in the fourth century B.c. Ancient 
obstetrics reached its high-water mark in the works of 
Soranus and his translator Moscbion in the second century 
A.D. From this time it made very little advance till the 
time of Par6—in fact, there was decided retrogression daring 
the middle ages. 

Midwifery was in the primitive stage from the earliest 
times till the days when Greek learning made a bright 
spot in the general darkness, and it remained primitive 
throughout the centuries except where Greek, Roman, and 
Arabian medicine spread, and even here obstetric art was 
but too little removed from the realm of superstition and 
ignorance. It remains primitive to-day wherever Western 
science has not spread and forms a most interesting field for 
the study of the obstetrician and ethnologist. The human 
race has shown wonderfully little precocity in the practice 
of obstetrics. Nations who have perfected the arts of agri¬ 
culture and of the chase, who have forged offensive and 
defensive weapons, built temples and palaces, woven textile 
fabrics, produced pottery, sculpture, poetry, and philosophy, 
have remained woefully ignorant of an art which, if necessity 
begetB invention, might, one would think, have been one of 
the oldest and most advanced known to mankind. To some 
extent this may be due to the fact that the management 
of childbirth has been so very largely in the hands of women. 
The history of the race seems to show that all the mechanical 
arts have been developed not by women but by men. Obstetrics 
never began to develop till men took it from the exclusive 
practice of women, studied the mechanism of childbirth, and 
supplied the necessary mechanical aids. But man has no 
place in primitive obstetrics; uncivilised man would certainly 
decline to concern himself with such woman's affairs. She 
is regarded as an inferior being. As one writer says: “She 
is worth so little, so easily replaced; she is good for the 
bearing of children, to look after them, and to give satis¬ 
faction to her master, and especially to do the work of the 
field. As soon as she is a nuisance she is left, sold, 
killed, possibly eaten.” It is certain that if scientific 
treatment were available but its cost exceeded the 
market value of the woman it would be refused. The 
birth of scientific midwifery coincided with the revival 
of learning, the introduction of printing, the Reformation, 
the discovery of the new world, and the introduction of 
inductive methods of research. The exalted estimate of the 
value of woman’s life which the spirit of chivalry engendered 
prepared the way. 

In studying this subject I have made use of Herrgott’s 
French edition of Siebold’s " History of Obstetrics ” and also 
of the valuable historical sketch prefixed to Winckel’s 
colossal “ Handbuch der Geburtshiilfe,” but more especially 
of Floss’s ethnological monograph “ Das Weib in der Natur- 
und Volkerkunde ” (eighth edition, by Dr. Bartels, 1905). 
Also of Engelmann's “Labour amongst Primitive Peoples,” 
and Mackay’s “History of Ancient Gynaecology.” There are 
various other papers scattered through the journals of the 
Anthropological Institute and elsewhere. An almost exhaus¬ 
tive bibliography will be found in Ploss, Yol. II. 

The subject has two aspects. One is concerned with 
various rites, superstitions, and customs which have little 
or no direct bearing on the progress and welfare of the 
parturient woman, Buch as the various deities that have to be 
propitiated. These I pass by here. Secondly, there are 
various modes of practice (or malpractice) which bear 
directly on the obstetric management of the case and on 
the issue as regards mother and child. This attempt to give 
a concise, though by no means exhaustive, review of these 
will, I hope, interest those who may not have paid much 
attention to the subject. Perhaps this article may lead some 
readers of Tee Lancet who have the opportunity of first¬ 
hand study of the practices referred to to add to our know¬ 
ledge by recording personal observations, such as those 
which have already been given in this paper. 

The question has bees raised as to how far any obBtetric 
art is necessary amongst uncivilised people. Are there not 
many of the primitive races where the process of parturition 
is so easy that difficulties and fatalities are rare 1 The 
answer gathered from Engelmann and Ploss seems to be that 
so long as the woman lives in a perfectly natural state, 
leading an active outdoor life and taking her share in manual 
toil, labour is usually short and easy and the process remains 
purely physiological and is only a rather difficult physio¬ 
logical evacuation. So that we find amongst nomadic 




The Lancet,] PROFESSOR J. B. HELLIER : THE METHODS OF PRIMITIVE MIDWIFERY. [Feb. 8, 1908 . 421 


tribes that a childbirth may be only an incident in a day’s 
march, the voman after an honr or two resuming her walk 
carrying her newly bom child, or mounting her horse and 
galloping on after her company, and many native races know 
almost nothing at all of- a “ lying-in ” period. But on the 
other hand, as soon as the more natural conditions are inter¬ 
fered with difficulties and dangers arise. Even amongst the 
former class such conditions as the falling of the womb and 
of the vaginal walls have a notable frequency. Inter¬ 
marriage of different races, especially of lower with higher, 
produces dystocia, and women with half-breed children 
often die in labour. But the evidence available suffices to 
make it abundantly clear that amongst untaught nations 
there is a very serious amount of ignorance, maltreatment, 
and brutality which entail a vast amount of suffering and 
death which might be avoided by the introduction of Western 
methods. Let no one adopt the comfortable notion that it 
is superfluous to seek to diffuse scientific obstetric teaching 
in the world. One object of this paper is to prove the 
contrary. 

Let ns take an example. China is known to be a land well 
advanced in certain arts. How is it with midwifery 1 In the 
China Medical Minionary Journal for 1890 Dr. J. C. Thomson 
tells us that Chinese women natnrally suffer less and have 
easier deliveries than Western women, but owing to the 
violent massage and other manipulations to which they are 
subjected the severest ruptures and lacerations are seen, 
with all the inevitable consequences of sloughing, necrosis, 
sepsis, and death. The mortality in childbed is excessively 
high, and he says : “ In the practice of obstetrics in China 
we see century after century of the blindest empiricism, with 
no ray of medical science to shine into the habitations of 
cruelty.” 

As examples of the atmosphere of ignorance and supersti¬ 
tion in which such races dwell I may remind the reader 
that many races recognise no death from natural causes, 
ascribing all fatalities to witchcraft or “ the evil eye,” or to 
the malevolence of some supernatural being. We find such 
absurdities as the custom of putting the husband to bed 
when the child is born, whilst the wife waits upon him. 1 
Amongst one tribe of Finns the pregnant woman changes 
her shoes every month to throw off her tracks the devil who 
is waiting to devour the newly born child. The Chinese hold 
that pregnancy may last for three years if the child does not 
wish to leave the womb. The Indian women will whisper to 
the unborn child that a rattlesnake is near so as to induce the 
child to leave the womb. Chinese women will wear stockings 
which have been blessed by the lama, so as to expedite 
delivery, and will swallow pilules of paper on which magio 
words are written, while for cross-births a remedy is found in 
the ashes of the hnsband’s hair. Examples of such puerile 
and ludicrous practices could be multiplied indefinitely. 

III. 

We will now consider some of the actual methods 
employed in primitive midwifery with some allusion to 
traces of the same amongst more civilised peoples. The 
different postures occupied by women in labour have been 
studied by Engelmann and Floss and will be found described 
and illustrated in the works already referred to. The most 
common and natural position in ordinary cases seems to be a 
squatting posture, like that of delineation, bnt almost every 
conceivable position has been noted. 

Administration of internal remedies .—Of world-wide pre¬ 
valence is the use of medicines to strengthen the patient, to 
ease her sufferings, or to excite uterine action. Probably 
every kind of aromatic drug has been employed for this pur¬ 
pose. The Hippocratic school esteemed silphion which the 
Latin calls laserpitium and which was perhaps asafoetida. 
The Romans used pomegranate and fenugreek, and the Arab 
physicians use an enormous cumber of drugs, and amongst 
European nations honey, myrrh, henbane, adderswort, castor, 
savin, mint, rne, pepper, cinnamon, figs, various balsams and 
oils, and bo on, infused in water, wine, or beer. Amongst 
other nations than European we may select from many 
examples, turnip juice (Caribs), decoction of tobacco 
in cow or ewe milk (Hottentots), decoction of opium 
(Chinese), the powdered vertebrae of the electric eel 
(Venezuelans), slippery elm (North American Indians), and 
so ad infinitum. Nauseous and repulsive substances also 
may be employed such as cold water in which a woman has 
just washed her feet or even urine (a tribe in the Dutch East 

1 See Lubbock : Origin of Civilisation and Primitive History of Man, 
chap. 1. 


Indies), and sometimes irritant or poisonous substances. 
Emetics have been widely used. Engelmann depicts a mid¬ 
wife amongst the Kiowa Indians blowing an emetic into the 
month of a parturient woman. It is obvious that the strain¬ 
ing caused might act on the uterus mechanically. The 
Chinese often excite vomiting and uterine action by thrust¬ 
ing the woman’s own pigtail down her throat till she is sick. 
Sternutatories played a considerable part in ancient mid¬ 
wifery. They were condemned by Soranus but are advocated 
by Roesslin. Ergot does not seem to have been used until 
the sixteenth century. To deprive a woman of food or drink 
or both from the beginning to the end of labour is a not 
uncommon custom. This was the practice in Germany in 
the seventeenth century : while the woman was on the ‘ ‘ birth- 
chair ” absolutely nothing to take was allowed her. In some 
parts of India it is thought to be very dangerous for a woman 
In labour to drink water. 

Bxternal remedies .—The use of unguents to facilitate 
delivery is one of the oldest practices in obstetrics. Susruta, 
whose date is anything up to 1000 B.C., recommends anoint¬ 
ing of the external aDd internal genitals. Similar advice is 
given by Moschion, Aetius, Faulus Aegineta, and Avicenna, 
and the practice has continued to the present day, and it is 
only modern aseptic ideas that exclnde these miscellaneous 
lubricants. The abdomen also is rubbed with various 
medicaments. For example, I may mention the use of oil 
in Guatemala, of an infusion of an astringent plant in 
Mexico, of Kalapa milk in the Babber Islands, and of a 
mixture of fat and brandy in Galicia. The Greeks and 
Romans used medicated bougies or pessaries plaeed in the 
vagina or os uteri. 

Baths and affusions .—These are also employed. For 
example, hot water is applied to the abdomen in Peru. Some 
Australian tribes pour cold water over the abdomen. In 
Doreh, in New Guinea, the parturient is held by two other 
women while a third pours cold water over her till the child 
is born. 

Vapour haths and. fumigations have a very wide distribu¬ 
tion. Felkin gives a sketch from a tribe on the White Nile 
of a woman who is in labour and is squatting over a bole dug 
in the ground in which is a fire and over it a pot containing a 
decoction of herbs. The rising steam is said to make labour 
easier. Steam baths with medicated vapour are similarly 
used in Russia, in China, and in many other places. In 
Central California in difficult labour a plaster consisting of 
hot ashes and wet earth is placed on the abdomen. The 
Arabians used many such methods and in the oldest German 
works for midwives many substances are recommended for 
fumigation, such as galbauum, castor, cow's hair, sulphur, 
opopanax, and the dung of pigeons or hawks. In German 
South-West Africa in lingering labour the woman is placed 
in a bath or has applied to her body the abdominal viscera of 
a recently killed ox, while the still moist skin serves for a 
wrap. These are sufficient examples of very widespread 
practices. 

Mechanical assistance to rconien in labour by employment of 
external force .—The idea that labour may be assisted by 
pressing or squeezing the abdomen is obvious, and very 
primitive, and has given rise to almost universal practice. 
It has a basis of sound principle in it, and applied within due 
limits and according to right methods it has a well-recognised 
place in obstetric art, but nothing that we shall discuss in 
this paper shows more forcibly how a right idea may be 
exaggerated and abused till it gives rise to the most brutal 
and dangerous malpraxis. Gentle finger pressure and 
massage, rhythmic and well designed, may really be of service 
in exciting pains and even in rectifying cross-births; and 
massage has been very widely practised in various times and 
amongst various races. The Japanese may be especially 
mentioned for their skill in this respect. As varieties and 
examples of the more violent methods of applying external 
force I may mention : 1. Violently kneading the abdomen 

of the parturient or giving blows with fists, knees, or feet, or 
by butting with the head. 2. Forcible compression with 
the arms. For this purpose the helping woman may sit 
behind the patient and compress the womb with hands 
clasped around the abdomen. Sometimes the husband or a 
strong man may be employed for this purpose. The woman 
may kneel or stand meanwhile or may even be hanging to a 
bar or partially suspended to a tree-trunk or branch. 
3. The pressure may be made with a bandage surrounding 
the abdomen, the ends being pulled by one or more women or 
by a man. 4. Or pressure may be made by kneeling or 
standing on the patient’s abdomen while she lies on her 





422 The Lancet,] PROFESSOR J. B. HELLIER : THE METHODS OF PRIMITIVE MIDWIFERY. [Feb. 8, 1908. 


back, or made on her back while she lies on her face, while 
a pillow may be placed under the abdomen. Felkin 
depicts a woman on her knees leaning over a log whilst 
a bandage round the abdomen is twisted with a stick like 
a tourniquet, the pressure being applied intermittently. 

5. Pressure is sometimes applied by weights. Heavy weights 
are used by the Tartars in Astrakhan, great stones in 
Serang, and warm bricks with great pressure (Malays). In 
the Philippine Islands a beam or plank may be laid across 
the abdomen and assistants may sit or stand on this. A 
carved wooden idol of great weight is used in Siberia. 

6. The woman may stand and compress her body against a 
bamboo or may lean over a horizontal pole or cord. These 
violent methods often result in internal injuries, such as 
rupture of the uterus and bladder and other viscera. 

7. Shaking the woman in labour was much esteemed in 
ancient Greece as a method of expediting delivery. A cloth 
was passed around her and she was shaken violently at 
least ten times. Then they laid her in bed so that the head 
lay downwards and the feet upwards, and the assisting 
women, who held the legs of the patient placed on their 
shoulders, shook her repeatedly to and fro. Soranus was 
wise enough to condemn this. As examples of the same 
barbarous method amongst savage races take the following : 
raising and shaking the woman with a jerk, as in shaking flour 
ont of a sack (Mexico) ; rolling on the ground and then sus¬ 
pending by the feet and shaking (Southern India) ; and 
rolling violently in a blanket by four people and shaking in all 
directions. The woman may be slung to the branch of a tree 
by a cord running under the arms, whilst a woman hangs 
around her waist (Coyotero-Apachen Indians) ; or a man will 
take the woman on his back and rnn about shaking her (North- 
West Russia). 8. Another strange practice is to invert the 
woman with the idea of altering the position of the child into 
a more favourable one when delivery is delayed. This was 
done amongst the ancient Greeks. It has been observed in 
Algeria. Also amongst some Indian tribes this !b done 
repeatedly, and if it prove of no avail the midwife inserts 
her hand and pulls at anything she can reach. Fatal results 
follow this treatment. An instance of extreme barbarity is 
reported by Stern and quoted by Ploss as occurring in Persia. 
In extreme cases the woman is held head downwards with the 
legs fully abducted, and the kabli, with rusty scissors or 
kitchen knife, cuts the perineum mercilessly. If the woman 
bleeds severely it matters but little, although the midwife 
would be blamed if the child’s arm or leg were severed. 

The serious nature of a transverse presentation is widely 
recognised. It is obvious that where no obstetric science is 
known a cross-birth will almoBt always be fatal. Various 
nations have made attempts to rectify the position of the 
fates during pregnancy and here and there some have 
learned bow to do it by external manipulation. The preva¬ 
lence of massage may depend partly on this idea. Metzger, 
quoted by Ploss, is of opinion that the women in Damara- 
land, South Africa, have a successful method of performing 
cephalic version by external manipulation. The art is 
banded down from mother to daughter. Liibbert says that 
the natives of German South-west Africa are well acquainted 
with cross-births and seek to rectify them by external 
manipulations, but if these fail they will put the parturient 
woman on a cart and drive her over a rough road to shake 
the foetus into better position. Other crude attempts to 
rectify the malposition are recorded in various tribes. 

That internal manipulations for the rectification of cross¬ 
births and other malpositions have been practised in the past 
to some extent is certain. The ancient Hindu understood 
how to turn for cross-presentation and how to deliver breech 
presentations by pulling down the legs. Probably the 
Talmudists refer to the same thing. The writings of Soranns 
give plain directions with figures for dealing with various 
presentations by cephalic and podalic version and the 
Japanese in this direction also show skill and know¬ 
ledge. There does not seem to be much evidence of the 
practice of internal manipulations amorgst savage peoples 
of to-day. Engelmann emphasises the rarity of such a method 
of manipulating within the vagina. As exceptions we may 
notice that the Calmucks have for a long time been able to 
perform version in difficult labour. The modern Greeks are 
said by Ploss to seek the help of shepherds In difficult cases, 
for these have experience in the delivery of sheep. Emin 
Pasha found in Unyoro in Africa men who were able in arm 
presentation to replace the arm and to turn the child in the 
womb. Version is said also to be performed in Massana in 
East Africa and also by midwives in Algeria. 


To pull violently on any presenting part is, on the other 
hand, the most obvious way of attempting delivery by those 
who do not understand anything about the anatomy of the 
parts. It is a sign of advanced knowledge to know when to 
refrain from doing it. Arms are often pulled off this way. 
I have been privately informed of a confinement in Africa 
where the head presented but would not advance, when a 
cord was tied round the neck of the child and then carried 
through a wall to be pulled by men outside the delivery 
chamber. The head, as might be expected, parted company 
with the trunk. 

Embryotomy .—The idea that a child may be delivered in a 
difficult case by cutting it into pieces as far as it can be 
reached might occur to the savage mind and from this might 
come the discovery of the fact that perforating the head 
often is followed by speedy delivery after previous long 
delay. Susruta describes embryotomy and so do the ancient 
Greeks, who also employed hooks to assist in extracting the 
foetus. Soranus describes the operation of embryotomy and 
speaks of its use in hydrocephalus, and from this time 
onwards it is well recognised. Amongst other nations we find 
mention of embryotomy performed with a knife by the 
medicine men of the Sungari (Manchuria). Schoolcraft 
describes a case amongst the Dacota Indians of an impacted 
arm presentation. The arm was cut off and the child 
extracted piecemeal by thoroughly ignorant women. Similar 
crude embryotomy is described by Baumstark as being per¬ 
formed amongst the Warangi in the Massai steppe in East 
Africa, and the necessity of delivery by destruction of 
the child is recognised amongst the natives of German 
South-west Africa. It is also performed in the same rough 
and dangerous fashion in extreme cases by women in 
Sumatra. 

Casarean section. —Post-mortem Csesarean section is of 
very ancient date and was even enjoined in the law of Numa 
Pompilius, and the Talmudist Rabbis discussed the legiti¬ 
macy of the performance of post-mortem Csesarean section 
on the Sabbath day. Niebuhr in the eighteenth century 
observed the practice amongst the Hindus; the child was 
buried if dead and the mother burned. In Malabar also, 
according to Speerschneider, the child was excised and' 
buried separately. Emin Pasha relates that in Unyoro if 
the mother died in labour the child had to be removed with 
the knife, whether dead or alive. To neglect this was of 
evil presage for all concerned. From Bosnia comes an 
account of a horrible superstition which led thieves and 
burglars to kill a woman in the seventh month of pregnancy, 
extract the child, and cut it in pieces to make a charm 
which made the inmates of a house sleep like the dead 
while a burglary was being accomplished. A similar 
superstition is made the basis of one of the iDgoldBby 
Legends (“The Hand of Glory”). It is said by Ploss that 
even in 1889 this frightful superstition was in force. The 
removal of a living child from the living mother is said to 
have been first performed in 1500 by Nueffer. In a lecture 
published in The Lancet of Jan. 9th, 1904, p. 76, I have 
given an account of this case. There are references to the 
operation in the Talmud and in the Norse Sagas and other 
legendary histories. But that which is of special interest 
in this place is the evidence that amongst savage nations 
in recent years Carsarean section has been known to be suc¬ 
cessfully performed. The best example of this will be found 
in a paper by R. W. Felkin in the Edinbvrgh Medical 
Journal for April, 1884, a very accessible reference which 
everyone who may be interested in this subject should read. 
Felkin saw one case in which it was proposed to perform 
the operation, but obtaining permission to examine the 
patient he found it to be a simple case of uterine inertia, and 
he delivered with forceps. In a second case he was not 
allowed to examine and did actually see the operation 
performed by a man in Uganda, both mother and child sur¬ 
viving. The uterus was not sutured, the abdominal wound 
was closed with pins that are compared to acupressure- 
needles, and with string made from bark which held the pins 
together. The woman made a rapid recovery. Schoolcraft 
speaks of a case amongst the Cbippeway Indians in which 
a man successfully delivered his wife of a living child by 
Cmsarean section, but he did not witness the operation. And 
a slave woman in the West Indies is said to have delivered 
herself by abdominal section. 

Support of perineum in labour .—In a certain number of 
instances it has been observed that native women give support 
to the perineum in labour. The practice is rare, but there 
are some well-established examples, as in certain tribes in 


s i: 


I s 
. C 
iSC3 
tSK 
:2S l 

£S1 


i & 
Vi 


1 1: 



of* 

issa 

1*32 
j ms 


*6e 





35 





x i 


*2 5 

*3?l 

ti 

C 4- 


• £ a 


I 



' 

'SSo 




-■C'j 


45 , 


The Lancet,] PROFESSOR J. B. HELLIER: THE METHODS OF PRIMITIVE MIDWIFERY. [Feb. 8, 1908. 423 


Palestine, Russia, and India, and also in Japan and Persia. 
In the East Indies rags are sometimes stuffed into the anus 
and in Southern India a bag of ashes has been used to support 
the perineum. In our survey of primitive midwifery it is 
possible to find many grains of common sense amongst an 
overwhelming quantity of rubbish. 

IV. 

Treatment of the umbilical cord .—The widest differences 
are observed, in this respect. The severance may be made by 
the father or by an assisting woman, or by the mother 
herself. It may be bitten through with the teeth, the 
mother even doing this for her own infant. It may be cut 
with sharp shells or sharp stones or pieces of wood, or with a 
kind of knife or saw fashioned from bamboo, fee. Some¬ 
times the cord is ligatured with vegetable fibre or string, or 
may be tied in a knot. Many tribes never ligature. The 
cord is then often divided with a blunt instrument and being 
tom and crushed natural bremostasis may be thus secured. 
Often some rough kind of styptic is applied to the foetal end, 
such as ashes or charcoal or chalk. Sometimes it is 
cauterised with a glowing piece of wood or iron. In some 
parts of China the end of the cord is wrapped in oiled paper 
and then ignited. Fatal hajmorrhage is common when these 
primitive methods are in vogue. The cord may be cut close 
to the body, or, on the other hand, be left very long, some¬ 
times even looped around the neck of the child. Umbilical 
hernia is a common result of such modes of treatment. The 
cord may be divided as soon as the child is born, or not till 
the placenta is delivered, and the placenta may undergo 
various anointings and washings first. Sometimes the child’s 
body is twisted round directly after birth, so as to produce 
torsion of the cord. 

Delivery of the placenta .—In very many cases where labour 
is easy the woman is delivered without assistance and 
remains squatting on the ground and straining till the 
placenta comes, as with patience it usually will. Sometimes, 
although the placenta is retained, no further efforts are made 
to extract it and this, of course, may lead to septic 
symptoms. To assist the delivery of a retained placenta all 
kinds of drinks are in use, also emetics, disgusting nauseants, 
and sternutatories. Sometimes the finger is thrust into the 
patient’s mouth till she vomits or a lock of her hair is used 
for the same purpose ; in China I am told by my friend 
Dr. C. Wenyon that the woman's own pigtail is thus 
employed. Barbarous methods are also common. The woman 
maybe made to stand up and jump or be jolted by others. 
Amongst the Khirgis we read of her taking a wild ride on 
horseback over hill and dale to dislodge the retained 
placenta, often returning more dead than alive. The steam 
or vapour bath is used for this purpose also. To pull on the 
cord when the placenta is not delivered as soon as is deemed 
proper is a universal error. Fatal hfemorrhage, inversion, and 
prolapse follow this practice. Some tribes tie a stone to the 
cord and let the woman walk about. Others tie the cord to 
the thigh to prevent the imaginary danger of the placenta 
being drawn up into the abdomen. There are some tribes 
amongst the North American Indians who have learned that 
only gentle traction is permissible ; it is obvious that when 
the placenta is lying in the vagina traction on the cord will 
appear to be a brilliantly successful method. Abdominal 
manipulations for the same end are common all the 
world over. They vary from gentle massage with perhaps 
inunction of oil to firm or severe hand compression 
of the uterus, violent kneading of the abdomen with 
fists, or pressure with hot stones placed on the abdomen. 
Worse still, a woman may stand on the patient's abdomen 
kneading violently with her feet; or, while the patient 
stands erect she may be clasped forcibly aronnd the body. 
The abdomen may be compressed by a cloth passed around it 
and dragged or twisted with a stick after the manner of a 
tourniquet. Also water may be poured from a height on to 
the abdomen. That very serious injuries often result from 
the more violent measures it is unnecessary to say. Internal 
manipulations for placental extraction are not very common, 
but examples are recorded in various parts. Some of the 
North American Indian women have been known to intro¬ 
duce the hand, and so in India and some of the Pacific 
Islands. In German South-West Africa Liibbert has seen 
this done with very great care and very reasonable pre¬ 
cautions. Here, also, the Japanese are distinguished by 
careful treatment of the third stage of labour. 

Treatment of post-partum hivmorrhage .—All sorts of drugs 
and decoctions are in use. Kneading of the abdomen is a 


more rational remedy and doubtless is often effective. It is 
often doue with great violence and we read of a woman 
being made to stand against a wall while another woman 
strikes the abdomen with her head or her knee (Indian 
tribe). Binding the abdomen is a common expedient. 
Various charms are in vogue and one cure is to make the 
woman swallow a spoonful of her own blood. In Annum post¬ 
partum haemorrhage has been treated by laying the patient 
on her back while another woman treadB on the abdomen, 
thus giving violent massage with her feet. Or she may be 
violently dragged by the hair. Cold affusion is sometimes 
used, or heat may be applied to the genitals till the pubic 
hair is singed. As the result of such treatment, of which the 
above are but a few examples, falling of the womb is very 
common. 

The puerperal period .—With the idea that something must 
be done -after delivery to restore the womb to its place we 
find amongst certain tribes such measures as massage and 
compression, various vaginal injections, the application of 
hot stones to the abdomen, or even violent tamponade of the 
vagina (tribe in Palestine). Especially noteworthy is the 
very widespread practice of applying heat, smoke, or steam 
to the woman in the puerperal period. This may be done by 
digging a hole in the ground, putting in hot stones, and 
pouring vinegar over them while the patient sits above. 
Or she may be exposed near a fire or may stand or lie above 
it. This is often carried out so severely that the mother is 
badly scorched or fatally burned. She may be kept in a 
small hut and the heating process continued for many days, 
and even a whole month. Flagrant examples of this are seen 
in Cochin China and amongst the Siamese, in New Guinea, 
in some Indian tribes, and in many other places. The child 
may share the treatment. Milder forms of vapour baths 
and fumigations have been common in various parts of 
Europe. 

Most various are the customs in regard to bathing and 
ablution after childbirth. Religious belief governs this 
to some extent. Near Cape Horn a woman was seen to 
take four sea baths on the day on which she was confined. 
In another tribe we read of a woman being confined on the 
bank of a river and taking a plunge in the water imme¬ 
diately after. Others are washed two or three times daily, 
whilst on the other hand we find that all washing may be 
postponed for 14 days or more. Various medicated solu¬ 
tions may be used for the ablutions of the puerperal period. 
In Turkestan the woman after delivery has been known to be 
treated by wrapping the loins and abdomen in the skin of a 
black sheep just flayed alive, while the skin of a hare 
recently killed enwrapped her feet. To feed the woman 
after delivery on fluid or exclusively vegetarian diet or on 
some form of broth is Very common. The most brutal prac¬ 
tice we read of in this connexion is the refusing of drinks to 
the woman after delivery. In Malacca they may not drink 
cold water for 14 days. Among the Hindus, for instance, 
the custom is found of allowing the woman to hunger and 
thirst for five days, giving only some dry rice, and this in 
spite of the heat. This withholding of water even 
accompanies the barbarous treatment by scorching fire 
of which I have spoken. Sometimes women are made to 
drink urine. The idea that water is harmful and must 
be given in very small quantity is a barbarous notion, 
of which we have scarcely shaken ourselves free in 
the treatment of fever and post-operative thirst. Child¬ 
birth usually takes place in more or leBS seclusion, and 
it is a practice somewhat widely diffused to erect a 
special hut either near the house or at a considerable 
distance, say in the shelter of a wood, where the woman may 
pass the days of her lying-in, her husband being more or 
less attentive to her requirements or more or less completely 
neglectful of her according to local custom. On the other 
hand, the confinement may take place corampopulo, with a 
crowd of interested spectators, who may contribute invoca¬ 
tions or encouraging cries (Loyalty Islands). 3 Space 
forbids extending this article further, but fuller details will 
be found by the student in the authorities indicated. In 
India the education and provision of native midwives are 
promoted by such excellent institutions as those founded by 
Lady Dufferin and others. Many mission hospitals are 
doing similar work in various parts of the world. I know 
that it has been found in some parts of Ohina that native 
Chinese women when properly trained are very apt to learn 
and make excellent midwives who can even use forceps with 


2 See Journal of the Anthropological Institute, vol. six., p. 503. 



424 The Lancet,] MR. REGINALD HARRISON : OBSERVATIONS ON PHOSPHATURIA, ETC. [Feb. 8. 1908. 


skill. For those English and American ladies who having 
qualified themselves by a full curriculum at home have 
devoted their lives to helping their suffering sisters in regions 
remote from civilisation by skilful practice of scientific 
obstetric art we feel a degree of respect and admiration 
which is beyond expression. 

Leeds._ 


OBSERVATIONS ON PHOSPHATURIA AND 
THE TREATMENT OF DISEASE BY 
CONVERSION. 

By REGINALD HARRISON, F.R.C.S. Eng., 

PAST VICK-PRESIDENT AND HUNTERIAN PROFESSOR, ROYAL COLLEGE OP 
SURGEONS OF ENGLAND. 


An interesting article on the conversion of diseases in a 
worn by Dr. John Ferriar, physician to the Manchester Royal 
Infirmary, entitled “ Medical Histories and Reflections,” 
published in 1795, opens with the following passage : “ A 
disease is said to be converted when new symptoms arise in 
its progress which require a different designation and which 
either put a period to the original disorder or combining with 
it alter the physician's views respecting the prognostics or 
the method of cure.” In the course of this article, which is 
Dow as suggestive as it was when written over 100 years ago, 
numerous illustrations from practice in support of his views 
will be found. I am mainly interested in one of Dr. Ferriar’s 
references which provides an additional reason for ventilating 
the application of conversion in the instance I am taking. 
The reference is as follows : “ It must be added that general 
fever sometimes cures looal inflammation; Mr. Hunter says 
he has seen a gonorrhoea extinguished by the accession of a 
fever.” Such an experience must not be unknown to many 
others. 

It has not infrequently been observed in the treatment of 
chronic urethritis and muco-purnlent discharges following 
it, irrespectively of the internal administration of alkalies and 
often imperceptibly to the patient himself, that the urine 
became altered in character and assimilated with that known 
as phosphaturia. And, further, that when this change was 
observed the oessation of the discharge or gleet, as it is com¬ 
monly called, for which the patient had originally come 
under treatment, usually soon followed, either spontaneously 
or by treatment appropriate to the phosphaturic state with¬ 
out apparent reference to the cause which preceded it. This 
casual observation raised the question whether it was 
possible that there was any relationship between this 
incident and what followed, whether, in fact, the phos¬ 
phaturic state of the excretion was inimical to the existence 
of the infecting bacillus. The observation was made so 
frequently as to suggest this and led to the systematic 
examination of the urine and other discharges for gonococci 
in all persons coming under treatment for gleet more care¬ 
fully and frequently than previously. From them the follow¬ 
ing conclusions appeared to be grounded. 

1. That in a considerable number of instances thus desig¬ 
nated and of undoubted specific origin there was no evidence 
at the time of my examination that there was anything 
wrong with the urine or with any urethral discharge com¬ 
plained of inconsistent with the phosphaturic state alone. 
This condition was either apparent to the eye on allowing 
the urine to stand for a short time in a glass vessel or was 
evidenced by boiling the excretion when any cloudiness 
whiob followed was immediately removed by the addition of 
nitric acid. Here any pus corpuscles which the microscope 
detected were physically explainable by the crystalline pre¬ 
cipitates the urine contained and which were often present 
in sufficient quantities to give this excretion a semi-purulent 
or opaque appearance. How or when this phosphaturic 
transformation took place in the history of an ordinary case 
of chronic infecting urethritis was not always easy to 
determine. In many instances which were carefully tested 
and microscopically examined this change appeared to 
mark the concluding stage of gonococcal life and was also 
often coincident or nearly so with the adoption of such treat¬ 
ment as the phosphaturic state usually requires. Further, 
these examinations showed how easily and frequently 
phosphaturia may counterfeit and be treated for a specific 
urethritis and even be intensified by the remedies commonly 
used for the latter. 

2. The second inference was that the artificial produc¬ 
tion and temporary continuance of a state of phosphaturia 


might be utilised in the treatment of specific gleety affec¬ 
tions following upon gonococcal infections. To produce a 
urine having the prominent features of phosphaturia by 
the administration of alkalies—bicarbonate of potassium was 
generally selected for this purpose—is not a matter of much 
difficulty or of any detriment to the patient. The effect on 
the urine should be sufficient to render it responsive to the 
usual tests, microscopical and otherwise, by which phos¬ 
phaturia is recognised, and not merely to produce an alkaline 
reaction to test paper. Further, it is necessary to maintain 
this condition for some little time, during which period all 
looal applications should be suspended. It will usually be 
found after a period of ten days or so and as the phosphaturic 
condition gradually passes off under the influence of altered 
treatment and diet appropriate to this state that no signs will 
be found such as were previously complained of. In some in¬ 
stances the artificially induced phosphaturia was slow in pass¬ 
ing off, whilst in others its presence appeared to have been too 
limited to effect the desired object and required repetition. 
On the whole, however, the results have proved satisfac¬ 
tory. There was a time when infecting urethritis—at all 
events in its earlier stages—was very generally treated by the 
administration of alkalies, though the reason for this was not 
such as I am offering. I am not at all sure in the matter of 
rapidity of cure that we have much improved upon this older 
practice by the more mechanical processes which are now 
often substituted. 

If these observations are found in their wider application 
such as I have construed them a more convenient and leBs 
unpleasant method of treatment may be arrived at. They 
have extended over some years, and though they may not 
embrace the whole truth they may be read in the light of a 
contribution towards it. 

Lower Berkeley-street, W. 


HjEMO-PERICARDIUM associated with 
SYPHILIS. 

By J. LOUGHEED BASKIN, L.R.O.P., L.R C.S. Edin., 

MEDICAL SUPERINTENDENT, FISHERTON ASVLtTM ; I.ATK DEPUTY 
MEDICAL SUPERINTENDENT, DEVON COUNTY ASYLUM. 


The following case came under my notice some time ago 
and presents some interesting features. The patient was a 
married man, aged 65 years, of German nationality. When 
first examined by me he was fairly well nourished and well 
developed. His expression was gloomy and unintelligent; 
he was partly demented ; he retained a delusion that he had 
been given 129 pints of medicine in one dose at a hospital. 
No other symptom of megalomania had been forthcoming and 
his general condition alternated chiefly between emotioDal 
restlessness and apathy. The skin of his entire body was 
very dry and slightly jaundiced. On the skin over the 
sternum and the interscapular region were several scars of 
either circular or crescentic shape, each of the Bize of a large 
pea. There was a painless swelling on the anterior border of 
the right tibia of the size of a florin and below this 
and immediately above the ankle were several small 
cicatrices irregular in shape; on the left leg were 
several ulcers with “punched-out edges” below the 
tuberosity of the tibia, and several similar ulcers on 
each forearm and extending on to the dorsum of the 
hand, and vaccination marks on the left upper arm. He 
walked slowly and with Borne stiffness of the hip-joints ; the 
patellar reflexes were diminished and delayed ; his grasp was 
feeble. Babinski’s sign was absent and ankle clonus was not 
elicited. His right pupil was larger than the left; both 
reacted sluggishly to light and for the process of accom¬ 
modation; the consensual reflex was present. The hearing 
was bad on each Bide; his tongue protruded in the middle 
line and was fleshy and grossly tremulous and furred 
posteriorly. He had only four teeth in his mouth (in 
the upper alveolus) and those were carious. His palate 
was unduly arched anteriorly. The cardiac somids were 
irregular in rhythm ; a slight bruit was audible at the 
first sound; his pulse was 70 aDd the radial and tem¬ 
poral arteries were tortuous and thickened. The respiratory 
system was healthy. His appetite was good ; his intestinal 
movements were performed regularly. The liver was 
tender bnt no enlargement or alteration in shape or sur¬ 
face was discoverable. There wa9 a brown discoloura¬ 
tion on the glans penis one-eighth of an inch in 




Tfflt lancet,] DR. VINING : A CASE OF ACUTE ASCENDING PARALYSIS WITH RECOVERY. [Feb. 8, 1908. 425 

2 


diamettr ; the inguinal glands were hard but easily move¬ 
able on each side. There was no urethral stricture. 
He was treated with antisyphilitic and cardiac remedies, 
chiefly sodinm iodide and tincture of strophanthus, and con¬ 
siderable improvement occurred. The ulcers, which were 
dressed aseptically, healed rapidly, the swelling in the leg 
diminished, and the hepatic tenderness disappeared. The 
right inguinal glands still remained hard but his tongue 
showed more tremor on protrusion a few weeks after the ulcers 
bad healed. On going into the water-closet one evening he 
became giddy and fainted, and though he rallied for a little 
time he died half an hour afterwards. 

I am indebted to Dr. W. Lind Walker for his assistance in 
the post-mortem examination which revealed the following 
conditions. The basal arteries of the brain were 
markedly atheromatous, thickening of the arterial wall 
being noticeable in the anterior cerebral; no sign of 
cerebral or other hemorrhage was present. The cerebral 
substance was so soft as to break down on touching 
slightly with the fiDger and was consequently not 
examined microscopically. The brain weighed 49 ounces. 
The right lung presented a calcified mass at the apex of 
about the size of a pigeon's egg. The heart weighed 
11 ounces. The pericardium was distended with post-mortem 
clot. The coronary arteries were calcareous in character ; the 
left one was ruptured li inches from the aorta ; at the seat 
of rupture was a small node of pale yellowish coloured 
material which extended about 11 inches into the myo¬ 
cardial substance, which was hypertrophied and around 
it the tissue was of fibrous consistency and tough under 
the knife. On the pericardial aspect the necrotic changes 
appeared to have involved the artery which lay on the 
gumma ; the arterial wall where ruptured presented a star¬ 
shaped tinsure. The aortic valve was thickened at the base 
of each cusp; the column® carneas showed signs of fatty 
degeneration. The liver was congested. Nothing worth 
recording was found in the examination of the other organs. 

Remarki .—Signs of marked distension of the pericardial 
sac were found on the occasion of the patient's collapse, 
and gentle percussion revealed dulness extending up into the 
second left intercostal space; the cardiac sounds were 
muffled and the respirations were stertorous in character; 
the pulse was imperceptible at the wrist. When found in 
the heart gummata are usually multiple and often of 
cartilaginous-like consistency ; only the one described was 
found in this case. Virchow has described a case in which 
at the same time was found syphilitic disease of the testis ; 
in the above case the testicles were not involved, though 
there were pigmentation on the glans penis and a caseating 
code in the tibia and inguinal glands. Aitken recorded 
in his “ Science and Practice of Medicine " (seventh edition) 
how there used to be in the Army Medical Department at 
Netley two preparations showing gummata of the heart— 
one from a soldier, 24 years of age, who had been under treat¬ 
ment for nine months for venereal nlcers ; in the above case 
some of the ulcers had healed only three weeks before the 
patient’s death. Gummata are usually found in the septum 
between the ventricles. 

Salisbury. 


A CASE OF ACUTE ASCENDING PARALYSIS 
WITH RECOVERY. 

BY D. WILFRED VINING, M.B., B.S. Lond., 

BOUSE PHYSICLAX, SX. MARYS HOSPITAL, PADDIXOTO.Y, W. 


Tub patient in the following case was a well-nourished 
muscular mac, aged 24 years, who was admitted into 
St. Mary’s Hospital on Dec. 2nd, 1907, under the care of Dr. 
Sidney P. Phillips. He felt quite well up to Nov. 28th when 
he experienced a feeling of weakness in the calves of hie 
legs. He started out to work the next day, but while on the 
way he had to return home owing to the increasing weak¬ 
ness On the 30th he noticed blurring of vision on reading 
the newspaper. On Dec 1st the weakness of his legs was 
still more pronounced and he could not articulate distinctly. 
On the following day he could not stand without assistance 
and his arms were also weak. He had fallen off a ladder on 
to his feet a week previously to the onset of the symptoms 
but experienced no inconvenience at the time. 

On admission he was unable to walk but could just stand 
with assistance. There was also considerable weakness in 
the muscles of his arms, especially in the extensors. The 
muscles were flaccid but not wasted and there was an 


absence of all reflexes, including the palatal reflex. The 
respiratory, abdominal, and intercostal movements were 
normal. There was slight right-sided facial weakness. The 
external muscles of the eye were normal. The right pupil 
reacted sluggishly to light and to accommodation and was 
somewhat larger than the left. The fundi were normal. 
Speech was a little indistinct, apparently due to difficulty in 
the movements of the tongue, and there was slight difficulty 
in swallowing. There was no alteration in the sensory 
functions except that he appeared to have lost sensa¬ 
tion of the palate. His mouth was dirty with sordes 
on the lips. Cultures were obtained from the mouth 
and throat, but nothing resembling a diphtheritic organism 
was found. A lumbar puncture was performed soon after 
admission and 15 cubic centimetres of clear fluid with a 
few whitish floating particles were obtained. In this an 
organism having the appearance of a streptococcus was 
found but no growth could be obtained on culture media. 
The patient was given five minims of liqnor strychnin® hydro- 
chloratis every four hoars and at a later period hot-air baths 
were administered. The muscular weakness quickly increased 
and on Dec. 7th there was evidence that the diaphragm was 
commencing to be paralysed and chest expansion was reduced 
to a minimum. Rhonchi appeared in both longs with marked 
cyanosis and difficulty in swallowing. There was now com¬ 
plete paralysis of the legs, he could barely move his arms, 
and there was incontinence of nrine and foeces. The outlook 
now seemed hopeless. The pulse-rate increased, reaching 
100, and the cardiac apex passed from a point half an inch 
internal to the nipple to a quarter of an inch external to it. 
The strychnine had been stopped on Dec. 4th bat it resulted 
ia the condition becoming so much worse that on the 8th it 
was resumed in doses of seven minims, quickly increased to 
10 minims, every four hours, and oxygen was also adminis¬ 
tered. On the 8th there were signs of improvement, the 
chest movements increasing and the difficulty in swallowing 
lessening. From the 8th to the 15th his condition remained 
stationary, except that some muscnlar wasting became 
evident. There were now also some slight, rather indefinite 
alterations in sensation over his legs, especially the right one, 
and he complained at times of severe pain in his knees. Sensa¬ 
tion for heat and cold was normal. These only lasted a few 
days and were apparently the only sensory disturbances 
present daring the course of the illaess, except the anaes¬ 
thesia of the palate mentioned above. On the 15th the 
diaphragm descended during quiet respiration, and from 
this time onwards he steadily improved. There was never 
any pyrexia. On Jan. 24th he could walk without assistance, 
had perfect control over the sphincters, and felt very well. 
There was no residual paralysis, bat mnscular wasting of the 
limbs was still marked and knee-jerks were still absent. 
The electrical reactions taken during the course of the 
illness showed no reaction of degeneration, but there were 
reduced response to faradism and no response to galvanism. 
Later there was reaction to both, but less than in a normal 
person. Daring bis recovery galvanism and later faradism 
were applied daily. 

The interest of this case consisted in the recovery from 
what appeared to be a severe example of Landry’s paralysis 
and which when the diaphragm showed signs of paralysis 
threatened to be speedily fatal. The diagnosis lay between 
(1) diphtheritic paralysis, (2) Landry’s paralysis, and (3) a 
toxic paralysis affecting the anterior cornua or nerves. 
There was, however, no evidence or history either of diph¬ 
theria or of any exposure to such toxic influences as syphilis, 
gonorrhoea, lead, or alcohol, and on the whole the case 
seemed to correspond better with Landry’s acnte ascending 
paralysis than with any other disease. Against this diagnosis 
there may be urged (1) the anaesthesia of the palate and the 
slight sensory disturbance of the legs, and (2) the fact that the 
parts affected were not altogether anatomically in succession 
from below upwards, but in Landry's own description of the 
condition diminution in cutaneous sensibility over the distal 
parts of the limbs is mentioned and the arms and face were 
affected before the legs were completely paralysed. Io the 
present case strychnine appeared to have a very beneficial 
effect. I am indebted to Dr. Phillips for permission to 
publish these notes. 


Royal Institution.— At a general monthly 
meeting of the members of the Royal Institution held on 
Monday afternoon last it was announced that the managers 
had appointed Dr. Kenneth Robert Hay as medical officer to 
the Royal Institution in succession to the late Mr. Woodhouse 
Braine who had held the appointment for 36 years. 




426 Thb Lancet,] DR. H. WILLIAMSON: ENUCLEATION OF A UTERINE FIBRO-MYOMA, ETC. [Feb. 8, 1908. 


A CASE OF ENUCLEATION, DURING THE 
SEVENTH MONTH OF PREGNANCY, 

OF A UTERINE FIBRO-MYOMA 
WEIGHING 17| POUNDS ; 
PREMATURE LABOUR 
TWO DAYS LATER. 1 

By HERBERT WILLIAMSON, M.A., M.B. CANTAB., 
M.R.O.P. Lond., 

ASSISTANT PHYSICIAN ACCOUCHEUR TO ST. BARTHOLOMEW'S HOSPITAL; 
PHYSICIAN TO OUT-PATIENTS, QUEER CHARLOTTE’S LYING-IN' 
HOSPITAL. 


On Dec. 15tb, 1906, I was asked by Dr. T. H. Fowler of 
Epping to see a woman in whom pregnancy was complicated 
by the presence of an abdominal tumour. The patient was 
32 years of age and had been married for 15 months. Men- 
strnation commenced at 14 years of age. The periods had 
always been regular every 28 days, had lasted six days, and 
the amount lost had never been excessive. The date of the 
last period was June 15th to 21st, 1906. Shortly after this 
the patieDt became pregnant and from that time no vaginal 
hmmorrhage occurred. Previous to conception she was in 
her usual health, had not noticed any enlargement of the 
abdomen, and had not found it necessary to loosen her 
clothes. Towards the end of September, 1906, in the fourth 
month of her pregnancy, whilst engaged in her household 
duties, she was seized with acute abdominal pain. The pain 
did not cause vomiting but was so severe that she was 
unable to stand upright. She went to bed and remained 
there for two days, the pain gradually subsiding. A few 
days later in the early part of October the pain was 
so much less that she undertook a short railway journey 
and whilst in the train was seized with another attack 
similar to the last, though more severe. She was unable to 
sit or lie down bnt had to finish the journey standing up 
clinging to the carriage door. On reaching her destination 
she was put to bed and remained there for six days but 
gradually recovered and at the end of another week was able 
to return home. To use her own words, “the journey home 
seemed to bring back the pain.” For a fortnight she was 
confined to her bed and from that time until I saw her some 
five weeks later was unable to leave her room. There was 
rapid loss of flesh and the abdomen became distended to such 
a degree that it was impossible for her to lie down. Fcetal 
movements were felt in November and from that time 
onwards. On Dec. 15th I made the following note: “The 
patient looks ill and is anmmic ; she is very thin, almost 
emaciated. The tongue is furred. Temperature 99-5°. Pulse 
100, of poor volume. When lying down there is grave 
difiiculty in respiration. The breasts are active and contain 
secretion. The abdomen is enormously distended, the skin 
over it tense and shining, a number of large dilated veins are 
seen on the surface. On palpation the abdomen is tender 
all over. Two tumours can be detected. The larger 
lies to the right; it is hard, feels solid, and nodular 
on the surface; it extends upwards for a considerable 
distance beneath the costal margin and has displaced the 
diaphragm causing respiratory embarrassment. It reaches 
well beyond the middle line and descends into the pelvis. 
The second tumour lies to the left and below ; its limits 
cannot be accurately determined, for it is overlapped by the 
one just described ; it lies over the left iliac fossa and bulges 
the abdominal wall outwards in the left flank. Its consist¬ 
ence is soft and elastic, like that of the pregnant uterus ; 
foetal parts cannot be distinguished nor can the fcetal heart 
be heard. The uterine souffle is clearly audible. Per 
vaginam the cervix is soft and lies high up to the left; the 
fiDger can be introduced through the os internum, the bag of 
membranes can be felt, and in this a child's foot which moved 
on touch. Bimanually, the tumour to the right rests upon 
the pelvic brim, whilst the lower pole projects into and 
occupies the right half of the pelvic cavity. The tumour to 
the left is identified as the pregnant uterus. ” 

As to the nature of the mass to the right I was in grave 
doubt but thought it was probably a rapidly growing 
malignant tumour of the ovary. The reasons which led me 
to form this opinion were briefly these : (1) the rapidity of 
growth was in favour of a tumour of the ovary rather than of 


the uterns, yet the tumonr felt too hard and inelastic for an 
ovarian cyst; (2) I could not satisfy myself that the tumour 
was definitely connected with the uterus; and (3) the 
cachectic appearance of the patient, the rapid loss of fie6h, 
and the evidences of a toxmmia were in favour of a malignant 
growth. In spite of this view I urged strongly that an 
exploratory operation should be undertaken because it was 
clear that the patient would soon die from respiratory 
trouble if nothing were done and also that delivery of the 
child per vias naturalct was an impossibility. The patient 
and her friends consented to my proposals and she was 
brought up to town on an ambnlance. 

On Deo. 19th I opened the abdomen by an incision in the 
middle line. The incision was subsequently enlarged so that 
it extended from two inches above the pubes nearly to the 
ensiform cartilage. When the abdomen was opened two- 
tumours presented ; the pregnant uterns deep red in colour 
lying below and to the left and a large nodular growth 
lying to the right extending upwards beneath the costal 
margin and downwards into the brim of the pelvis. The 
tumour was adherent to the parietal peritoneum, to the bowel 
and omentum, but the adhesions were easily separated. 

I found that the growth was a fibro-myoma attached to the 
right side of the anterior aspect of the uterus by a pedicle 
rather thicker than a man s wrist. After separating the 
adherent viscera it was brought out of the abdomen without 
difficulty and enucleated from the uterine wall. I do not 
think I opened the uterine cavity during this procedure but 
the mucosa was exposed. Free haemorrhage occurred from 
the cavity left in the wall of the uterus after enucleation. 
So free was the bleeding that 1 feared it would be necessary 
to complete the operation by performing Caesarean section 
and possibly hysterectomy. Eventually, however, by under¬ 
pinning the whole of the raw surface and closing it in by 
means of cat gut sutures the haemorrhage was arrested. 
The abdominal wound was closed by through and-througb 
sutures with a separate layer for the fascia. For 48 hours 
the progress was entirely satisfactory, but on the morning 
of Dec. 21st labour pains commenced and after a short 
and easy labour the patient was delivered of a six 
months child which lived only 18 hours. There was no 
post-partum hemorrhage but with the expression of the 
placenta two masses of dark blood-clot, each of the size 
of a hen’s egg, were expelled. These clots were evidently 
two or three days old, and I have very little doubt that 
during the manipulation of the uterns I partially detached 
the placenta. To this accident is to be attributed the onset 
of labour. From this point convalescence was uninterrupted 
and the patient returned home a month after the operation. 

I noticed a number of fibroids in the wall of the uterus, 
one of the size of a Tangerine orange and two or three 
others nearly as large as this. When the patient came 
to see me six months later the uterns had involuted well and 
the whole mass, uterus and fibroids, was no larger than a 
man's fist. There can be no doubt that in this case the 
individual fibroids were much smaller six months after 
delivery than at the time of labour. 

I show to-night a portion of the tumonr removed. Its 
weight was 17A pounds, its length 12£ inches, its breadth 
9 inches, and its circumference 26 inches. On section it is 
seen that the tumour is degenerate, more especially towards- 
its centre. Areas of mucinoid degeneration, cyst-like 
cavities, and patches of necrobiotic tissue are scattered 
through it. Microscopical sections show the histological 
appearances commonly seen in a degenerating fibro-myoma. 
These call for no special description. 

I have related this case because of its clinical interest 
and because it is important to record instances in which 
premature expulsion of the ovum follows operations upon 
the uterus during pregnancy. So many cases have been 
published of pregnancy continuing in spite of the enuclea¬ 
tion of uterine fibroids that a false idea of the safety of th© 
ovum may become prevalent unless our failures are recorded 
also. I do not mean to imply that abortion is the rule, bnt 
it occurs with sufficient frequency to make me hold that a 
fibroid should not be enucleated during pregnancy unless it 
causes, or clearly threatens to cause, urgent symptoms. 

The rate of growth in this case is remarkable. I have no 
doubt that the tumour existed before the commencement of 
pregnancy, but it had been noticed neither by the patient 
nor her friends. Its increase in size must be attributed to 
two factors: (1) the richer blood-supply of the uterns 
associated with gestation ; and (2) the degenerative changes 
in the tumour partly mucinoid and partly necrobiotic. It i© 


1 A paper read at a meeting of the Obstetrical and Gynecological 
Section of the Koyal Society of Medicine on Jan. 9th, 1908. 


The Lancet,] CLINICAL NOTES— ROYAL SOCIETY OF MEDICINE: MEDICAL SECTION. [Feb. 8, 1908. 42 T 


clearly established that fibroids are particularly liable to 
undergo degenerative changes during pregnancy ; why this 
is bo we do not know. Necrobiosis is generally regarded as 
the result of vascular lesions, but as to what is the nature of 
these lesions, or what are the factors which determine their 
onset we possess no certain knowledge. The process is, as 
iar as we know, neither infective nor thrombotic, and it is 
difficult to explain why it should occur at a time when the 
vascular supply of the uterus is richest. 

The onset of the symptoms was strikingly sudden. At the 
time of operation I looked carefully for torsion of either the 
tumour or the uterus, but I could find none. There was 
extensive local peritonitis and this may account for the 
severity of the pain in this case, but a necrobiotic fibroid is 
often per te a painful tumour, and in some instances where 
the pain has been great no adhesions or other evidences of 
peritonitis have been found. The constitutional symptoms, 
the raised temperature, the frequent pulse, the furred tongue, 
and the loss of flesh are evidences of the profound toxiemia 
associated with the change. Finally, I would draw attention 
to the fact that during the involution of the uterus the 
fibroids in its walls became smaller. 

Wimpole-street, W. 


Erratum. —In the last sentence of an article by Dr. 
A. Eddowes and Dr. J. G. Hare published in The Lancet 
last week (p. 282) an error has occurred. It was Dr. M. K. 
Hargreaves who was speaking and not Dr. Eddowes or Dr. 
Hare, and the sentence should run : “ In a second case Dr. 
Hargreaves is indebted to Dr. Alan B. Slater for carrying out 
the treatment at the patient's own home.” 


Clinical Stoics: 

MEDICAL, SURGICAL, OBSTETRICAL, AND 
THERAPEUTICAL. 


NOTE ON A CA8E OF ACUTE PULMONARY (EDEMA. 

By J. M. Pearson, M.D. 

It is somewhat curious that the English-speaking medical 
profession should have had to wait until the early years of 
the twentieth century for a clear recognition of such a well- 
defined dramatic affection as acute pulmonary cedema. A 
very typical case occurred in my practice in the years 
1901-02 and, like Dr. Leonard L. B. Williams, I searched, 
but searched in vain, through a somewhat limited field, it is 
true, for any adequate mention of such a condition. 

The patient was a woman about 50 years of age, stout, 
ruddy, and energetic. The most diligent search between 
attacks, for she had several, failed to reveal anything grossly 
wrong with either heart or kidneys. The subject of arterial 
tension had not then risen on my medical horizon. The 
attacks took place invariably at night—two in a month at 
one time and then four or five months’ freedom. She would 
retire to bed early in apparently tbe best of health, to be 
awakened soon after midnight with shortness of breath. By 
tbe time I arrived on the scene she would be sitting up In 
bed quite unable to speak, with her face livid, beads of 
perspiration on her forehead, her chest heaving for breath, 
and a pint or more of frothy, slightly blood-tinged 
sputum in the basin held in front of her. The 
family got into the way of spplying hot things to her 
chest and back, and on general principles I used to give 
strychnine hypodermically. The pnlse was small and rapid. 
In an hour or less the severity of the attack would be over and 
she would be put back to bed, well propped up with pillows. 
Next day all would be well and two or three days would see 
her at her usual occupation, minding a small shop. From 
first to last the condition went on for 12 months, and I have 
records of five attacks during that time. Finally the end 
came, the old lividity was there but the weakened or tired 
respiratory muscles failed to respond with their accustomed 
vigour, and after a few sighing breaths she died two or three 
minutes after I reached her bedside. There was no necropsy 
and I left the case as mystified at the end as at the beginning. 

I noted that the serous fluid appeared to be poured into the 
luDgs practically all at once, and that when it was cleared 
away there was no continued secretion. I also learned that | 


the patient ought to be kept in an upright posture, which ia 
the attitude the patients naturally tend to assume. 

Blood-letting might suggest itself but reflection shows that 
all the mischief is done before the medical man arrives. ^The- 
bleeding has already been accomplished and certainly the 
pulse has none of the attributes usually associated with_the 
necessity for the operation. 

Vancouver, British Columbia. 


THE FREE USE OF AMYL NITRITE IN PULMONARY 
HAEMORRHAGE. 

By Alexander Lundie, M.B., Ch.B.Edin. 


It fell to me three years ago to treat an extremely profuse 
pulmonary haemorrhage, and after very much misgiving 
about taking it in hand at all 1 determined to use amyl 
nitrite. The results were such as I never regretted, 
but I was personally rather sceptical about the role of 
amyl nitrite in their production until 1 saw articles on the 
subject in The Lancet in 1906. My reason for using this 
agent may therefore be of interest to others. 1 knew at 
that time of the lung reflex of Abrams but thought it bad no 
bearing on the subject. I thought, like an ancient Greek 
historian, that it was entirely a matter of hydrostatics that 
had to be dealt with. Recollecting the story of a 
Greek, probably one of the “ten thousand,” wounded 
in battle and bleeding profusely till he fainted and 
remained long nnconscious, his wound becomirg staunched 
meanwhile, so that he eventually recovered, I determined 
to imitate this condition, seeing my case was just as 
desperate. 1 hoped to lower the blood pressure and bring 
about a condition temporarily like surgical shock, trusting 
to clotting takiDg place meanwhile in the wound. I 
accordingly administered amyl nitrite on a towel like 
chloroform without regard to official dosage, guiding 
myself entirely by the pulse and the general condition. 
It quickly produced slight transient anaesthesia, with an 
insignificant preliminary stage of excitement. The pressure 
in the radial artery was very much lowered, the pulse being 
almost imperceptible, and I stopped at this stage as the 
respirations became very shallow. The results were goocb 
and a satisfactory recovery followed. 

* Dalmulr, Dumbartonshire. 


glttol Sandies. 


ROYAL SOCIETY OF MEDICINE. 


MEDICAL SECTION. 

The Kinematogroph in Medicine.—Pathology and Treatment 
of Chronic Constipation. 

A meeting of this section was held on Jan. 28th, Dr. S. J, 
Gee, the President, being in the chair. 

Dr. H. Campbell Thomson gave a demonstration of the 
Use of the Kinematograph in Medicine. He showed films 
demonstrating certain gaits in nervous complaints. These 
will be found described and illustrated in the first number of 
The Lancet of this year. 1 

Dr. A. F. Hertz read a paper on the Pathology and Treat¬ 
ment of Chronic Constipation. He said that the treatment 
of chronic constipation was experimental. One method 
was tried and then another until by chance the method 
suitable to the individual case was discerned. That unsatis¬ 
factory state of affairs was due mainly to the fact that 
it had hitherto been impossible to determine the actual 
part of the intestines in which the delay causing the 
constipation occurred. In the case of medicinal treatment 
the difficulty was made greater by the lack of trustworthy 
information as to the relative effects exerted by any given 
purgative on different parts of the alimentary canal. Hence 
there were no rational guides to indicate what drug, if any,, 
should be employed in a case. It seemed probable that 
enemata would prove of value in those cases in which the 
delay occurred somewhere between the splenic flexure and 
the anus. For that reason it might perhaps be assumed that 


1 The Lancet, Jan. 4th, 1908, p. 12. 





428 Thh Lancet,] 


OPHTHALMOLOGICAL SOCIETY. 


[Feb. 8, 1908. 


constipation relieved by enemata was due to sluggish action 
of the lower part of the colon. But enemata were not often 
employed without the simultaneous administration of purga¬ 
tives, so that it had not been possible to separate clinical 
groups of cases in which enemata and not aperients were 
indicated. He had attempted by the aid of the x rays to 
discover what part of the intestines was to blame in different 
cases of constipation and thus to obtain a rational basis for 
treatment. It was only in the severer forms of chronic con¬ 
stipation such as those in which the question of operative 
interference might arise that the somewhat prolonged in¬ 
vestigations required could be profitably carried out in 
practioe. But he hoped that the examination of a large 
number of cases of constipation of every variety and degree 
might lead to the discovery of some simple clinical signs 
which would show what part of the intestines was at fault. 
It might also be possible to discover by similar means the 
exact effect of the various drugs and other measures em¬ 
ployed in the treatment of constipation so that each case 
might be provided with a suitable treatment. The method 
employed consisted in the administration t breakfast of one 
and a half ounces to two ounces of bismuth carbonate mixed 
with bread-and-milk and then subsequently periodically 
examining the patients with the aid of the x rays. This 
large dose of bismuth had never produced any unpleasant 
symptom and on no single occasion in healthy individuals 
was constipation or any other disturbance of the normal 
activity of the alimentary canal produced. The time rela¬ 
tions obtained by means of the x rays could therefore be 
looked upon as normal. The average normal time for the 
food to reach the csecum was four and a half hours. Two 
hours more were required for it to reach the hepatic flexure 
and another two and a half hours for it to reach the splenic 
flexure. The rate of passage through the descending colon was 
somewhat slower and the activity of all parts was lessened 
during sleep. In a severe case of constipation descrioed by 
Dr. Hertz the method showed that the passage of the intes¬ 
tinal contents through the colon as well as through the small 
intestine was unduly rapid rather than unduly slow. By 
means of the investigation with bismuth he found that the 
seat of the constipation in this case was the sigmoid flexure 
and the rectum. The rectum was considerably distended 
and faeces were present in the anal canal but the patient 
experienced no definite desire to defcecate. That meant that 
the rectum and anal canal must have become so far anaes¬ 
thetic that the normal defaecative reflex no longer occurred. 
That together with the atonic condition of the sigmoid 
flexure and rectum caused the constipation. In this case by 
the use of daily enemata the constipation was “done away 
with ” and the toxic symptoms and the pain were relieved. 
After this treatment an investigation made with bismuth 
carbonate showed that the sigmoid was no longer distended 
and that the bismuth passed at the normal rate through the 
intestines. Dr. Hertz then proceeded to relate the circum¬ 
stances of a second case of severe constipation of 33 years’ 
duration in a woman, aged 44 years. In this case as 
in the former one, bismuth carbonate passed through 
the small intestine at the normal rate and the distance 
reached in the first 28 hours also was not abnormal, 
but from the last part of the transverse colon onwards 
there was considerable delay. The constipation was 
probably due to anaesthesia of the rectum and anal canal and 
atony of the muscular wall of the pelvic colon and rectum. 
Dr. Hertz did not consider that the case would have been 
suitable for the operation of colectomy. In this case by the 
use of daily enemata the pelvic colon and rectum were pre¬ 
vented from becoming distended. The abdominal pain due 
to the ftecal mass disappeared with the enema treatment and 
the patient felt in every way better. It this case it was 
found that the patient did much better when the enema was 
given at night just before going to bed. In a case of tabes 
dorsalis and one of lead poisoning Dr. Hertz described the 
effect of drug treatment and observed in regard to a case of 
constipation in chlorosis that the cause was due to the 
sluggish action of the part of the large bowel beyond the 
middle of the transverse colon and if the case proved to be 
typical of the constipation of chlorosis it explained why 
ordinary aperients were able to relieve the constipation 
as the sluggish action occurred in a part of the intestines 
which was readily influenced by drugs. In the case 
of a patient suffering from constipation with neurasthenia 
the bismuth carbonate method showed that the constipation 
was due to sluggish action of the colon beyond the hepatic 
flexure, the last part of the transverse colon being most 


at fault. By treatment with liquor strycbninm and mag¬ 
nesium sulphate the condition was relieved and the bowels 
became regular.—Dr. H. Mori.ey Fletcher asked what 
was the position of the patient when the x ray photograph 
was taken.—Dr. C. E Beevor said Dr. Hertz had given 
interesting details concerning constipation in cases where 
there were definite causes for the condition. What was the 
explanation of constipation coming on in a man between 
50 and 60 years of age who found himself compelled to use 
purgatives or enemata 1—Dr. F. DE Havili.AND Hall laid 
stress on the importance of giving enemata at night time.— 
Dr. Hertz, in replying, said that the position of the patient 
when x ray photographed was lying down, but there was 
now at Guy’s Hospital an apparatus by meanB of which the 
x ray investigation could be carried out with the patient in 
the upright posture. In regard to the question asked by Dr. 
Beevor, Dr. Hertz said that he had not examined such a 
patient, but he considered the constipation was similar to 
that seen in cases of the neurasthenic type. 


DERMATOLOGICAL SECTION. 

Exhibition of Cases. 

A meeting of this section was held on Jan. 16th, Dr. 
H Radcliffe Crocker, the President, being in the chair. 

Dr. K. G. Graham Little showed a young girl with 
Granulomatous Swellings on the hand, wrists, ankle, and 
neck, which seemed to be of the same type as the cases of 
disease grouped under the title of “ granuloma annulare.” A 
specimen of a section of the skin was shown and its appear¬ 
ance was like that described in some cases of the disease to 
which this name had been applied. Several members 
suggested that the skin lesions were like those of acnitis, 
and it was decided to try the effect of a Calmette ophthalmo- 
tuberculin reaction. 

Dr. J. M. H MacLeod showed a case of Annular Lichen 
Planus in a man in whom the lesions were confined to the 
penis and the forearm. The annular lesions could be traced 
as being formed by the peripheral extension and central 
involution of papules. 

Dr. J. A. Ormerod showed a case of very extensively dis¬ 
tributed Pityriasis Rubra Pilaris in a man, aged 30 years. In 
spite of the wide area of surface covered the scalp was little 
affected. 

The President and Mr. George Pernet showed a 
Case for Diagnosis—a man with a number of Circum¬ 
scribed Patches of Redness and Scaliness, the skin being free 
both from Infiltration and atrophy. This case had been seen 
by a dermatologi-t in Chicago and had been published as an 
example of parakeratosis variegata. Diagnoses of mycosis 
fungoides and of leprosy had also been offered. The exhibitors 
thought the case corresponded more nearly with the type of 
xantho-erythrodermia perstans. 

The President and Mr. Pernet also showed a case of 
Lichen Planus Verrucosus treated with the violet rays of a 
mercurial vapour vacuum tube. The patient had benefited 
greatly by this treatment. 

Dr. J. H Sequeira showed a case of Tuberculides in & 
girl, aged 19 years, in whom the lesions had been noted for 
several years. These were of the type of acnitis. The opsonic 
index had been found to be 11. Calmette’s ophthalmo- 
tuberculin reaction had been demonstrated in this case, but 
there was no other evidence of tuberculosis in the patient 
aDd there was no family history of the disease. 

Dr. J. H Stowers showed a case of a small Rodent Uloer 
on the Bald Scalp of a man, aged 53 years. This was of the 
size of a threepenny-piece and had lasted for 12 months. 


OPHTHALMOLOGICAL SOCIETY. 


Microphthalmia resembling Glioma .— Optic Eeuritvs in. 

C rt bral Tumours .— Carcinoma, of Orbit. - - Coinhoma of 
Iris in Each Ege.—Exhibition of Specimens. 

A meeting of this society was held on Jan. 30th, Mr. 
R. Marcus Gunn, the President, being in the chair. 

Mr. M. S. Mayou described a case of Microphthalmia re¬ 
sembling Glioma, with lenticonus and hypertrophy of the 
ciliary body, lie said that the case belonged to the class of 
phthisis bulbi. Some of those cases had been of inflammatory 
origin, but this, and possibly some of the other cases, were 
attributable to the imperfect development of the mesoblaat 


1 

I 


M 

it 

A 

.ft 


a 

f\ 

n 

*1 

31 


Bt 

V 

re 

II 

c a 
:w 
ii 


*< 
l 5 

:a 

GCB 

»: 

•Si 

i« 

l? 2 

ei 

Ul 


in 

ft a 

>l\ 

i ] 

ft* 
' ( 
i 

'lr, 

n 



The Lancet,] OPHTHALMOLOGIOAL SOCIETY.—BRADFORD MEDICO-CHIRURGICAL SOCIETY. [Feb. 8,1908. 429 


at its entrance to the ocular cleft to form the vitreous. The 
child was six months old and was admitted to hospital 
under Mr. W. I. Hancock. The mother had noticed that 
the left eye was very small from birth but the child had 
no other deformities. There were no signs or history 
pointing to congenital syphilis. The right eye was 
normal in size and there was nothing abnormal in 
the fundus 1 . In the other eye there was a well-marked 
pupillary membrane. Behind the lens, which was clear, was 
a yellowish-white reflex with vessels on it similar to that 
seen in glioma and pseudo-glioma. As diagnosis was 
doubtful enucleation was performed and the child made a 
good recovery. The eye wag hardened in formol and 
sections were cut antero-posteriorly. The optic nerve 
was removed and cut in transverse section. The globe 
measured 15 millimetres antero-posteriorly, 10 vertically, 
and 10 horizontally. The sclera showed no change. 
The angles of the anterior chamber were imperfectly 
formed owing to incomplete separation of the iris from the 
back of the cornea. The ciliary body was free from signs of 
inflammation. Behind, and lying on the pars plana, was a 
large mass of pigmented and unpigmented cells derived 
from the ciliary body. Towards the outer part was an 
attempt at alveolar formation. The retina was detached 
but did not stop at the ora serrata but passed close 
behind the ciliary process, where it was continuous with 
the anterior layers of the epithelial cells and the mass 
mentioned. The lens was thickened and thrown into 
folds and consisted principally of neuroglial tissue but 
possessed no regular structure. The retinal detachment 
was of earlier date than the haemorrhage separating it 
from the choroid. The choroid presented a coloboma below 
but the blood-vessels were not thickened. The lens showed 
a condition of posterior lenticonus. The central artery was 
well developed and showed no changes in its walls. 
Generally in such cases the distortion of the posterior part 
of the lens was associated with a persistent hyaloid artery 
or a gap in the posterior part of the lens capsule, but neither 
of those conditions was present in this case. There was 
hypertrophy of pigmented and non-pigmented epithelial 
cells, the reason of which it was difficult to understand, 
unless it was due to nutritional disturbance in the line of 
separation of the two layers in the primary optic vesicle. 

Mr. L. J. Paton read a paper on Optic Neuritis in Cerebral 
Tumours. The paper was based on the records of 252 con¬ 
secutive cases seen at the National Hospital, Queen-square. 
In 202 of those the localisation of the intracranial tumour 
was definite, and 148 were confirmed by operation or post 
mortem. Of the 202 cases, 38 (or 18 1 8 per cent.) had no 
neuritis ; 12 had only very Blight nenritis, the edges being at 
no period completely blurred ; 27 were in a condition of post¬ 
neuritic atrophy when first seen ; and the remaining 125 had 
marked neuritis. Mr. Paton pointed out that the great 
majority of cases without neuritis occurred in subcortical 
and pontine tumonrg. The percentage of cases with no 
neuritis in tumours of those two areas was respectively 
38 and 43'5. He pointed out, further, that when sub¬ 
cortical tumours developed optic neuritis it almost invariably 
indicated that the growth had involved either the grey 
matter of the cortex or the grey matter of the base, and that 
when pontine tnmours developed optic nenritis it practically, 
without exception, indicated very definite involvement of 
the cerebellum. He showed that in tumours of the 
cerebral cortex the intensity of the neuritis seemed to 
vary inversely with the distance of the tumour from the 
anterior pole of the middle fossa. He adduced evidence 
to show that the nature of the growth bad little, if any, 
influence on the development of optic neuritis, except in to 
far as the nature of the growth might influence its position. 
He stated that the figures showed that very little reliance 
could be placed on differences in the intensity of the neuritis 
as indicating on which side the tumour developed and that in 
the cases of frontal and of cerebellar tumour neuritis was just 
as frequently most marked in the optic disc of the opposite 
eye as it was in the eye on the side of the tumour. The 
neuritis commenced more frequently in the eye on the side 
of the tumour than in the opposite eye. but even here the 
preponderance—23 to 13—was not sufficiently marked to 
make the sign one of much value for localising purposes 
He described in detail the development of the macnlar 
changes seen in intense cases of tumour neuritis, and 
showed that these changes were most probably produced 
by an overflow of cedematous fluid from the much 
swollen disc into the nerve-fibre layer, and that the 


presence of very well-marked macnlar fans was com¬ 
patible with the retention of perfectly good vision. The 
causation of temporary attacks of blindness, lasting 
from a few seconds to half an hour, was discussed and 
it was shown that these were probably not associated with 
optic neuritis, as they had been observed three times in cases 
where no optic neuritis developed, and in other cases these 
fleeting amblyopias had occurred before ophthalmoscopic 
evidences of disc change were present. It was suggested that 
these attacks were due to sudden rises in intraventricular 
tension, causing a bulging of the thin floor of the third 
ventricle, and to direct pressure on the chiasma. The 
attacks were invariably accompanied by increased head¬ 
ache and giddiness. He pointed out that there was 
no evidence in favour of optic neuritis in these cases 
being due to an inflammation descending from the 
basal meninges, nor was there evidence in favour of 
it being due to pressure of fluid in the vaginal space. The 
clinical evidence against it being a descending inflammation 
in the nerve trunks was even stronger, nor was there any 
more evidence in favour of the nenritis being produced 
locally by the action of toxin or of its being a vaso motor 
phenomenon. He regarded their knowledge to be, as yet, 
insufficient to justify any definite theory as to the cansation 
of optic neuritis, but a general review of the subject in 
its clinical aspects inclined him to the view that in so- 
called optic neuritis there was simply a manifestation 
locally of a general cedema of the cerebral tissues due to 
the irritation set up by the tumour as an actively growing 
foreign body. 

The following two papers by Mr. Simeon Snell were, in 
his absence, taken as read: 1. Carcinoma of the Orbit 
originating in a Meibomian Gland. The case occurred in a 
woman, aged 63 years. In 1904 another surgeon had re¬ 
moved a lump from the right upper eyelid. In July, 1905, 
there had been a recurrence at the site of that scar reaching 
back to the orbit, of about the size of a walnut. This was re¬ 
moved with the portion of eyelid, but in June, 1906, there 
was another recurrence and then the eyeball was removed 
and the whole orbit cleared out and chloride of zinc paste was 
applied. Still further recurrence had occurred and the orbit 
was filled with a large ulcerated growth and the pre-auricular 
and cervical glands were enlarged. Dr. A. E. Barnes re¬ 
ported that it was a spheroidal-celled carcinoma and was of 
opinion that it had probably originated in a Meibomian 
gland. Mr. E. Treacher Collins corroborated this. 2 The 
second paper was on Coloboma of the Iris in each Eye, 
occurring in five generations. Mr. —— was the first person 
seen and he had a large coloboma in each eye, down and 
out. The defect was known to have existed in hiB grand¬ 
mother, in her sister, and in bis mother. Mr.-had six 

children, three of whom were affected, and of these two had 
children—one had three children, of whom two were affected, 

and the other had one child who was affected. Mr.-was 

the only child of his father, but his mother had, by a second 
husband, five children, of whom three were affected. One 
of these had three children, two of whom were affected. The 
other had one child who was not affected. In all, of 41 per¬ 
sons 12 were affected—five males and seven females. In the 
great-great grandchildren the defect was complete aniridia. 

The following card specimens were shown :— 

Mr. E. E. Henderson : Sections from case of Sarcoma 
developing under Calcareous Plate. 

Mr. P. C. Bardsley : A New Form of Scotometer. 

Mr. S. Stephenson : A case of Buphthalmia apparently 
Cured by the performance of Iridectomy. 

Dr. L. G. Guthrie and Mr. Mayou : Right Hemiplegia 
with Obstruction (? Thrombosis) of the Left Common Carotid 
and Central Artery of the Retina, with Perception of Light 
in the Eye. 

Mr. G. H. Goldsmith : Optic Neuritis. 

Mr. J. S. Horsford : Essential Shrinking of the Con¬ 
junctiva. 

Mr. C. Wray: Sympathetic Iridocyclitis. 


Bradford Medico-Chirorgical Society.—A 
meeting of thifl society was held on Jan. 21st, Mr. H. 
Shackleton, the President, being in the chair—Mr. J. 
Basil Hall showed: (1) A Fibroid, weighing 15 pounds, 
from a patient, aged 70 years; (2) two specimens of Intus¬ 
susception removed by Enterectomy ; (3) an Ectopic Gesta¬ 
tion producing Torsion of the Fallopian Tube ; (4) an Excised 
Gastric Ulcer which had produced hour-glass contraction ; 





430 The Lancet,] 


GLASGOW MEDIOO-CHIRURGICAL SOCIETY. 


[Feb. 8, 1908. 


(5) Colloid Carcinoma of the Colon from a case of Colectomy ; 
and (6) Calculi from the Female Bladder.—Dr. Gilbert T. 
Beatton read notes on a case of Neurasthenia.—Dr. J. 
Metcalfe read notes on a case of Ureteric Calculus, with 
skiagram.—Mr. W. H. Horrocks read a paper on the Classi¬ 
fication of Appendix Abscesses. He said that so much had 
been written about appendicitis that it seemed almost futile 
to attempt to say anything fresh about this condition. 
The anatomy and pathology had been fully discussed, 
and after the numberless cases which had come under 
observation the time Seemed to have arrived when some 
classification of the different forms of appendix abscess 
might with advantage be attempted. In carrying out this 
idea the subject would be approached from its clinical rather 
than its pathological aspect. The first point to which he 
would call attention was the significance of the tender point 
lying in the line between the anterior superior spine and 
the umbilicus known as McBurney’s point. This tender¬ 
ness was generally present in appendicitis, but it was 
obvious that it did not indicate the position of the 
part of the appendix most affected. The appendix varied 
greatly in position. It might lie transversely acrosB the 
iliac fossa, point downwards, towards the internal abdominal 
ring, or lie behind or outside the cmcum. Yet in all 
these cases there was tenderness over McBurney’s point. This 
point really marked the attachment of the appendix to the 
Cieonm, where the mesentery contained the lymphatic glands 
■which became inflamed and tender. Hence this point gave 
no indication as to the position of the acute disease. Some 
years ago Sir F. Treves pointed out that a ridge might be 
felt crossing the appendix line in chronic appendicitis. This 
in some cases was mistaken for a thickened appendix as it 
was tender on palpation. Sir F. Treves pointed out that this 
ridge was probably the ileo-c:ecal valve, and certainly not the 
appendix. On examining the blood supply of the appendix 
two arteries were usually found, one of which ran along the 
free margin of the mesentery and the other near the attach¬ 
ment of the appendix to the cmcum. Generally from one- 
fourth to one-third of an inch of the termination of the 
appendix was without mesentery. This part was most subject 
to perforation. In other cases a kink occurred from ad¬ 
hesions or stricture about midway in the appendix and per¬ 
foration might occur less commonly in this position. 
For purposes of classification appendix abscess might be 
grouped into three divisions. In all three cases the 
appendix lay in a plane behind the intestines, attached to 
the posterior wall of the peritoneum or in some rare cases to 
the under surface of the intestinal mesentery. Group I.— 
In which the appendix lay transversely across the iliac 
fossa so that its tip approached the brim of the pelvis. 
This was, perhaps, the commonest form. The small 
intestines matted together by plastic lymph formed a 
large tumour. There were marked local peritonitis and 
swelling of the abdomen. The bladder was frequently 
affected, there being pain and frequency of micturition. 
The abscess formed in the iliac fossa near the brim of 
the pelvis and might remain there, or it might gravitate 
into the pelvis occupying a position between the 
bladder and the rectum. Such abscesses might point by 
coming forwards between the coils of intestine to the 
anterior abdominal wall, usually near the outer margin of 
the rectus muscle, about a hand’s breadth above the pubes. 
This form of appendicitis was the most dangerous from its 
liability to cause general peritonitis or to burrow among 
the organs of the pelvis. In this form examination 
per rectum was most valuable. Group II.—Where the 
appendix lay in the iliac fossa as a direct continuation 
■of the cieoum. The affected part of the appendix lay 
usually near the internal abdominal ring. This form was 
not generally characterised by a large abdominal tumour. 
The abscess was frequently of small size and could be 
quite readily felt above, and parallel to, Poupart's 
ligament. The tendency of this abscess was to follow the 
cord along the inguinal canal. It was the least dangerous 
form of appendix abscess. Very often this form of abscess 
■discharged into the caecum and so cured itself. Group III. 
—Where the appendix lay between the layers of the 
■csecal mesentery or on the outer side of the colon. This 
was the most obscure form of appendicitis. It was 
attended by no definite tumour. The pain and tenderness 
seemed to travel upwards. The risk of general peritonitis was 
very slight, but on the other hand there was a tendency for 
the formation of subdiaphragmatic abscess with secondary 
empyema of the right side. There was often cedema of the 


skin of the right loin. In dealing with such abscesses there 
was considerable difficulty and a deep dissection might be 
required.—A discussion followed the paper and Mr. Horrocks 
then replied. 

Glasgow Medico-Chirurgical Society.— A 

meeting of this society was held on Jan. 17th, Dr. J. 
Walker Downie, the President, being in the chair.— 
Dr. G. Burnside Buchanan reported a case of Extensive 
Iujury to the Brain. The patient sustained a compound 
fracture of the skull from a block of wood falling on 
his head. There was a large irregular wound about 
the right parietal eminence. Some of the fragments were 
depressed under the edge of the fracture. A splinter of 
wood about one inch by a quarter of an inch thick was 
imbedded in the brain. There were much effusion around 
and considerable haemorrhage from the wound. He was not 
entirely unconscious. The left side of the body and face 
was paralysed. Loose fragments of bone and the piece of 
wood were removed. Detached brain tissue and gritty par¬ 
ticles were removed and the wound was packed with iodoform 
gauze. Anti-tetanic serum was given, The wound healed 
slowly without suppuration but a large quantity of necrotic 
brain matter escaped. He regained slight power over the 
leg. Sleeplessness and restlessness were very troublesome 
and could only be controlled by morphine. The leg 
and facial paralysis made marked improvement but 
the mental condition deteriorated.—Dr. A. N. McGregor 
described a Method of Recording the Efficiency of the 
Discharge of Urine per Uretbram. He considered the 
estimation of the size of the urethra from casts, as done by 
Reybard, and the use of the urethrameter of Otis, Luis, Ac., 
did not give the rate of discharge in a given case, which was 
the chief point of importance. His method was to get the 
patient to measure the urine passed during five seconds 
without voluntary exertion and in similar circumstances 
from day to day. These results recorded on a chart gave a 
permanent record of variations in the efficiency of urination. 
A number of charts were shown and demonstrated the more 
lasting effects after moderate dilatation as compared with 
extreme dilatation. Charts from normal cases were also 
shown.—Dr. W. S. Syme showed : 1. A boy, aged six years, 
operated on for Septic Sinus Thrombosis consequent on 
Middle-ear Disease. There was a small carious opening into 
the mastoid antrum on admission. The whole mastoid 
process was carious. At the operation this was cleared out 
and the lateral sinus was exposed. Its wall was covered 
with unhealthy granulations. Three days later symptoms 
of septic infection developed. The sinus was opened and a 
thrombus was found adherent to the inner surface. The 
internal jugular was tied. Progress was slow but progressive. 
2. Patients operated on for Diseases of the Accessory Sinuses. 
Intranasal treatment should be given a good trial first. 
Extensive operations should be performed externally and the 
extent of operation depended on each individual case. The 
sphenoidal sinus could be opened externally (the Killian 
operation), by way of the maxillary antrum, by the naso¬ 
pharynx, or by the anterior nares. The last method was 
generally preferable. 3. A case where part of the Root 
of the first Upper Right Molar was removed from 
the Maxillary Antrum into which it had been driven six 
years before as the result of an unsuccessful attempt at 
extraction. 


The King and the Royal College of Physi¬ 
cians of London.— Excellent photogravures of the portrait 
of the King, which was painted by Sir Luke Fildes. R.A., by 
His Majesty’s command, for the Royal College of Physicians 
of London, of which corporation His Majesty is an Honorary 
Fellow, can now be obtained from the Berlin Photographic 
Company, 133, New Bond-street, London, W. The portrait 
represents His Majesty, to use the words of the publishers of 
the photogravure, "not in the uniform of a soldier, nor as 
the head of the State, but in that garb to which his fine 
presence lends fresh dignity—namely, as the First Gentle¬ 
man of the Realm.” An advanced proof of the engraving 
was submitted to the King, when the publishers were 
fortunate in finding that they had secured His Majesty’s 
approval. Artist’s proofs on Japanese paper, signed by the 
artist, and limited to 300 impressions, are now to be purchased 
priced at 5 guineas. India prints will be published at a 
later date at the price of 1 guinea each, and members of the 
medical profession will receive special consideration from the 
publishers 





The Lancet,] 


REVIEWS AND NOTICES OF BOOKS. 


[Feb 8,19(8. 431 


Jettetoi Hub ftotfos of $aak 


Arterial Ifypertonun , Sclerosis, and Blood Pressure. By 
William Russell. M.D., F.R.C.P. Edin., Physician to, 
and Lecturer on Clinical Medicine in, the Royal Infir¬ 
mary, Edinburgh, &c. Witli 36 illustrations and plates. 
Edinburgh and London : William Green and Sons. 1907. 
Pp. 194. Price 7s. 6rf. net. 

Mich attention has been paid in recent years to the 
eabject of disease of the blood-vessels but in spite of this, 
or perhaps because of the very number of writers setting 
forth divergent views and using technical terms with 
different shades of meaning, there is considerable con¬ 
fusion of ideas in this field. Dr. Russell in the book 
before us makes a praiseworthy attempt to straighten out 
the tangle. As the outcome of much careful clinical 
observation he has formed clear ideas of the conditions 
met with and he appreciates the need not only of 
clear thinking but of defining the terms in which they 
are set out. 

The author first draws a distinction between two 
affections which are often confused—atheroma and arterio¬ 
sclerosis. The former, he holds, is a localised affection 
produced by irritation combined with degeneration ; the 
latter is a generalised change consisting in permanent 
thickening of the walls of the vessels which may involve the 
middle coat alone or the inner and outer coats along with it. 
Not every vessel, however, which feels thick and rigid to 
the examining finger is the seat of sclerosis. The arteries 
are muscular tubes and as such are capable of contraction 
and relaxation. A contracted artery may feel thick and 
rigid, just as a degenerate one does. This condition of 
spasmodic contraction is called by the author “ hypertonus, ’’ 
an exaggeration of the normal tone of living vessels. 
It may be brought about by toxic substances circu¬ 
lating in the blood such as are present in renal 
disease and if it persist owing to continuance of the cause 
permanent sclerosis (hypermyotrophy) ensues. Constriction 
of any part of the arterial system is necessarily followed by 
increase of blood pressure aDd this sequence is recognised to 
occur in renal troubles. Some confusion of thought seems, 
however, to prevail as to the point at which the raised 
pressure exists. The author has devised (with the assistance 
of Dr. Cargill Knott) a model which reproduces some of the 
features of the circulation and shows that the rise in 
pressure occurs behind the obstruction, while a fall is met 
with beyond it. This might, indeed, have been anticipated. 
The apparatus does not show, and it is the point which most 
needs proof, whether there is a rise of pressure nithin an 
artery which is constricted throughout some considerable 
portion of its length. 

Another point on which new light is shed in this 
volume is the value of hsomomanometer readings in 
disease as measures of actual blood pressure. It seems 
satisfactorily demonstrated, as might indeed have been 
anticipated, that the wall of a thickened artery offers 
considerable resistance to compression and that this factor 
has to be taken into consideration as well as the aotnal 
pressure of the blood in drawing conclusions from the 
readings of an instrnment which works by obliterating the 
lumen of an artery. It is a question, however, how far this 
criticism applies to such an instrument as the Hill-Barnard 
sphygmometer, in which the principle is the equalisation of 
the pressures inside and outside the vessel as shown by the 
degree of oscillation of the column of fluid in the instru¬ 
ment. 

In the stage of hypertonic contraction mach may be 
done for the patient by the administration of drugs which 
relax arterial spasm; the author speaks highly of erylhrol 


tetranitrate. Even sclerotic and degenerated arteries are 
capable of a considerable degree of spasm and relaxation 
and must not be looked upon as beyond treatment. 
Spasm is often brought on by exaggeration of the 
physiological reflex by which the peripheral vessels con¬ 
tract after a meal coincidently with a relaxation of 
the splanchnic system. Proteid decomposition products, 
alcohol, and tobacco are also causes of arterial con¬ 
striction. In the light of the views just set forth 
the author discusses various cerebral conditions associated 
with spasm of arteries and also the condition known as 
angina pectoris. Incidentally he makes the suggestion that 
the secretion of the pituitary gland may have the special 
function of acting on the cerebral arteries. Into these dis¬ 
cussions we cannot here follow him. 

The views enunciated in this book offer a clear and a 
consistent account of the phenomena of vascular disease 
which should give pathologists and clinicians food for 
thought and discussion. The book may be commended to 
the attention of all who are interested in one of the most 
important problems in the theory and practice of medicine. 
We congratulate Dr. Russell on a valuable piece of work. 


Manual of Surgery. By H. Alexis Thomson', F.R.C S. Edin., 
Assistant Surgeon, Edinburgh Royal Infirmary ; Surgeon 
to the Deaconess Hospital, Edinburgh ; and Alexander 
Miles, F.H C.6. Edin., Assistant Surgeon to the Edin¬ 
burgh Royal Infirmary ; Surgeon to the Leith Hospital. 
Second edition, revised and enlarged, with many illustra¬ 
tions, mostly wood engravings. Vol. I., General Surgery. 
Pp. 808. Vol. II., Regional Surgery. Pp. 816. London 
and Edinburgh: Young J. I'entland. 1906 and 1907. 
Price 21 s. net. 

The student must have a good deal of difficulty in dis¬ 
tinguishing between the many manuals of surgery which 
compete for his notice, bnt he cannot go far wrong in 
choosing this excellent text-book. It is always difficult 
to know how muoh to put into a book intended for 
students ; on the one hand, the author has to 
avoid overburdening the student’s mind with an excess 
of facts and particulars, and on the other it is essential that 
everything should be included that may be reasonably 
required at the examination. We do not know a more trust¬ 
worthy work than this. We are inclined to think that it 
would be Letter to isBue the work in one volume, the page 
being made larger, for there is certainly on the part of 
students a preference for a work in one volume. We hope 
the authors will resist strenuously any inclination to increase 
unduly the amount of material in the work ; we notice that 
the present issue has 100 pages more than the first, and all 
books have a natural tendency to grow. We are glad to see 
that the book has reached a second edition in which it has 
been brought up to date. We notice a misprint “pruritis” 
for “pruritus” : we mention it because in some works, 
especially in America, it appears to be regarded as the correct 
spelling. 


LIBRARY TABLE. 

Primary Nursing Technique for Font-year Pupil Nunes. 
By Isabel McIsaao, tormerly superintendent of the Illinois 
Training School for Nurses, Associate Director of the 
Amerioan Journal of Nursing, &o. New York: The Mac¬ 
millan Company. 1907. Pp. 197. Price 3s. net.—It is a 
truism that the only way to learn the art of healing is by 
observation of the patient at the bedside and it is no less 
certain that the art of nursing can only be acquired in a 
practical manner. But text-books, intelligently used, may 
be of as muoh help to the nurse as to the student of 
medicine, and the book before us is one that the first-year 
probationer will find of very valuable assistance in her 
training. It is written clearly and concisely and is not 
F 3 




432 The lancet,] 


REVIEWS AND NOTICES OF BOOKS. 


[Feb. 8,1908. 


overloaded with descriptions of detail which can only 
be properly appreciated when they are seen actually per¬ 
formed. Bat a young nurse who has mastered the con¬ 
tents of such a book as this will be in a position to 
appreciate her practical instruction more intelligently 
and so to derive an added advantage from it. That the 
practical side of the nurse’s training has been in the 
author's mind is apparent from the fact that she prefaces 
the book with an excellent scheme of demonstrations for 
adoption by those who are responsible for the practical 
instruction of probationers, which we commend to the notice 
of those matrons of the smaller hospitals who are engaged 
personally in lecturing to their junior staff. We need not 
discuss the matter of the book, as we have already indicated 
its range, and the teaching is laid down on the lines of 
accepted authority. There are one or two wordB which are 
strange to English ears. How many of our readers know 
what is meant by “gastric gavage” (sic) or an “alcohol 
sweat ” ? But we can forgive much in the case of an 
American writer who spells “technique" as it ought to 
be spelt. 

The Spectroscope : An Intermediate Text book for Practical 
Chemists. By T. Thorne Bakek, F.C S., F.R.P.S. London: 
Baillit-re, Tindall, and Cox. 1907. Fp. viii.-130, with three 
coloured and 63 plain illustrations. Price 5r.—The practical 
applications of the spectroscope are extremely numerous and 
it is indispensable in such medico-legal inquiries as involve 
the identification of blood stains. Our issue of Jan. 4th 
also contained a reference to its use in determining the 
nature of the light emitted by photogenic bacteria. The 
hemoglobin of blood produces dark absorption bands in the 
spectrum and the test is usually accomplished by means of 
a direct-vision spectroscope adapted to a low power of the 
microscope. In the present volume there is no actual 
mention of blood but all the apparatus necessary for exhibit¬ 
ing the various spectra of hicmoglobin are so fully described 
that it deserves the attention of medical readers interested in 
this subject. The book is divided into nine chapters, of which 
the first deals mainly with optical principles and the second 
with the constructional details of various instruments in 
which equiangular prisms, diffraction gratings, combinations 
of prisms and gratings, and compound direct-vision prisms 
are respectively employed. Chapters III., IV., and V. 
describe the adjustments and practical use of the apparatus 
and the interpretation of continuous and bright-line spectra 
obtained from various sources, including phosphorescent 
bacteria. Chapters VI. and VII. give a satisfactory account 
of spectrum photography as applied to the determination 
of the wave-length of unknown lines, to simple methods of 
analysis in inorganic chemistry, and to the colour-sensi¬ 
tising of photographic plates. Chapters VIII. and IX. are 
devoted chiefly to the relations which the bands and lines 
of the spectrum bear to questions of chemistry, chemical 
physics, and chemical constitution. Students working with 
the spectroscope in ohemical and physiological laboratories 
will find this a very serviceable book. 

The Science Year Book, ISOS. London : King, Sell, and 
Olding, Limited. Price 5s. net.—This work of reference 
and diary will be found useful by workers in all depart¬ 
ments of science. In the diary a separate page is de¬ 
voted to each day of the year and at the top of each pag e 
various astronomical facts are given and space is provided 
for recording the barometer, wind direction and pressure, 
rainfall, and so forth. The reference portion of the book 
contains a great deal of information dealing with astronomy, 
physics, chemistry, meteorology, and other departments of 
science, and gives facts and formnlse of every-day ntility. 
Among the features of the work is a summary of the progress 
of science during the year 1907, a glossary of recently intro¬ 
duced scientific terms, names of periodicals, and a list of 


scientific societies. Brief biographical notes of prominent 
scientific men are also included. Some new tables have been 
added to the present issue, among them being a useful table 
of four place logarithms. 


JOURNALS AND MAGAZINES. 

The St. Mary’s Hospital Gazette for January contains a 
very interesting paper by Dr. W. H. Willcox on the Medico¬ 
legal Importance of Wounds produced by Firearms in which 
he deals with certain points connected with the laws relating 
to such wounds, the causes of death resulting from them, 
and the types of wounds produced by revolver or pistol, rifle, 
and shot-gun wounds respectively. Illustrative cases are 
quoted, including the Whiteley, Moat Farm, and Chorley 
Wood murders. The paper is a useful contribution to 
medico-legal literature. Much of the remainder of the 
Gazette is devoted to an account of the Christmas doings at 
8t. Mary’s, which were wound up by two performances of 
The Private Secretary in the out-patient hall by the residents 
for the benefit of patients and nurses. The production seems 
to have been very successful. This number also includes 
a photographic supplement illustrating the Students’ Cot, 
supported by St. Mary’s students. 

The Illuminating Engineer.— The first number of this 
new monthly journal contains an interesting article on 
Vacuum Tube Electric Lighting by Professor J. A. Fleming, 
F R.S., of University College. One of the disadvantages of 
lighting by the ordinary incandescent filament is the 
extreme harshness of the shadows, the sharp contrasts 
being very trying to the eyes. If the shadows are softened 
by frosting the globes there is naturally great loss of 
efficiency. Another disadvantage is the great richness of 
the light in ultra-violet rays which are useless for illumina¬ 
tion and are responsible for most of the damage done to the 
eyes by electric light. There is good reason to believe that 
both of these drawbacks may be to a very large extent re¬ 
moved by the new form of illumination. The method has 
been used for some time in America but has received little 
attention here. It may, however, be seen at work in the 
courtyard of the Savoy Hotel. It has long been known 
that light could be obtained by passing a high tension 
current through rarefied gas. The gas undergoes absorption 
with diminution of pressure. This practical difficulty baa 
been overcome by the invention of an ingenious valve oy 
Mr. Macfarlane Moore. By Moore’s method a tube one and 
three-quarter inches in diameter and of any length up to 200 
feet can be made incandescent. For ordinary purposes 
nitrogen is the best gas and it can be obtained easily from 
the air. The light has a rich golden hue, or with carbon 
dioxide whitish blue. From the hygienic point of view 
it is desirable that experiments should be made to 
determine the quality of the rays emitted in different 
circumstances. Professor Fleming, from experiments 
carried out at the Savoy Hotel, has shown that the illu¬ 
minating power is 9 6 candle-power per foot. The in¬ 
tensity of light from such a linear source varies approxi¬ 
mately inversely as the distance, not as the square 
of the distance as with ordinary methods. Hence the 
illumination three feet above the ground is equivalent to that 
of about 100 16 candle-power lamps equally distributed over 
the ceiling at the same height above the ground as the tube. 
The light intensity is directly proportional to the voltage and 
is therefore much more constant than with glow lamps. 
Both initial cost of installation and working expenses are 
less. With carbon dioxide in the tube tinted surfaces appear 
as in daylight, so that artistic work can be carried on as by 
day. The new journal contains articles on illumination and 
eyesight, with special reference to the eyesight of school 
children and the effectual lighting of schoolrooms, on the 
protection of the eyes from ultra-violet rays, and so on. They 



Tub Lancet,] 


REPORTS AND ANALYTICAL RECORDS. 


[Feb. 8, 1908. 433 


afford important evidence that theae hygienic'matters are 
receiving greater and more intelligent attention from 
practical engineers. 

Man .—In the January number of Man Dr. W. L. H. 
Duckworth describes a human cranium obtained from a 
stone cist in the Isle of Man. Its measurements in milli¬ 
metres were as follows : Maximum length, 180 ; maximum 
breadth, 146; and horizontal circumference, 527. The 
cephalic index was 81 • 1. It was therefore brachycephalic 
and probably belonged to a young adult. A noteworthy 
feature was the persistance of a suture (comparable to a 
prolonged sagittal suture) between the two halves of the 
frontal bone. 

The Phonographic Record .—With the January number our 
small contemporary begins its fourteenth annual volume. In 
his account of the Medical School of Montpellier in the 
thirteenth century Dr. O. C. Gruner presents many curious 
facts. At its prime the number of students was not less than 
1000. They had the power of regulating the manner of 
teaching and even the subjects to be taught, and they could 
suspend altogether an unsatisfactory teacher. Perhaps an 
explanation of this is to be found in the fact that any un¬ 
qualified person, as we Bhould say, was at first able to be a 
teacher; not until 1272 was the possession of a diploma 
necessary. In an account of the Murmurs of Mitral Con¬ 
striction Sir William Gowers mentions two phases or stages 
rarely observed. The first is at the beginning of the diastolic 
mnrmur, when a distinct interval intervenes between the end 
of this and the beginning of the presystolic murmur, 
because the narrow ing of the orifice is only enough to cause 
the sound at the commencement of the diastolic flow. It is 
more often noted in an irregular heart, when the diastole is 
occasionally prolonged. The other stage is terminal ; the 
presystolic murmur ceases and only the diastolic persists. 
He observed a case in which the cause of this was found to 
be the formation of a layer of clot over the whole inner 
surface of the auricle, making its contraction impossible. Dr. 
R. Hingston Fox contributes a sketch of “ Hmmatogenous ” 
Albuminuria, often called “ functional,” a subject on which 
it will be long before the last word is said. 


departs aitir Jnalgiiral gUrcrfcs 

7 BOM 

THE LANCET LABORATORY. 


ALEXINE. 

(J. Chatelain, 15. Rue de Paris. Pcteaux. Aoexts: T. Christy 
Aim Co., Old Swan-lane, London, K.C.) 

We have submitted this preparation to analysis and the 
results confirm the statement that it contains free phosphoric 
acid with iron and manganese. The preparation occurs in 
granular form but is distinctly hygroscopic. It is by no 
means unpleasant to take and for the most part is soluble in 
water. The acid phosphates of manganese and iron are 
regarded as presenting both these metals in an assimilable 
form. The preparation appears to supply an effective tonic 
and has been used in nervous diseases, in dyspepsia, in 
anaemia, and in pulmonary tuberculosis. 

IRISH WHISKY. 

(Dusville and Co., Limited, Belfast.) 

Two specimens of Irish whisky were submitted to us, one 
distinguished by the letters V.R. and the other by the title 
of “ Special Liqueur.” Analysis readily discriminated the 
two, the former being a blend of pot-still and patent-still 
spirit and the latter a pure pot-still spirit. The V.R. 
whisky, for example, showed a relatively small proportion of 
secondary products, the ethers amounting to 26, the higher 
alcohols to 107, and the furfural to 0 1 3 parts per 100,000 


parts of absolute alcohol present. On the other hand, the 
specimen marked “ Special Liqueur ” yielded on analysis 
1 part of furfural, 65 parts of ethers, and 400 parts of higher 
alcohols in 100,000 parts of absolute alcohol present. It will 
be noticed that the amount of furfural is relatively low 
having regard to the fact that the spirit iB distilled in a pot 
still. Doubtless this is due to careful selection of a par¬ 
ticular “running” from the still. Since furfural is held to 
be a poisonous constituent of whisky this fact may be 
regarded as satisfactory from a dietetic point of view. Both 
spirits evidently belong to the class of whisky described as 
“thoroughly matured.” Those who know the peculiar 
characteristics of genuine Irish whisky will appreciate the 
flavour in particular of the “ Special Liqueur.” The speci¬ 
mens were entirely free from acrid flavour and were 
peculiarly smooth to the palate. They were, moreover, free 
from excess of extractive matters and exhibited practically 
no acidity. 

FORM AMI XT. 

(A. WULFING AND Co., 85, UPPER THAMES-STBF.ET, LONDON, E.C.) 

Formamint is described as a chemical combination of 
formaldehyde and milk sugar. Apparently it is a true com¬ 
pound of the two substances, the milk sugar neutralising the 
irritating effect of the formaldehyde. The result is that the 
compound may be formed into a lozenge for the treatment of 
infective throat conditions. When the tablet is dissolved in 
the mouth the taste of formaldehyde is distinctly observed, 
though it is not unpleasant. The act of dissolving in the 
saliva sets free the aldehyde. Under these conditions the 
bactericidal action of the aldehyde is powerful and immediate. 
Several clinical notes have been published recording the 
value of the Formamint lozenge in tonsillitis, diphtheria, 
thrush, and so forth. We had no difficulty in recognising 
the presence of formaldehyde, lactose, and some starch. 

TABLOID QUININE COMPOUND. 

(Messrs. BuRROUons, Wellcome, and Co., Snow-hill Buildings, 
London, K.C.) 

The formula of this compound will explain the purpose for 
which it has been designed. Each tabloid contains cin¬ 
chona alkaloids, 1 grain ; acetanilide, J, th grain ; camphor 
monobromate, jth grain ; powdered ipecacuanha, n th grain ; 
and extract of cascara sagrada, li grains. It is suggested 
that one tabloid may be taken every hour in the early stages 
of catarrh of the kind to which many persons are prone 
daring a cold and changeable season. 

VARIOUS FOOD PREPARATIONS. 

(Eustace Milks, 40, 41, and 42. Chandos-street, Charing Cross, 
London, W.C.) 

These foods in general show, according to analysis, a high 
nntritive value in regard to all classes of material which 
minister to the needs of the body. The “ Proteid Food,” for 
example, contained as much as 32 per cent, of proteins 
which are more or less in a soluble state, and the mineral 
salts amounted to 7 1 10 per cent. Its addition to other 
foods is, of course, calculated to raise their nutritive value. 
The food for infants contains a well-balanced proportion of 
proteins, fats, carbohydrates, and mineral matter. It is a 
particularly satisfactory fact that this food showed no 
deficiency in regard to fat, the amount being 21 per cent. 
The proteins amounted to 22'75 per cent, and the mineral 
matter to 4 50 per cent. We have also examined cocoa, 
biscuits, and soup tablets, which all evidenced a rich pro¬ 
portion of nourishing constituents. 

“DRY SACK." 

(Williams and Humbert, 38, Mincing-lane, London, B.C.) 

This is a very fine wine, representing the best that can be 
produced in the Jerez district. It iB Bald to have been fully 
matured in wood, which we can well believe from the 
excellent flavour of the wine. The results of analysis accord 
with those commonly obtained with a fine old matured 





434 Thu Lancet,] REPORTS AND ANALYTICAL RECORDS.—NEW INVENTIONS. [Ebb. 8, 1908. 

sherry; they were as follows: alcohol, by volume, j smell. It is alkaline to test paper and on adding hydro- 


20 ’24 per cent.; extractives, 5'30 per cent.; mineral 
matter, 0 49 per cent ; volatile acidity, reckoned as acetic 
acid. O'084 per cent. ; fixed acidity, reckoned as tartaric 
acid, O '33 per cent. ; and sugar, 4'06 per cent. The ethers 
amounted to as much as 0 ■ 68 gramme per litre. We have 
before referred to the fact that the amount of ethers in 
Bherry exceeds that found in other wines. As a stimulant, 
therefore, sherry must be placed in the front rank. The wine 
belongs to the description of a Palo Cortado sherry which, 
although of the Oloroso type, is delicate in flavour. From the 
point of view of the connoisseur this sherry will be regarded 
as a really elegant wine, while its satisfactory characters in 
general commend it for medicinal use when a stimulant is 
ordered by the medical man. 

ALKUHIS TABLE WATER. 

(Alkubis, Limited, 37, Shren-bwad, Richmond, S.W.) 

We can well believe that this excellent table water is 
manufactured with care having regard to its purity as shown 
by our analysis. The water is clear and bright and pleasantly 
sparkling, while its taste is satisfactory, beirg very ‘'clean’’ 
on the palate. The water is further slightly mineralised and 
contains the citrates of potassium and lithium and the bi¬ 
carbonates of sodium and potassium, together with a small 
quantity of solium chloride. According to our analysis the 
total salts present amounted to 1 • 39 grammes per litre. We 
found amongst these 0'28 gramme of lithium citrate, 0 ■ 40 
gramme of alkaline caibonate, and 0 42 gramme of common 
salt per litre. The water shows an excellent condition of 
organic purity, as might be expected since it is carefully 
distilled. The water is obviously useful when a course of 
alkaline treatment is indicated. Its free administration is 
calculated to preserve an alkaline state of the blood, and 
alkaline table waters in general are often valuable in gastric 
catarrh and favour the excretion of waste toxic products. 

V.V. (VIS VIT.E) BRBAI). 

(V.V. Bread Company - , Limited, 16 to 32, Beewehy-road, 
Loxdoh, N.) 

We are always glad to recognise any attempts to make 
bread a palatable and nutritious article. Nowadays paya¬ 
bility and nutritive value are too often sacrificed in 
favour of appearance; the loaf must be spotlessly white 
without regard at all to its dietetic properties. The 
V.V. loaf is both palatable and nutritious. It has not 
that tastelessness which characterises so much of the 
bread of the present day, while donbtless owing to the 
use of good Hour and of a specially pure barm it keeps 
fresh for a much longer time than ordinary bread. The 
flour used is clearly of high quality, since our analysis 
of the bread shows a maximum proportion of proteins 
for wheat flour; the mineral matter, too, is present in 
equally satisfactory proportions. The flavour of bread is an 
important factor in dietetics and it is mncb to be deplored 
that the bulk of the bread offered to the public is prac¬ 
tically tasteless. The flavour to which we refer is difficult 
to describe, as are all flavours, but everyone knows the 
peculiar attractive nutty flavour of the unsophisticated 
bread made in the country home. Such bread as a rule 
is neither colourless nor flavourless, nor should it be. We 
have examined several varieties of V.V. bread and have 
found them to be most satisfactory ; they are palatable, 
and largely because they are palatable they are readily 
digestible, for a good appetising flavour invariably invokes 
good digestive power. 

PETOL PREPARATIONS. 

(1*. S. Syndicatk, St. Andrew's Works, St. Andrew's-9tkekt, 
Bethnal Grken, Londoh, E.) 

Petol is an interesting oily substance obtained from peat. 
It does not appear to contain bodies of the phenol type but 
certain hydrocarbon oils which have a germicidal value. 
“Petol fluid ” is a brown turbid mixture with a characteristic 


chloric acid to the fluid there is a separation of brown oils. 
Petol appears in a number of preparations intended for the 
purposes of antiseptic treatment. There are, for instance, 
petol soap, salve, disinfectant powder and fluid, and sup¬ 
positories. While there is evidence of petol having marked 
germicidal power it is non-corrosive and non-poisonous. It 
has been used, it is said, internally in typhoid fever. It 
appears also, in the form of ointment, to be an excellent 
antiseptic and healing application for wounds. 

SUto Indentions. 

A PORTABLE SURGICAL ENGINE. 

The accompanying illustration represents a manual and 
portable surgical engine designed to perform the work of the 
ordinary surgical motor in a private house. The most attrac¬ 
tive feature of this little machine is its portability—the 
handle, flexible spindle, and fixation clamp are all detachable 
and can, together with the body of the engine, be most 
easily accommodated in a hand-bag of the size of the 
ordinary midwifery bag. The construction is such that it 



can be clamped to any table or projecting ledge conveniently 
near the surgeon and the most unskilled person can supply the 
motive power. Practitioners are mostly agreed as to the value 
of the burr in the performance of mastoid operations : the diffi¬ 
culty hitherto has been to obtain a mechanism which would 
be serviceable anywhere and at the same time capable of being 
carried easily. This instrument, made at my suggestion by 
Messrs. Mayer & Meltzer, of London, I think supplies the 
want. Neil Maclay, M.B., C.M.Glasg., 

Honorary Assistant. Surgeon, Throat and Ear 
Wallaond-on-Tync. Hospital, Newcastle-on-Tyne. 

THE FIRST AID SNAKE BITE OUTFIT. 

A great many deaths are caused every year in tropical 
countries by the bites of venomous snakes and more than 30 
years ago the late Sir Joseph Fayrer recommended the local 
application of permanganate of potassium as an antidote. 
On account of the rapidity with which death follows a bite 
the treatment to be of any avail must be employed imme¬ 
diately. Sir Lauder Iirunton a few years ago accordingly 
devised a form of lancet set in a wooden handle, one end of 



The Lancet,] 


ROYAL COLLEGE OF PHYSICIANS OF LONDON —LOOKING BACK. [Feb. 8, 1908. 435 


which is hollowed oat so sis to contain a supply of the per¬ 
manganate. On the infliction of a bite free incisions are 
made in the part with the lancet and crystals of the perman¬ 
ganate are rubbed into them. The accompanying illustration 



shows at B an instrument of this kind, manufactured by 
Messrs. Ferris & Company, Limited, of Bristol, who have 
added some useful adjuncts, the whole of which are contained 
in a cardboard box of a size convenient for the pocket. B is 
a double-ended case of polished hardwood, having at one end 
a short spear-pointed lancet protected by a cover and at the 
other end a receptacle for the crystals. When closed it is 
three and a half inches long and half an inch in diameter; 
it may be carried alone if desired bnt the outfit as shown 
includes a small stock of dressing materials and an extra 
supply of crystals in a glass tube marked F. The price is 
3 1 . 6 d. The permanganate treatment of snake-bite has 
received official approval in Burma and in The Lancet of 
Jan. 2Eth one of our India correspondents gave an abstract of 
recent regulations on the subject. 


ROYAL COLLEGE OF PHYSICIANS 
OF LONDON. 


A Comitia was held on Jan. 30th, Sir R. Douglas 
Powell, Bart., K.C.V.O., the President, being in the chair. 

The President announced the following appointments : 
Dr. L. G. Guthrie to be the FitzPatrick lecturer for 1908, 
Dr. J. A. Ormerod to be the Harveian orator for 1908, Dr. 
W. Pasteur to be the Bradshaw lecturer for 1908, and Dr. 
R. T. Hewlett to be the Milroy lecturer for 1909. 

The following gentlemen having passed the required 
examinations were admitted as Members of the College : 
Jehangir Cawasjee Balsara, L.K.O.P.; Hector Charles 
Cameron, M.A., M.B. Cantab., L.R.C.P. ; Carey Franklin 
Coombs, M.D. Lond. ; John Gallic Fraser, M.B. Edin. ; 
Charles Edward Iredell, M.D. Lond., L.R.C.P. ; John Owen, 
M.D. Lond.; Herbert Chavasse Squire, M.A., M.B. Oxon., 

L. R.C.P.; Henry Letheby Tidy, M.B. Oxon. ; Godfrey 
de Bee Turtle, M.D. Dnrh., L.R.C.P. ; Rupert Waterhouse, 

M. D. Lond., L.R C.P. ; and John William Watson, L.R.C.P. 
Licences were granted to 68 gentlemen who had passed the 

required examinations. 

Diplomas in Public Health were granted jointly with the 
Royal College of Surgeons of England to the following 
gentlemen: Robert Cecil Turle Evans, L.S.A. ; Ernest 
Edward Scott Joseph Galbraith, L.R.C.P. A S. Edin., 
L.F.P. &S. Glasg. ; William Henry Hillyer, L.R.C.P. Lond., 
M R.C.S. Eng., M.D. Durh. ; Wharran Henry Lamplough, 

L. R.C.P. Lond., M.B.C.S. Eng., M.D., B.S. Durh. ; Arthur 
Rienssett Litteljohn, L.R.C.P. Lond., M.R.C.S. Eng.; James 
Mair, M.B., C.M. Glasg.; Fairlee Russell Ozzard (Major 
I.M.S.), L.R.C.P. Lond., M.R.C.S. Eng. ; George Elliott 
Frank Stammers (Captain R.A.M.C.), L.R.C.P. Lond., 

M. R.C.S. Eng. ; James Batson Stephens, L.R.C.P. Lond., 
M,R.C.S. Eng., M.B., B.S. Lond.; and John Tate, L.R.C.P. 
Lond., M.R.O S. Eng. 

The following communications were received :—1. From 
Mr. Charles Coates of Bath (to the President) presenting the 


College with the sum of £1000 to be used, invested, or dis¬ 
posed of as the President might deem most desirable. The 
thanks of the College were ordered to be given to Mr. Coates 
for his generous gift. 2. From the Secretary of the Royal 
College of Surgeons reporting proceedings of the Council on 
Jan. 16th, 1908. 3. From the council of the Geological 
Society conveying the thanks of the society to the College 
for its assistance in the recent celebration of the centenary 
of the society. 4. From the General Medical Council re¬ 
questing recommendations from the College in reference 
to the new edition of the British Pharmacopoeia. A com¬ 
mittee was appointed to consider any alterations or additions 
which might be deemed advisable. The committee consisted 
of Dr. F. Taylor, Dr. J. Mitchell Bruce, Dr. N. I. C. Tirard, 
Dr. W. Hale White, Dr. H. A. Caley, and Dr. J. Calvert. 
5. From Dr. Norman Moore, presenting a report on the 
November meeting of the General Medical Council. The 
report was received and adopted. 

Dr. G. K. Herman, Dr. D. A. Finlay, Dr. N. I. 0. 
Tirard, and Dr. W. P. Herringham were elected councillors. 

Dr. T. D. Acland was elected an examiner in medicine in 
place of Dr. H. M. Murray, deceased. 

Dr. F. H. Champneys was re elected a representative of the 
College on the Central Midwives Board. 

Sir W. S. Church proposed, and Dr. G. A. Heron seconded, 
that a small standing committee should be elected the busi¬ 
ness of which would be to keep the College informed of the 
arrangements and methods of teaching elementary hygiene 
in training colleges and schools, of the working of Section 13 
of the Education Act (medical inspection of the public 
elementary schools), of the position of the medical officers 
employed under it, and of any alterations which might be 
proposed by the Government' or others in the education or 
inspection of children or in the administration of the Act. 
The motion was adopted. The nomination of the com¬ 
mittee was postponed. 

The quarterly report of the College finance committee was 
received and adopted. 

After some further formal business the President dissolved 
the Comitia. 


Hooking Back* 


FROM 

THE LANCET, SATURDAY, Feb. 6th, 1830. 


MONSIEUR CHABERT. 1 

This person having advertised that he would repeat the 
whole of his “extraordinary performances " on Thursday, 
the Editor thought it his duty to attend, in order to 
administer a dose of prnssic acid to him. When challenged, 
however, Monsieur Chabert, in the most peremptory manner, 
refused to take the poison. Considerable uproar ensued, and 
Monsieur Chabert, after mucb prevarication, promised that 
the money should be returned, and he left the room to give 
the check-tickets, as he said, to the cashier. He was imme¬ 
diately followed by a large portion of the company—pressed 
upon rather severely by several gentlemen down the stair¬ 
case, and at length was fairly got out upon the pavement in 
Regent Street, where, finding one of the gates of the area 
open, he bolted from his pursuers down the steps, ran np the 
entire length of the area towards Oxford Street, and 
ultimately concealed himself in a coal-cellar. Attention was 
then directed to the proprietor of the rooms, Mr. Welch, 
who, after much clamour on the part of the assembly, 
directed that the money should be returned, or tickets be 
given to the claimants, securing payment od another day. 
The exhibition-room was crowded to excess, and it was 
Btated, at the doors, that upwards of five hundred persons 
left who were unable to obtain admission. 

As we are just going to press with this part of our Journal, 
we have neither time nor space to say more on the subject of 
this disgraceful humbug ; bnt in our next Number we will 
endeavour to publish a full and accurate report of the pro¬ 
ceedings. It is, however, more than probable, that public 
curiosity will be gratified by an account of them in the daily 
journals. 

1 Vide “Looking Back" in The Lancet of Jan. 18tb, p. 178, and 
Feb. 1st, 1908, p 383. 




436 Thb Lancet,] THE ASSASSINATIONS IN PORTUGAL.—QUACK MEDICINES IN JAPAN. [Feb. 8, 1908. 


THE LANCET. 


LONDON: SATURDAY, FEBRUARY S, 190S. 


The Assassinations in Portugal. 

For the third time within ten years the ruling house of a 
European country has had one of its most prominent 
members struck dead by the weapon of an assassin. On 
Sept. 10th, 1898, the EmpreBs of Austria was done to death 
by Luccheni. On July 29ih, 1900, King Humbert of Italy, 
whose life had been twice previously attempted, was shot at 
Monza by Bresci. And on Feb. 1st, 1908, King Carlos of 
Portugal and his son the Crown Prince were shot dead in 
their carriage by sundry assassins armed with repeating 
carbines. Queen Amelie and the Infante Manuel, now the 
King, escaped as by a miracle, for the assassination had been 
most carefully planned, for there are said to have been 
some 30 men told oil to carry out the plot, which apparently 
included the killing of the whole Royal Family. In the 
presence of such a tragedy our modern civilisation stands 
dumb ; we can but offer our sympathy to the widowed 
Queen deprived at one blow of her husband and her son. 

All modern political assassinations have one marked 
feature in common and that is their absolute uselessness 
from the point of view of the fanatics who plan them. 
From the murder of President Lincoln in 1865 down to 
that of King Humbert not one assassination has brought 
abont any change of constitution, and in some instances, 
instead of obtaining more liberty, the killing of the 
ruler has very naturally been the means of increas¬ 
ing repressive measures. No common reason has ever 
governed these crimes. In many instances the slain ruler 
was the head of a republic, for instance, Lincoln, Garfield, 
Carnot, and McKinley, while the Empress of Austria was 
not a ruling monarch. Alexander II., the last Emperor of 
Russia who met his death by assassination, had already freed 
the serfs and was on the eve of granting a constitution when 
he was killed. Humbert of Italy was unsparing in his care 
for his people and his devotion during the appalling calami¬ 
ties which afflicted his country, such as the earthquakes in 
Ischia in 1881 and in 1883 and the cholera at Naples in 1884, 
was as humble and self-sacrificing as any man’s action could 
be. Carlos of Portugal was a popular and (in the words of 
our Prime Minister) “ a manly, friendly, kindly king.” His 
desire to promote the well-being of his subjects was genuine. 
Our readers, for example, will remember his eloquent speech 
at the opening of the International Congress of Medi¬ 
cine at Lisbon in 1906, in which he referred to the 
necessity for organised work against the ravages of tuber¬ 
culosis, while testifying to the personal efforts in this direc¬ 
tion made by Queen Amelib. 1 The Crown Prince was 
a popular and blameless youth. The brutal murder of father 
and son leaves the dynasty at least as firmly seated on the 
throne as it was before, though the principle of the dictatorship 
has been abolished. The latest crime proves once again that 

1 In our issue of April 28th, 1906. we published an interesting picture 
of the King and Queen of Portugal presiding at the opening ceremony 
of the International Congress. 


nothing is sacred to the modern political assassin. He has 
but one ideal—namely, a blind hatred of any authority. It 
is enough that a man should be the titular head of a State 
and at once he is a mark for the knife, the bullet, 
or the bomb. The political assassin—that is to say, the 
actual murderer—is, as a rule, a man of no education, or 
of worse than no education, some one who has imbibed 
washy theories about liberty, which word he translates into 
license. Behind the actual murderer we find usually a group 
of badly educated unemployed professional men who disdain 
a life of honest work and who knowingly or unknowingly 
are always ready to hound on the worse educated lower 
classes to deeds of blood which they themselves are too 
cowardly to perform. 

As to the political events which have led up to the present 
crime it is not our province to discuss them. Given a Latin 
population, a widespread ignorance, a people quick to feel 
and quick to resent, and one conscious, or partially so, of the 
time when Portugal was paramount throughout nearly the 
whole known world, political unrest is to be looked for; 
the appointment of a dictator seems to have been the spark 
which set tire to the powder. To the young king who 
with his widowed mother will, it seems, have to share 
between them for some years at least a burden the weight 
of which might well overcome an experienced ruler 
the sympathies of all in this country will go out. 
Portugal has been leagued in friendly relations with the 
inhabitants of these islands since 1145, and there was a 
formal alliance between the two Crowns in the reign of 
Henry V. In many ways our peoples are alike. Both 
Portugal and these islands have bred hardy warriors, 
explorers, and navigators. From both lands great geo¬ 
graphical discoveries have resulted, while the sovereigns of 
either country have only recently been received in the other’s 
land with every mark of affection and respect. In no 
foreign country more than in the United Kingdom will 
sorrow for the living, regret for the dead, and horror at 
the crime be more widely spread. 


Quack Medicines in Japan. 

“ Dans l’adversiU de nos meilleurs amis,” wrote La 
Rochefoucauld, “nous trouvons toujoursquelque chose qui 
ne nous diplait pas,” and we are indebted to the number for 
last August of the Journal of the Asiatic Society of Japan 
for the information that our very good friends in the island 
empire of the East are sufferers to almost as great an 
extent as ourselves from the plague of quack medicines and 
quack advertisers. There is at least this much which may 
not be displeasing to ns in the intelligence that, assuming, as 
we may surely do, the supply of quack medicines to be a 
response to some demand deeply seated in human nature, we 
are very likely to receive from Japan before long some prac¬ 
tical suggestions concerning the way in which this demand 
may be satisfied with the smallest amount of injury to the 
community. Our allies are usually both scientific and 
thorough-going in any reforms which they undertake ; and 
if it were ever shown that quacks and quack medicines were 
to them the public injury and nuisance which they are to 
ourselves, we have little doubt that remedial measures from 
which we might take a lesson would be adopted with regard 
to them. 



Thk Lancet, ] 


A MINISTRY OF PUBLIC HEALTH: IS IT PRACTICABLE ! 


[Feb. 8, 1908. 437 


In the meanwhile, it is interesting to hear that the 
public places of Japan are being systematically invaded 
by the nnsightly advertisements which were first introduced 
in the United States and have spread with lamentable 
rapidity amongst oarselves ; because an outrage to the public 
sense of beauty and fitness is perhaps more likely to bring 
about reforms than any probable recognition of the mischiefs 
done by quacks and their nostrums to the public health. 
There is, at least, one point in which the Japanese adminis¬ 
tration contrasts favourably with our own, and it is that 
although the makers and sellers of quack medicines are 
taxed, as prostitution and other noxious trades are taxed in 
many countries, they are not, as with us, taxed in a manner 
whioh appears to imply governmental sanction or approval. 
There is no such a thing as a “ government stamp ” without 
which the preparation is not “ genuine,” and which is 
accepted by the ignorant as implying that if not Sir Henry 
Campbell-Bannerman or Mr. Balfour at least the Home 
Secretary is responsible for the “ genuineness ” in question, 
and is an accessory to the statements put forth by bold 
advertisement. Whenever Japanese statesmen realise that 
the national expenditure on quack medicines is, to say the 
very least, an entirely wasteful one, that reliance upon 
these preparations constantly serves to postpone the proper 
treatment of originally curable maladies until- the 
period of curability has passed away, and that a very 
large proportion of the so-called remedies are merely 
combinations of “nips” of alcohol with soothing doses 
of narcotics, calculated to bring these things into 
homes to which they would not otherwise have obtained 
access, we shall no doubt see the prompt adoption of 
remedial measures against the insidious sale of very 
dangerous poisons. If that time should come we may at 
least hope that some among our own politicians will be able 
to discover a chance of popularity in following the Japanese 
example. 

It appears from the articles by Mr. Royds and Mr. 
CLEMENT in the journal to which we have referred, that 
while the sale of quack medicines in Japan is effected by an 
organisation of pedlars rather than in shops, the repre¬ 
sentations put forth by the makers do not differ in 
any material degree from those with which we are only 
too familiar. Among the things sold are “brain- 
healing pills,” “poison-expelling pills,” "spirit-cheering 
pills,” “ heal-everything powders,” "one-dose-healing 
powders,” “ life-supporting powders,” and “ tonch-the-spot 
pastiles.” Our "pills worth a guinea a box” are fairly 
surpassed by the "thousand dollar pills” of Japan, 
pills the selling price of which is, we believe, 
expressed in fractions of a penny. In other respects, 
too, there are many points of resemblance ; and the chief 
differences between the English quack and his Japanese 
brother appear to depend on the fact that the popular 
superstitions to which both appeal are somewhat different in 
the two countries. But for this the methods and the 
pretensions are the same in both, and scarcely depart from 
those which prevailed among ourselves 150 years ago and 
were described by Goldsmith in bis “ Letters from a Citizen 
of the World.” Then, as now, our quacks received their 
knowledge of medicine by immediate inspiration from 
heaven and often spent a great part of their lives in 


unconsciousness of any latent excellence until a bankruptcy 
or a residence in jail called their miraculous powers into 
exertion. Then, as now, notwithstanding the existence of 
infallible remedies for every disease which it is possible to 
mention, there were many who thought it proper to be sick 
and even sometimes to die. “ Y’es, by theheadof CONFUCIUS, 
they die, though they might have purchased the health- 
restoring specific for half a crown at every corner.” 


A Ministry of Public Health : Is it 
Practicable ? 

The people of this country are at last awakening to the 
fact that if the nation is to hold its own in the constant 
struggle for survival which is part and parcel of nature’s 
method of improving the world’s stock, the physical fitness 
of the individual must receive more attention than hereto¬ 
fore. It is true that the death-rate is steadily declining 
and that the toll levied by that disease which has been 
erroneously termed the “white man’s plague” is slowly 
but surely becoming less, but it is equally true that the 
birth rate has reached a dangerously low figure, that our 
infantile mortality is still appalliDg, and that the aggrega¬ 
tion of the bulk of our population into towns may be, and not 
improbably is, interfering steadily with the stamina and 
physique of the people. The appeal to a declining death- 
rate is liable to delude us, seeing that it is possible by 
shielding weakly persons against all those conditions which 
are likely to determine life by accidents or to cause a fatal 
issue through disease to rear a race which under un¬ 
toward conditions, such as war or famine, would melt 
away into death or incapacity with amazing celerity. 
We fully admit that much of this may be mere specu¬ 
lation ; but the fear that the speculation may be true 
and that we may ere many years be past have, 
like France, a birth-rate only equal to our death-rate is 
bringing home to all seriously minded persons the need for 
every effort to be made to improve the public health. Dis¬ 
content with existing conditions of affairs is finding expres¬ 
sion in a demand that the central health department, the 
Local Government Board, shall be given a better 
position amongst Government departments and in the 
Cabinet than it at present possesses, and everyone who 
speaks upon the subject is expected either in his prologue or 
his peroration to call for the creation of a “Ministry of 
Health.” 

We are afraid that most of those who make this demand 
have but little knowledge of what they really mean in a 
creative sense; bat it is assumed that they are expressing 
dissatisfaction at the circumstance that while foreign, 
colonial, Indian, and military affairs are presided over by a 
Secretary of Stats, the health of the nation is consigned to 
a Minister who has multifarious and heterogeneous 
duties and who, although in the Cabinet, occnpies an 
altogether inferior position, and who receives as an emolu¬ 
ment a sum less than half that accorded to a Secretary 
of State. In other words, Mr. Burns —who is, or 
should be, responsible for the physique of those who 
man our ships and form our territorial forces, and who 
should be doing something to insure that there may still 
be a margin of popnlation which may help to keep out 


438 The Lancet,] TUCKER r. WAKLEY AND ANOTHER: SYMPATHY OF MEDICAL PROFESSION. [Feb. 8,1908. 


colonies supplied with immigrants—is practically in a sub¬ 
ordinate position, with a result that considerations as regards 
health are relegated to a second place in the councils of the 
nation. So much is clear, but the immediate creation of a 
Ministry of Public Health does not follow. To detach a 
small portion of the administrative routine of the Local 
Government Board and to accord to it the title of a 
“Ministry of Health” would be to create an additional 
Government department with no status, no direct voice in 
the Cabinet, and no power with the Treasury. Suoh a step 
would seem to us to put back the public health progress of 
this country by a quarter of a century, much as we sympathise 
with many of the arguments of those who desire such an 
innovation. 

The remedy for the present admittedly unsatisfactory state 
of affairs is, we think, not the division but the aggrandise¬ 
ment of the Local Government Board, the expansion taking 
the form of creating a Secretary of State for Public Health, 
upon which would follow the development of that medical 
department the classical researches and reports of which 
have carried its fame far beyond these isleB but 
which has not received from the State the encourage¬ 
ment which it unquestionably deserves. A Government 
department occupying but a very secondary rank in the 
Cabinet always runs the risk, a6 events have over and 
over again shown, of losing by promotion the services of a 
valuable- Minister. We have recently heard rumours of 
changes which would transfer Mr. Burns to a higher 
office and which would fill the Local Government Board 
with an untried hand who might occupy the next few years 
in learning the work, only to be removed at the end of that 
time by promotion. In the name of public health we 
protest against a condition of things which makes this 
waste of force possible at a time when the President of 
the Local Government Board is about to introduce into 
the legislature measures of the greatest importance as 
regards health. The subject will be shortly discussed 
in Parliament by Mr. Chaplin, who is to move an amend¬ 
ment to Sir William Holland's amendment to the 
address, and this, if carried, will express the opinion 
of the House of Commons that the Local Government 
Board shall be placed on a par with the office of a 
Secretary of State. We sincerely hope that this move¬ 
ment will be supported by all municipal and public bodies 
throughout the country and that powerful deputations will 
wait upon the Prime Minister urging the emancipation of 
public health from the disqualification and anachronism of 
being associated with a secondary position in the State. 


Harveian Society.— At the annual general 
meeting held at the society’s rooms the following officers 
were elected for the ensuing year. President : Mr. D’Arcy 
Power. Vice-Presidents: Dr. G. A. Sutherland, Dr. C. 
Buttar, Dr. H. J. Macevoy, and Dr. W. H. Blenkinsop. 
Treasurer : Mr. Francis Jailrey. Honorary secretaries : Mr. 
T. Crisp English and Dr. W. H. Willcox. A good programme 
of work has been arranged. The Harveian lecture will be 
delivered by Sir Almroth Wright upon Some Points in 
Connexion with Therapeutic Immunisation, and among 
other papers promised may be mentioned one by Dr, Samnel 
West on the Treatment of Pneumonia, to be followed by a 
discussion. 


Jirafftatimts. 


11 He quid Dimls." 


TUCKER v. WAKLEY AND ANOTHER: THE 
SYMPATHY OF THE MEDICAL PRO¬ 
FESSION. 

We are truly grateful to the many members of the medical 
profession who have written to us in terms of sympathy 
in regard to the issue of the recent libel action. It is plain 
to us that the medical profession has perceived fully that 
the course which we took was dictated to us by every reason 
there is for our existence and by every tradition of our 
career. At a meeting of the Council of the British Medical 
Association held on Jan. 29th, on reference being made to 
the case, the Chairman of Council, Mr. Edmund Owen, was 
requested to convey to us the following gratifying resolution 
which we learn from Mr. Owen was passed by the Council 
unanimously :— 

Resolution. 

That the Council, recognisiug the injury done to the 
public by the uncontrolled sale of secret remedies, desires 
to place on record its entire sympathy with the proprietors of 
The Lancet on the result of the recent action, Tucker c. 
Wakley and Another. 

We desire to thank the Council of the British Medical 
Association, and the great constituency which they rule, for 
their valuable support. _ 

DANGER IN GAMES FOR BOYS. 

An action was tried recently in the High Court in which 
a schoolmaster was the defendant and the plaintiff a school¬ 
boy whose leg had been broken while playing a game under 
the supervision of the master. It was contended that the 
defendant was negligent in permitting a dangerous game, 
consisting in races between boys, each of whom carried 
another boy on his back, across an asphalted playground. 
The plaintiff was said to have carried a boy heavier than him¬ 
self and to have slipped at a gully and fallen, fracturing 
his thigh. Medical evidence to the effect that the game was 
dangerous and also that it was not calculated to lead to any 
desirable physical improvement in the player and so 
fulfilled no useful object was given by Dr. J. N. McTurk 
of the Hospital for Sick Children, Great Ormond-street, 
but Mr. Justice Lawrance appears to have taken the view 
that to give effect to such an opinion would unduly restrict 
boys’ games, and comparisons were made by him between 
the accident which occurred and the possible injuries which 
may be inflicted at cricket by the ball striking a boy’s bead. 
The jury eventually found a verdict for the defendant with 
which none need find fault if allowance is made for the 
position of a master in an elementary school, who no doubt 
did his best to organise the amusements of those entrusted 
to his care in circumstances which render healthy and 
recreative exercise in which all can join a difficult thing 
to provide. At the same time, the opinion that the 
game played is not a desirable one is surely a correct one. 
It has attractions for boys because it requires no apparatus 
beyond wbat they themselves can supply and it lends itself 
to friendly competitions in strength and endurance. It is, 
however, very easy for the carrying boy to fall while over¬ 
weighted by his fellow borne on his back, and when he falls 
he does so not only with the other on top of him but with 
no power to save or to protect himself, as his hands are 
occupied in keeping his rider in his place and he 
has no time to disengage them. If the plaintiff bad 
oome down on the asphalt on his face he would pro¬ 
bably have suffered considerable disfigurement, and thongh 
he or any of his fellows might have fallen without actually 




Thb Lancbt,'] 


CALMETTES OPHTHALMOTUBERCULIN REACTION. 


[Feb. 8, 19Q8. 439 


injuring himself it was not likely that a fall would prove 
painless. The question how to provide exercise and amuse¬ 
ment for a large number of pupils in the small space 
available in metropolitan and urban schools is not an 
easy one to answer. Games as understood in “public 
schools” are out of the question, and the suggestion 
made by Dr. McTurk in reply to a question of Mr. Justice 
Lawrance, who asked if he would recommend diaboio as a 
safe form of recreation, was to the effect that dumb-bell and 
bar-bell exercises would be suitable. The difficulty, how¬ 
ever, of introducing exercises tending directly to physical 
development lies in the danger of their becoming merely an 
irksome and so an unpopular and a useless form of drill- 
Much, however, might be learned from the methods of train¬ 
ing and of exciting emulation in suoh matters practised in 
Switzerland and elsewhere on the continent, and it may be 
suggested that competitions between the various schools in 
the London Connty Council's district held in the public 
parks might arouse sufficient spirit of rivalry to make 
physical training generally popular and so generally 
beneficial. In order to produoe this result the competitions 
probably would have to be not between picked teams but 
between large bodies of the pupils consisting of all who had 
attained to a given degree of proficiency. The performance of 
such exercises is as least as manly a form of amusement as 
races “pick-a-back,” and it may be pointed out that such 
combined displays of thiB nature as are seen annually at the 
Military Tournament are always a popular item in the 
programme. _ 

CALMETTE'S OPHTHALMO-TUBERCULIN 
REACTION. 

Is our issne of Feb. 1st we published a short note from 
our Paris correspondent dealing with the ophthalmc. 
tuberculin reaction described by M. Calmette and we now 
lay before our readers a fuller ritvmi of the paper read by 
M. Calmette, referred to by our Paris correspondent. 
M. Calmette said that in the short time which has elapsed 
since he communicated his discovery to the Academie des 
Sciences (June 17th, 1907), the almost absolute accuracy 
with which the reaction reveals the existence of tuberculous 
lesions in evolution , although manifested by no clinical signs, 
has been confirmed by numerous observers. Many observa¬ 
tions have shown that the newly born children of tuber¬ 
culous mothers do not give the reaction. On the other hand, 
infants at the age of from 1 to 2 years react in the propor¬ 
tion of 3 ■ 42 per cent, and the percentage increases rapidly 
with age. It is 5'26 at the ages of from 2 to 5 years, 
13'5 at the ages of from 6 to 10 years, and 14 9 at 
the ages of from 11 to 15 years. These results are in 
accordance with the observations of Bang and Nocard that 
in cattle tuberculosis is scarcely ever congenital. By repeat¬ 
ing the test sufficiently often M. Calmette suggests that the 
exact time at which tuberculosis attacks a child may be 
ascertained. By studying at the same time the conditions of 
the family and the food supply he thinks that the part 
played by family contagion (contagion familiale ) and by the 
milk of tuberculous cows may be ascertained. By applying 
the test periodically to a family, or at least to those members 
in whom tuberculosis is feared, the infection may be detected 
at an early period, before even any clinical sign is perceptible. 
The patient may thus be isolated from his family and 
sent to a sanatorium and treated at the most favour¬ 
able time. At the anti-tuberculosis dispensary of Emile 
Konx at Lille the test was applied to the children of 
families the members of which were under treatment. 
Thns children apparently healthy were ascertained to 
be tuberculous and were sent to the country and 
placed in the best hygienic conditions. At the same time 
they continued their school studies until the instillation of 


tuberculin into the eye, repeated every two or three months, 
no longer gave a reaction. They were then sent back to 
their families. M. Calmette thinks, with Marfan, that 
experiments on animals and the observations on patients dis¬ 
charged several years from sanatoriums show that the 
complete enre of chronic tuberculous glands confers 
immunity against tuberculosis. He therefore hopes that a 
great number of theBe children will remain immune. The 
reaction would be equally useful in the examination of 
pupiU who seek admission to schools and are suspected 
to be tuberculous. Tuberculous pupils could thus be 
arrested “on the threshold '; in the army and navy the 
test could be put to a similar use. Professor Simonin of 
the military hospital of Val-de-Qriice has recently stated 
that the reaction reveals latent or insidious tuberculosis not 
evident clinically which provokes distant functional troubles 
of unknowu causation. It thus enables patients suffering from 
dyspepsia, palpitation, neurasthenia, “atonic rheumatism,” 
and so on, to be discharged from the military hospitals 
which they encumber. M. Calmette finally claimed that 
thanks to its fidelity and harmlessness, attested by more 
than 10,000 observations published in all countries, his 
reaction merited the confidence of clinicians and could play 
a great part in the social struggle against tuberculosis. By 
its use in families, in schools, in the army, in hospitals, and 
in all collections of persons those who were bearers of active 
tuberculous lesions could be detected. 


THE LEES AND RAPER MEMORIAL LECTURE. 

The eighth Lees ani Riper Memorial Lecture was 
delivered in the town-hall. Oxford, on Feb. 4th, by Mr. W. 
McAdam Eccles, under the presidency of the Regius Professor 
of Medicine, Dr. William Osier The subject of the lecture 
was the Relation of Alcohol to Physical Deterioration and 
National Inefficiency. Mr. Ejclea began by alluding to the 
action of alcohol upon living tissues, and then went on to 
quote figures from life assurance societies showing that 
total abstainers and their children were far better “ lives” 
than those who took alcohol. Mr. Eccles went on to point 
out that alcoholic stimulants led to physical degeneracy 
and this in turn to inefficiency. Inefficiency of indi¬ 
viduals led to inefficiency of the nation, and this 
in turn to loss of supremacy. He put forward the 
following suggestions to stem alcoholic indulgence : educa¬ 
tion of mothers and fathers, prohibition of the entrance 
of children into public-houses, feeding and teaching of the 
children of the land, limitation of the opportunities for 
adults to obtain liquor, the provision of sound recreation, 
and the promotion of research with the publication of its 
results. The numerous borough and parochial health 
societies springing into existence could do much to increase 
the knowledge of mothers. Municipal posters concerning the 
effects of the abuse of alcohol placarded on the boardings 
were very valuable. The recent disclosures as to the results 
on child life of the entrance of children into public-houses 
called for immediate and adequate legislation. But it was 
folly if, when the child was kept free from alcohol, he or she 
were allowed to become stunted in growth from a want of suffi¬ 
cient and proper food. Some means must be devised whereby 
hungry school children should be fed. The instruction of the 
child in the elementary school was of the utmost importance. 
The elements of hygiene and temperance were vital, and they 
could bo made very attractive to even the very young, 
if inculcated by a teacher of experience and ability. When 
a child had been taught these principles and had reached an 
age of discretion he or she should not be undnly tempted to 
fall from right paths by the continuance of a public-house at 
every street corner. If the public-house went something 
should take its place. What could be better than a happy 
home with a cheerful hearth, and a decent “ winter garden ” 




440 The Lancet,] 


THE CHARRED CEILING. 


[Feb. 8, 1908, 


or concert-house within reasonable distance? Moreover, to 
alter still further the trend of public opinion the universities 
should themselves encourage research into the many problems 
involved in the question of alcohol and publish the results 
with their weight of authority. By the establishment of a 
sensible and firm public opinion on the matter nearly all the 
difficulties of politicians and social reformers would disappear. 
While we are in agreement with Mr. Eccles as to the damage 
wrought by over-indulgence in alcoholic drinks and with many 
of his suggestions for dealing with the matter, yet we are 
not by any means certain that legislation will be of any 
avail. Education, the provision of places other than public- 
houses for amusement and light refreshments, combined 
with honest light beer or some similar drink, will do more to 
solve the problem than any amount of repression. Within 
the last 20 years the consumption of alcoholic drinks has 
diminished enormously and that not owing to legislation but 
to the development of common sense and the provision of 
rational amusement for those whose lives are cast among 
grey and dismal surroundings. 


THE CHARRED CEILING. 

A simple test which everyone can try for the presence of 
free sulphuric acid in a liquid consists in streaking the liquid 
upon a piece of white paper as with a quill pen and drying 
the paper before the fire. The track of the sulphuric acid, 
if any is present, is marked out by a black line appearing 
as soon as the paper is dry and warm. In short, the acid 
in this procedure is concentrated until it becomes strong 
enough to char the paper. The test is quite delicate and is 
practically demonstrated in the rooms of a house lighted 
by means of coal gas. Sooner or later the ceiling of a 
room in which gas lights are burning is blackened, and 
if chimneys over the burners are used the blackening 
is more or less localised in a ring immediately over 
the burner. The common acceptance of this is that 
soot is deposited, whereas the discolouration may not be 
due to soot at all. We had occasion recently to examine 
the circular patches of discolouration which appeared in 
just those places on a papered ceiling which were im¬ 
mediately above a gas burner. The apparently charred 
pieces of paper were very acid and sour to the taste and on 
soaking them in distilled water a weak solution of sulphuric 
acid was obtained. Further examination showed that the 
amount of sulphuric acid in the paper was equivalent to as 
much as 16 grains of pure acid to the square foot. The 
charred ceiling, therefore, is the result of the action of 
sulphuric acid derived from the combustion of the sulphur 
compounds contained in the gas upon the organic substances 
in the ceiling or in the paper (if it happens to be papered). 
It is fairly reasonable to suppose that the action of this 
sulphuric acid is not limited to one part of the ceiling but in 
course of time becomes general. The use of a chimney on 
the gas burner concentrates the mischief on the ceiling and 
hence the more or less rapid appearance of black circular 
patches immediately over the burners. In the case of a 
papered ceiling the paper is sooner or later destroyed, chars, 
crumbles, and peels off. When there is no chimney the 
products of combustion are to an extent distributed and 
then the charring is spread over a greater surface, the 
ceiling getting seared uniformly throughout, but not so in¬ 
tensely, of course, as when the effects of the gases are 
localised. This is why the inverted incandescent gas burner 
appears to blacken the ceilings to a less degree than the 
upright burner provided with a chimney The products of 
combustion in the former case are distributed, w hile in the 
latter they are concentrated and directed to a comparatively 
small part of the ceiling. The worst feature from a health 
point of view of gas lighting is undoubtedly thiB produc¬ 
tion of sulphurous ar.d sulphuric acids, for in comparison 


with these the other products of combustion—namely, the 
moisture and carbonic acid gas which are both normal 
products of human exhalation—may for all practical 
purposes be neglected unless, of course, no precautions are 
taken in regard to their removal by ventilation. It is to be 
regretted, therefore, that the hitherto strict requirements con¬ 
cerning the permissible amount of Hulpbur components in coal 
gas are in many cases relaxed. We are quite aware that the 
complete removal of sulphur from coal gas is a very costly 
business in its manufacture, but if an economical method of 
freeing coal gas entirely from sulphur could be devised and 
put into practice the chief argument which hygienic considera¬ 
tions raise against the use of coal gas for lighting and even 
heating purposes in some cases would have to be dismissed. 
As it is, the obvious drawback to coal gas containing sulphur 
compounds is that the products of its combustion are 
calculated to do damage to the appurtenances of the dwell¬ 
ing room and add to the atmosphere a constituent or con¬ 
stituents which in the interests of health should not be 
there. _ 


THE HISTORY OF KEFIR AND ITS MODE OF 
PREPARATION. 

Kefir has been esteemed as a beverage from time 
immemorial by the inhabitants of the northern part of the 
Caucasian mountains. Its history and mode of preparation 
are well described by Dr. J. V. S. Stanislaus in the January 
number of the American Journal of Pharmacy. Kefir is not 
an imitation of koumis which is made by the Tartars from 
mare’s milk. It is prepared from cow’s milk, by the action 
of a ferment called “ kefir grains.” The origin of kefir 
grains is not definitely known but the tribes of the Caucasus 
consider them to have a sacred origin. There is an Oriental 
legend that the first Mohamed conferred this blessing 
upon his chosen people. Hence the grains are known as 
the "millet seeds of the Prophet." In Europe they 
are variously known as "kefir champignons” and "kefir 
mushrooms." Professor Podwysocki of Riga has explained 
their origin in the following way. Certain tribes, migrating 
into the mountains, were obliged to raise more cattle than 
horses, with the result that there was a shortage of mare’s 
milk. They therefore added the koumis ferment to a mixture 
of cow's and mare's milk and in the course of time 
the ferment acquired a different form and composition, con¬ 
stituting what are known as kefir grains. Until recently the 
tribes dared not offer the grains for sale or even as a gift, 
because there existed a strong belief that by parting with 
some of them the remainder would lose their fetichistic power 
to ferment. At the present time they may be purchased 
without much difficulty. When kefir grains are added to 
cow’s milk alcoholic and lactic fermentations occur and the 
albuminous bodies are peptonised. Kefir, when 24 hours old, 
contains 4 ■ 15 per cent, of albuminous substances, as com¬ 
pared with 4 08 per cent, in cow’s milk. It contains, in 
addition, O'49 per cent, of alcohol, O'52 per cent, of lactic 
acid, and 2'05 per cent, of lactose, as compared with 
4'92 per cent, in cow's milk. It contains no fat, is whitish 
in colour, and pleasant to taste. In preparing kefir healthy 
grains may be recognised by their irregular form and size, 
their hardness, and yellow to brick-red colour. The first step 
consists in making the "starter.” This is done by 
macerating the grains in warm water for 24 hours, changing 
the water at least four times. Two tablespoonfuls of the 
soaked grains are then strained from the water and added 
to about 350 cubic centimetres of fresh inilk. The vessel 
is covered with muslin and kept at a temperature 
of 15° to 18° C. until the grains begin to float upon the 
surface of the liquid, care being taken to stir the mixture 
occasionally during the first few hours. The grains can be 
used again several times. The strained liquid constitutes 




The Lancet,] 


MEDICAL FEES AT CORONERS’ INQUESTS. 


[Feb. 8,1908. 441 


the “ starter,” and the grains can be covered with milk and 
set in a cool place until the next day. The “ starter ” is then 
mixed with 188 cubic centimetres of boiled milk in a bottle 
which should not be completely filled. The bottle is corked 
immediately and kept at a temperature of 20° to 23° C. until 
the liquid begins to thicken. This process requires from 18 
to 25 hours in winter and from 14 to 20 hours in summer. 
The thickened liquid is then agitated vigorously and kept in 
a cellar at 9° to 12'5° C., the agitation being repeated every 
two hours. Kefir is known as “day old,’’ “two day old,’’ 
and “ three day old,” according to the time allowed for 
fermentation. The longer the grains are used the better is 
the quality of the product. Kefir so prepared possesses a 
pleasant, refreshing, and slightly acid taste. By prolonging 
the period of fermentation the alcohol and carbon dioxide are 
increased and a more thorough peptonisation is secured. 
Kefir may be combined with ferric lactate or pepsin for 
administration in anmmia and dyspepsia. 


MEDICAL FEES AT CORONERS' INQUESTS. 

The Lancashire county council has come to the decision 
to pay in the future only 1 guinea per inquest to medical 
practitioners attending to give evidence, even if several days 
are required for the completion of the inquiry. In 
support of this decision the clerk of the council refers to 
Section 22 of the Coroners Act, 1887, which governs 
the question of fees to medical witnesses, making re¬ 
ference, we presume, only to the giving of evidence 
and not to the making of post-mortem examinations. 
This is a momentous decision of the council and we are not 
surprised to find our esteemed contemporary the Liverpool 
Courier asking “if the county financiers are right in their 
reading of the Coroners Act, how is it the discovery has been 
so long delayed!” and adding: “perhaps the committee 
has reached an interpretation which the legislature never 
contemplated 1 ” Looking carefully at the wording of the 
Act we are compelled to agree that the interpretation of the 
finance committee of the Lancashire county council may be 
literally correct, for we cannot find anything definite in the 
Act as to additional medical fees for protracted work. 
Donbtless the legislature had in mind that an inqueBt seldom 
occupies more than one day and that the coroner could easily 
make arrangements for additional medical assistance. At the 
same time the attitude of the Lancashire county council may 
eventually lead to a result which they hoped to avoid—viz., 
the undue swelling of expenses. Supposing, for instance, 
that a medical practitioner has obeyed the coroner’s 
summons—if he does not he renders himself liable to a fine of 
£5, attends on the first day and gives evidence, and then is 
re-summoned by the coroner on a subsequent day we are in¬ 
clined to think that he would be entitled to demand an extra 
guinea. Of course, the coroner, the servant of the county 
council, might have to pay the fee out of his own pocket or 
fight a pretty point on behalf of the medical profession, 
and we are not so unreasonable as to expect that he should 
be invited to do anything of the sort. But it is certainly 
ridiculous that should a prisoner be tried at the assizes on 
a coroner's inquisition alone the medical witness would be 
entitled to the ordinary fees allowed for attendances in 
criminal courts, while according to the recent decree of the 
Lancashire county council he would only receive 1 guinea 
for employing an equal or a greater amount of valuable 
time while attending the preliminary proceedings before 
the coroner. It is pleasant to read the forcible 
opinion of Mr. Coroner Brighouse, who is a solicitor, 
and his condemnation of the slight on the medical pro¬ 
fession. The subject is worthy of the attention of all our 
readers, for the precedent may be followed by other county 
councils to the detriment of a profession already burdened 
with many inadequately paid duties. We are grateful to the 


Liverpool Courier for its evidently sympathetic attitude 
towards the medical profession, for we have to remember 
that a certain section of the press owes an appreciable 
portion of its revenue to the misrepresentation of our calling. 


JANUARY AT HOME AND ABROAD. 


- 

Highest 

temperature. 

Lowest 

temperature. 

Mean maxi¬ 
mum tempera¬ 
ture. 

Mean mini¬ 
mum tempera¬ 
ture. 

Mean tem¬ 
perature for 
month. 

Mean range of 
temperature. 

J3 

% 

5--S 

Q 

Total fall in 
month. 



0 

o 

O 

o 

1 O 

o 


. 

ins. 

Scilly . 


54 

33 

1 49 

42 

45*3 

7 

11 

117 

Jersey . 

... 

52 

24 

1 45 

36 

40 5 

9 

6 

0-88 

Torquay. 


55 

24 

46 

36 

41 0 

10 

9 

1-26 

Weymouth ... 


53 

23 

44 

35 

394 

9 

6 

0 92 

Bournemouth 


53 

19 

43 

33 

380 

10 

5 

076 

Sandown, Isle 
Wight 

of 1 
.../ 

53 

25 

46 

35 

40 7 

11 

6 

1-38 

Brighton 


48 

20 

42 

33 

37 5 

9 

3 

1-46 

Bath . 


53 

17 

43 

32 

37 5 

11 

6 

1*27 

Harrogate ... 


56 

17 

41 

29 

350 

12 


1*60 

Manchester... 


57 

21 

42 

33 

37 3 

9 

7 

2-C4 

Nottingham... 


56 

16 

42 

30 

35 7 

12 

7 

107 

London. 


54 

20 

43 

32 

37 4 

11 

4 

1-50 

Paris . 


53 

12 

39 

26 

322 

13 

6 

0-62 

Berlin . 


50 

12 

37 

26 

31 5 

11 

11 

1*52 

Brussels 

... 

48 

8 

37 

24 

30 ; 5 

13 

11 

1*13 

Nice . 


67 

23 

51 

37 

44 3 

14 

No rain. 

Genoa . 


55 

32 

49 

42 

455 

7 

3 

1*65 

Florence 


64 

25 

45 

33 

39-0 

12 

6 

1*25 

Rome . 


57 

29 

51 

37 

43-6 

14 

7 

1 71 

Naples. 


64 

30 

53 

43 

48-0 

10 

9 

3 40 

Palermo 


68 

36 

60 

43 

51-4 i 

17 

6 

1C9 

Malts . 


65 

48 

60 

52 

557 

8 

5 

1-05 

Algiers. 


72 

43 

64 

51 

57-6 

13 

9 

5 06 

Biarritz . 


64 

32 

56 

41 

484 

15 

7 

1*74 

Lisbon . 


64 

39 | 

56 

47 

51-6 

9 

10 1 

3*42 


• A day with at least 0'04 in. 


The rather prolonged Bpells of frosty weather which prevailed 
over the United Kingdom during last mouth paid only 
transitory visits to Southern Europe, while Palmero, Malta, 
Algiers, and Lisbon escaped the frost altogether. The 
Scilly Islands experienced a like exemption, but over this 
country generally, and throughout Central Europe, the Low 
Countries, and the north and east of France the cold was 
often very severe. Although over the northern half of Italy 
the wintry rigour was reduced by the proximity of the 
Mediterranean, the sheltered thermometer descended to the 
freezing point or below it on nine different nights at Rome 
and on 16 at Florence. In comparing the temperature at 
places in the south of these islands with that in Southern 
Europe it will be observed that the figures at Scilly were 
almost identical with those at Genoa, while the nights at 
Scilly (as shown by the mean minimum temperature) were 
no less than five degrees warmer than those at Nice and 
Rome, nine degrees warmer than those at Florence, one 
degree warmer than those at Biarritz, and only just one 
degree cooler than those at Naples and Palermo. The warmth 
of the days was, however, far greater at nearly all the resorts 
on the shores of the Mediterranean, especially at Palermo. 
Malta, and Algiers. At this last-mentioned place the nights 
were as mild as the afternoons were at Bournemouth, Bath, 
and in London, and the days were as warm as the average day 
in the south of England towards the end of May. Paris, 
Berlin, and Brussels were all much colder than London and 
the English Midlands, the mean temperature of the month at 






442 The Lancet,] ALCOHOL IN THE TREATMENT OF PNEUMONIA AND ENTERIC FEVER. [Feb. 8, 1908. 


Brussels, 30'5°, being exceptionally low. Both at home 
and abroad the period was dry. On the French Riviera, a6 
represented by Nice, there was no measurable quantity of 
rain, while at almost all the other foreign resorts, as well as 
those on our own south coast, the number of days with rain 
was very small. As a rule, the month was very sunny in 
Italy, the Riviera, and the Mediterranean region generally, 
and there wa6 also much more sunshine than usual on the 
south and south-west coasts of this country. The figures 
from the foreign resorts were not available and those for 
the home resorts are not given in the above table, but the 
number of hours registered at many places in the south and 
south-west of England was between 80 and about 100. At 
some spots the figure was about twice as high as usual. Over 
the more inland parts of the country the sun was frequently 
obscured by fog and mist. In London (Westminster) there 
were only 22 hours of sunshine, while at Manchester there 
were no more than about ten hours. It would not be 
fair to compare the duration of sunshine in London with that 
at places on the south coast, but as the sun shone brightly 
for 64 hours at Bath, an inland spot practically in the same 
latitude as the metropolis, it may be assumed that the 
smoke and dust robbed the more central parts of London of 
at least 40 hours of health-giving sunshine. At Manchester 
there were 25 sunless days, at Westminster 14, and at 
Nottingham, where the aggregate number of hours of sun¬ 
shine was 38, there were also 14 sunless days. 


ALCOHOL IN THE TREATMENT OF PNEUMONIA 
AND ENTERIC FEVER. 

The International Union of Medical Abstainers, founded 
at Stockholm in 1907, has resolved as part of its operations 
to attempt the solution of the question as to the valne of 
alcohol in the treatment of lobar pneumonia and enteric 
fever. A statistical inquiry is to be instituted and “all 
hospital and infirmary physicians, medical superintendents, 
or registrars are earnestly requested to assist in this work, 
both in the interests of medical scienoe and of the siok.” 
Whilst agreeing that trustworthy information on this 
point is desirable we cannot give unqualified approval to 
the methods which it is proposed to adopt. The proposed 
lines of the inquiry are as follows. There are two distinct 
plans which may be adopted by those wishing to help in the 
accumulation of statistics: “Plan A. 1. Every participator 
declares himself prepared to treat all cases of lobar pneu¬ 
monia and enteric fever over 15 years of age which he may 
have to treat in hospital or otherwise between January 1st 
and December 31st, 1908, alternately—he., the first with, the 
second without, alcohol, and so on. 2. The administration 
of alcohol is to be as usually given by the reporter both as 
to form, quantity, and duration. It is desirable that a 
mixture of alcohol and water should be used of definite 
strength as the commercial wines and spirits vary consider¬ 
ably. 3. The other treatment will be on the usual lines 
according to circumstances. 4. Departure from the treat¬ 
ment in turn is especially deprecated, but if for some reason 
(such as intolerance of alcohol) it occurs it should be noted 
on the form with the reason for such occurrence. Plan B. 
5. If the alternate treatment of cases with and without 
alcohol is objected to it is hoped that the alternative proposal 
will be adopted—viz., a simple return of the treatment as 
regards alcohol and the result on the same form. 6. Every 
case is to be reported on a form which will be supplied on 
request. These forms should be returned to Dr. J. J. Ridge, 
Carlton House, Enfield, not later than January, 1909.” We 
imagine that few physicians, who have been accustomed to 
give alcohol in cases of lobar pneumonia and enteric fever, 
would consent to have their treatment dictated in this 
manner, so that their patients should be treated alternately, 
with or without alcohol, although they might be perfectly 


willing to give the statistics of the results of cases that have 
come under their care. Plan B commends itself to us more 
favourably than Plan A, but whether any trustworthy con¬ 
clusions will be arrived at from this inquiry remains to be 
seen. The personal eqnation in such an investigation is 
difficult to eliminate but nevertheless we have no wish to 
discourage any attempt to arrive at the value of alcohol as a 
drug and we shall watch the result of this endeavour with 
interest. __ 

ROYAL COLLEGE OF PHYSICIANS OF LONDON. 

The lectures of the Royal College of Physicians of 
London for the present year will be delivered at the 
College, Pail-mall East, on the following Tuesdays and 
Thursdays at 5 o’clock: The Milroy lectures on Melitensis 
Septicmmia (Malta or Mediterranean Fever) will be delivered 
by Dr. J. W. H. Eyre on March 5th, 10th, and 12th; the 
(Joulstonian lectures on the Influence of Pregnancy on 
certain Medical Diseases, and the Influence of Certain 
Medical Diseases on Pregnancy, will be delivered by Dr. 
Herbert French on March 17th, 19th, and 24th ; the 
Lumleian lectures on Points of Practice in Maladies of the 
Heart will be delivered by Sir James Sawyer on March 26th 
and 31st and April 2nd ; and the Oliver-Sharpey lectures on 
the Present Position of our Knowledge regarding the Supra¬ 
renal Capsules will be delivered by Professor A. E. Sobiifer, 
F.R.S., on April 7th and 9th. 

WATERSHEDS AND RAINFALL. 

At the annual meeting of the Royal Meteorological 
Society, which was held at the Institution of Civil Engineers 
on Jan. I5th, Dr. H. R. Mill, the President, delivered a most 
interesting address upon “Map Studies of Rainfall.” Dr. 
Mill Is the director of the British Rainfall Organisation, so 
that he dealt with a subject of which he possesses special 
knowledge. After describing the method of preparing 
annual, monthly, and daily maps of rainfall, he went on to 
draw attention to the extreme importance of accurate know¬ 
ledge of the rainfall of a county, for the problem of the 
rivers is becoming acute. He added that the increasing 
strenuousness of the straggle for the possession of large 
water-supplies is producing in England, and especially 
In Wales, a great amount of local jealousy and strife, 
for the boundaries of parishes and counties coincide but 
rarely with water partings and the argument has been 
brought forward again and again that the rainfall of one 
county should not be diverted for the use of the inhabitants 
of another. But, continued Dr. Mill, “ I think that the 
study of rainfall can do something to suggest the lines on 

which such disputes should be settled. Most of the rain 

is borne to our islands from the Atlantic ; ...... it is of the 

air, and no boundary checks it; the largest annual falls come 
down on and near the watersheds because there the land 
produces its maximum influence as a rain compeller.” There¬ 
fore, concluded Dr. Mill, care for the water-supply of the 
country Is by no means a parochial but in the fullest sense a 
national matter and should be dealt with in the interests 
of the nation as a whole, the units of subdivision 
when such are required being the natural units of river 
basins. We congratulate Dr. Mill upon his address which 
deals with a matter of the first importance. He shows that 
physical geography may be taken to afford as good an 
argument for the precipitation of the West being used to 
supply the great towns of the East of these islands as 
political geography may be taken to afford an opposite 
argument. London and the busy Welsh towns of Cardiff 
and Swansea are already arming for the fight for the 
possession of the Welsh watersheds. Liverpool has annexed 
the Vyrnwy district and Manchester the waters from Thirl- 
mere. Unless that congeries of cities called London becomes 






The Lancet,] 


INFANT MORTALITY IN HUDDERSFIELD. 


[Feb. 8, 1908. 443 


alive to the situation her citizens may soon have cause to 
complain with the chorus in Medea :— 

&VIU TTOTafUtlV icpuv x w P°v ffL ira-yal, 

Kal SIk a Kal navra iraXiv (Trr^r/i'rai. 

We must not be taken to imply that the Welsh scheme which 
has been put forward is the only solution of the problem but 
it is certain that the river water-supply at present available 
will not suffice for the population of 50 years hence. Our 
views on the matter were set forth at large in a leading article 
which appeared in The Lancet of Dec. 14th, 1907. 


always results from direct pressure of the effused blood on 
the heart. As the blood poured out from the left ventricle or 
from a coronary artery will exert almost the same hydrostatic 
pressure as that present in the left ventricle the pressure 
in the pericardium will be much greater than that in the 
intrapericardial portions of the venm cav:e ; so that these are 
compressed and no blood can enter the heart and syncope 
follows. The quantity of blood lost has practically nothing 
to do with the fatal result, for the total amount of blood 
which can be poured out into a normal pericardium is but 
small. 


INFANT MORTALITY IN HUDDERSFIELD. 


THE DEATH OF MR. W. A. SHENSTONE, F.R.S. 


A striking report by Dr. S. G. Moore, medical officer 
of health of the borough of Huddersfield, has been published 
by the borough council. The report shows the result of the 
systematic work which has been done in Huddersfield with 
the Intention of lowering infant mortality, and the figures 
for the year 1907 show the conspicuous success which has 
attended the efforts of Dr. Moore and his authority. 
During 1907, 2189 births occurred in the borough, and 212 
infants less than 12 months old died, giving an infant mor¬ 
tality figure of 97. The records of the department extend 
back for 31 years, and how very successful the work has been 
will be perceived when we say that the present figure 97 is 
not only the lowest on record—the figure for the first time 
having fallen below 100—but the mean for the ten preceding 
years, 1897 to 1906 inclusive, was 135. Thus there has been 
effected a reduction of 28 per cent. The mean for the three 
years 1905-06-07 during which the work has been in progress 
is 117, and for the ten years preceding this, 1895 to 1904 
inclusive, it was 142. The figures are shown on a chart which 
accompanies the report and are further summarised as 
below :—- 


Births 

registered. 


1907 . j 

Preceding 10 vears i i 

1897-1906 .( j 

The three years d ur-'i 
ing which special I 
work against in-1 
lant mortality has i 
been in progress, I 

1905-06-07 .J > 

Preceding 10 years, 1 
1895-1904 .11 


2,189 

22,991 


6,746 


22,681 


Dfaths 

under one 
3 *ear of age. 

I 

Infant 
mortality 
j figure. 

[ 

212 

' 97 \ 

Reduction 
23 per cent. 

3104 

135 

— 

792 

117 -j 

, Reduction 
18 percent. 

3215 

142 

- 


Huddersfield, as Dr. Moore points out, is an industrial 
centre with not less than 25 per cent, of the female popula¬ 
tion at child-bearing ages working in textile factories. It 
is therefore the more surprising to find the infant mor¬ 


tality figure reduced to a rate comparable with that of the 
healthiest counties and rural districts. We congratulate all 
concerned on the result of their labours and hope that other 
authorities may be stimulated to similar exertions. 


H/EMO-PER1CARDIUM FROM RUPTURE OF A 
CORONARY ARTERY. 

Apart from those cases which are due to injury, nearly all 
instances of fatal haemo-pericardinm are dne to the bursting 
of an aneurysm arising from the heart itself. Very much 
more rarely is a hmmo-pericardium produced by an aneurysm 
of the coronary artery. In the present issue of Thf. Lancet 
Mr. J. Lougheed Baskin records a case in which a fatal 
haemorrhage into the cavity of the pericardium resulted from 
a gummatous deposit in the wall of the heart involving the 
left coronary artery about one and a half inches from its 
origin ; the artery had given way but no obvious aneurysmal 
dilatation was seen. Death in these cases of hmmo-pericardium 


The death of Mr. W. A. Shenstone, F.R.S.. will be very 
widely regretted by chemists and physicists alike. He will 
be remembered most perhaps for his consummate skill at 
glass-blowing, which ultimately led the way to the 
use of pure silica or quartz for purposes of chemioal 
research. Silica vessels are now a commercial quantity, 
and since this beautiful material resists the action 
of extreme changes of temperature and is also unaffected 
by acids it threatens to replace the use of expensive platinum 
apparatus in many chemical operations. Mr. Shenstone was 
an able investigator of chemical science and contributed 
a number of valuable papers to the scientific societies. 
He was senior science master to Clifton College, Bristol, 
for 27 years, a post which he held up to the time of his 
death which took place in Cornwall on Feb. 3rd. He 
possessed a charming personality which contributed no little 
to his power as a teacher of principles and practice. His 
attitude towards science is well summed up in a very able 
series of essays on tbe new physics and chemistry which 
were published in the CornJiHl Magazine a year or so ago. 
“ Though science," he wrote, 11 reveals herself to most of us 
chiefly through her more obviously useful discoveries and 
inventions, those who look for them will still find amongst 
us not a few men and women as ready as any of their pre¬ 
decessors to devote days and nights to hard labour for no 
other fee than the hope of discovering a new truth, over¬ 
throwing an ancient error, or extending in some other way 
the boundaries of knowledge." Mr. Shenstone was amongst 
the great labourers of science. 


THE RELATION OF ADENOIDS TO PALATAL 
DEFORMITIES. 

In the course of a suggestive paper in the Dental Record 
for January, Dr. Eugene S. Yonge refers at some length 
to the interesting question of the relation of adenoids to 
palatal deformities. Tbe more important theories that have 
been advanced are briefly recounted, but in his opinion not 
one of them offers a satisfactory explanation. Some stress 
is laid on the fact that a large number of patients show 
deformed arches who are not, and never have been, mouth- 
breathers, while on the other hand such deformities are 
often entirely absent in those the subjects of well-marked 
nasal obstiuction. Reference is made to the frequent 
association of high arched and contracted palate and 
associated anomalies in people with long narrow faces 
and to the view held by some that this type of 
face is a departure from the normal and may be 
hereditary. Dr. Yonge is of the opinion that the adenoids 
and deformed palates are not in causal relationship but are 
rather due to a common cause, and as an explanation of 
this frequent association he suggests “ that if we assume 
that the deformities of the palate are principally due to an 
abnormality, which is of a hereditary or constitutional or 
even racial character, affecting the structure of the facial 
bones, we are enabled to understand why these defects may 
occur independently of mouth-breathing and why mouth- 
breathing of itself does not tend to them. We are also 





444 The Lancet,] 


THE METROPOLITAN STREET AMBULANCE SERVICE. 


[Feb. 8,'1908. 


enabled to understand why adenoids are so frequently 
found in association with these deformities; for it is 
well known that individuals with leptoprosopic heads 
are more liable to give evidence of the effects of nasal 
obstruction on account of the narrowness of the nasal 
and naso-pharyngeal cavities than persons with chamse- 
prosopic heads. Moreover, adenoids and other forms of 
nasal obstruction are, for some reason, far more common 
in leptoprosopes than in chammprosopes. These facts there¬ 
fore will help to explain how it is that the salient symptom 
of nasal obstruction (mouth-breathing) is noticed so fre¬ 
quently in conjunction with contracted alveolar arches. It 
is not, of course, that individuals with chamseprosopic heads 
enjoy an immunity from adenoids, but the symptoms do not 
develop in these subjects unless the collection of adenoid 
tissue in the naso-pharynx (which is indeed present in prac¬ 
tically all children) has hypertrophied to a considerable 
extent." __ 

THE METROPOLITAN STREET AMBULANCE 
SERVICE. 

Amongst the Parliamentary business connected with the 
public health and carried forward from la9t year the con¬ 
sideration of the street ambulance provision for London by a 
Departmental Committee bolds a prominent place. As that 
body will shortly make public the result of its deliberations 
we will again remind our readers of the importance of pro¬ 
viding easy and speedy means of transporting persons 
injured in the streets to the nearest general hos¬ 
pital and of the admirable model which the City 
police-force hers given the metropolis by the institu¬ 
tion of its motor ambulance servioe. In our issue 
of Nov. 23rd, 1907, p. 1474, we summarised in a 
leading article the history of the ambulance service for 
London, and on that occasion as on many others we 
pointed out the great measure in which the Metropolitan 
Street Ambulance Association has helped its development. 
The financial aspect, of conrse. must not be lost sight of in 
these days of municipal retrenchment, but a correspondent 
points out that the amount expended on ambulance work by 
the metropolitan police is very small in proportion to the 
sum paid to that body by the ratepayers. The official 
accounts show that in the financial year 1908-07 the 
metropolitan police received for all purposes £1,097,495 
from the rates and expended on “ medical attendance, 
medicines, &c., for prisoners and poor persons injured in 
public thoroughfares” £8098 13*. 5 d. We are not in a 
position to Btate to what extent this connotes expenditure 
on street ambulance work, but in any case the sum can only 
be a small fraction of the total police expenses, and if the 
urgent need of a more efficient and better organised 
ambulance service than at present prevails were more widely 
understood we think that few ratepayers would object to the 
appropriation of a larger share of their police-rate to so 
humane a purpose. It is to be hoped that before the end of 
the year the motor ambulance van will be a familiar object 
outside the boundaries of the City of London. 

HERPES FACIALIS IN DIPHTHERIA. 

Dr. J. D. Rolleston has contributed to the Brittih Journal 
of Dermatology for November an important paper on a com¬ 
plication of diphtheria which though not very rare has not 
received much attention—herpes facialis. Of 1370 cases of 
diphtheria, in all of which the diagnosis was verified bacterio- 
logically, herpes labialis was present in 55 (4 per cent.). In 
the great majority (42) the lips alone were affected. Much 
less frequently the cheeks (six cases), the chin (four cases), 
and the nostrils (three cases) were attacked. Orsi, the only 
writer who has produced a monograph on the subject of 


herpes facialis in diphtheria, pointed out that the herpes fre¬ 
quently developed on the side on which the angina was pre¬ 
dominant. This Dr. Rolleston has observed in some, but by 
no means in all, of his cases. The herpes was almost in¬ 
variably an early symptom ; it usually appeared on the third 
or fourth day ; in only two cases did it appear after the first 
week. In non-diphtheritic angina Dr. Rolleston finds that 
herpes facialis is still more common. Out of 145 patients 
admitted into hospital and certified as suffering from diph¬ 
theria, who were ascertained subsequently to have only 
tonsillitis, herpes facialis occurred in 19 (13 per cent.). 
Among the acute infectious diseases for which figures are 
available as to the frequency of herpes facialis diphtheria 
ranks sixth. Pneumonia, malaria, and cerebro-spinal 
meningitis lead with a frequency for each of about 40 per 
cent. ; influenza follows at a long distance with a frequency 
of 6 per cent. ; and typhus fever with one of 5 per cent. 
Diphtheria follows and then typhoid fever with a frequency 
estimated from 1 "3 to 3 ■ 5 per cent., relapsing fever (24 per 
cent.), and finally small-pox (2 in 3000 cases). Herpes 
zoster is very rare in diphtheria; it occurs in only 0 • 1 per 
cent, of the cases. Dr. Rolleston found that herpes facialis 
was most frequent in severe cases of diphtheria (5 • 4 per 
cent, of the cases) ; least frequent in the moderate 
ones (4 7 per cent.); and less frequent in the mild 
(2 5 per cent.). The herpetic lesions healed rapidly, leaving 
no 6Cir. They were not followed, as sometimes happens in 
herpes zoster, by paralysis of neighbouring structures. 
Paralysis of the lips occurred in 37 (2 • 7 per cent.) of the 1370 
cases but it was present in none of the cases of herpes. As 
to the pathology of the herpes, Orsi regards it as a cutaneous 
manifestation of a reflex originating in the mucous mem¬ 
brane of the throat or nose from a toxic stimulus to the 
nerves. The greater frequency of herpes in severe cases of 
diphtheria lends support to this view. But it is difficult to 
understand why in non-specific angina in which the degree 
of toxaemia is less herpes is more frequent. 


Sir Dyce Duckworth, M.D. Edin., F.R.O.P. Lond., will 
deliver an address before the Paris Faculty of Medicine 
on Feb. I8th, the title being “ Les Diatheses le Facteor 
Personnel dans les Maladies.” The address is to be given 
in French in the amphitheatre of the Faculty at 9.30 p.m., 
and Professor Landouzy, Dean of the Faculty, will be in the 
chair. _ 


The annual Hunterian oration will be delivered before the 
Fellows of the Hunterian Society by Mr. W. J. M. Ettles, 
at 8.30 P.M., on Wednesday, Feb. 12th, in the theatre of 
the London Institution, Finsbury-cirous, E.C. The title is 
"The Renaissance of Ophthalmology during the Hunterian 
Period.” All members of the medical profession are invited. 


The dinner of the West London Medico-Ohirurgical 
Society will be held at the Hotel Great Central, London, 
on Thursday, Feb. 13th, at 7 30 P M. The President, Mr. 
Richard Lake, will occupy the chair. Communications 
relating to the dinner should be addressed to Dr. F. G. 
Crookshank, 27, The Terrace, Barnes, S.W. 


The first of the three Lettsomian lectures was delivered 
by Mr. C. J. Symonds on Feb. 3rd at a meeting of the 
Medical Society of London. Mr. Symonds took as his 
subject Tuberculosis of the Kidney and we hope 
in a later issue to publish a full report of his interesting 
lecture. _ 

We regret to announce the death on Tuesday morning, 
Feb. 4th, of Mr. William Allingham, F.R.C.8. Eng. Mr. 
Allingham, who was formerly surgeon to the Great Northern 
Central Hospital and St. Mark’s Hospital, had a great 





Thb Lancet,] 


REPORT FOR 1906 OF THE ADMINISTRATIVE COUNTY OF LONDON. [Feb. 8, 1908. 445 


reputation as author and practitioner in his special line of 
surgery. 


A telegram from the Acttog Governor of the Gold Coast, 
received at the Colonial Office on Jan. 31st, states that on 
Jan. 30th there were 2 deaths from plague, 14 natives were 
in hospital, and 19 were isolated. 


ANNUAL REPORT FOR 1906 OF THE 
MEDICAL OFFICER OF HEALTH OF 
THE ADMINISTRATIVE COUNTY 
OF LONDON. 1 


ii. 


Continuing our review of this report, we observe that 
Sir Shirley Murphy devotes particular attention to the 
behaviour of the mortality from pulmonary tuberculosis in 
recent years, especial regard being paid first to the relative 
prevalence of the disease in different sections of the com¬ 
munity ; next, to the effect of overcrowding on it fatality ; 
and lastly, to an examination of some current theories con¬ 
cerning the mode of infection by pulmonary tuberculosis and 
of the several methods suggested for the prevention or sup¬ 
pression of the malady. 

In the year 1906 the mortality caused by pulmonary 
tuberculosis in the metropolis was equal to a rate of 
1 44 per 1000 persons living, without reference to age 
or st-x ; it was therefore higher than the average rate for 
England and Wales by 0 29 per 1000. A table in the report 
shows that in the year under notice pulmonary tuberculosis 
was not more than half as fata! in London as it had been in 
the decade 1851-60, the earliest period for which trust¬ 
worthy records exist. From an interesting diagram we learn 
that the male death-rate from pulmonary tuberculosis during 
the last half century has averaged 2 90 per 1000, or almost 
exactly 1 per 1000 above the female rate. Since the year 
1880, however, the rate in both sexes has been constantly 
below the average, the female rate having apparently 
declined faster than the male 

Very interesting is the table showing the distribution of 
fatal pulmonary tuberculosis in the several metropolitan 
boroughs; it is unquestionably trustworthy, for in its 
construction care has been taken not only to refer 
institution deaths to the districts from which the 
patients originally came but to correct the death-rate 
of each borough for differences in the age and sex con¬ 
stitution of the living. From the last two columns in the 
table which show the mortality in the several boroughs as 
compared with that of the county of London, taken as 1000, 
we Jeam that 11 of the 29 boroughs had in 1901-05 an 
average mortality in excess of the county rate. In the 
year 1906 this was again the case, the rates in certain 
boroughs being above the county rates in some instances 
by from 20 to 70 per cent. In the years 1901-05 pulmonary 
tuberculosis was most fatal in Holborn, where the corrected 
rate was 2 58 per 1000, in Southwark 2'40, and in Bethnal 
Green 2'28 per 1000. As in previous years, Hampstead 
appears most favourably in the list, the rate there being 
only 0-82 per 1000, as compared with 1-57 in the county 
of London. J 

Vi ith respect to the influence of overcrowding in deter¬ 
mining the relative fatality from pulmonary tuberculosis 
there is a highly instructive table in the present volume 
the like of which we should like to see included in the 
reports of medical officers of health outside the metropolis 
This table shows that after making due allowance for 
age differences among the living, the mortality from pul¬ 
monary tuberculosis varies from a rate of 11 per 1000 
in the least overcrowded sanitary areas to precisely double 
that rate in the areas where the overcrowding exceeds 27 • 5 
percent. 

Elsewhere in the report comparison is instituted between 
the death-rate from pulmonary tuberculosis in the new model 
dwellings built by the County Council and that in London 
generally. In these dwellings at any rate, it may be presumed 
that the Council has taken adequate precautions against over- 

lS08 T p e 250 t n ° tiC ° ° f thi8 reP ° rt ® pp “ rod ln Thl ‘ Laxcet of Jan. 25th, 


crowding. The figures cow available are for one year only and 
relate to the mortality among not more than 21,000 tenants. 
Still, as far »s they go, they are encouraging, for they 
indicate a reduction in the mortality from pulmonary 
tuberculosis of 14 per cent, as compared with that of other 
dwellers in the metropolis. 

As iegards statistics of mortality in different social strata of 
the population we have before commented on the advantage 
possessed by portions of Ireland over other parts of the 
United Kingdom. Sir Robert Matheson, the Registrar- 
General for Ireland, has, for many past years, published 
rates of mortality among different grades of the Irish people, 
and, as might be expected, these rates show remarkable 
disparity. Sir Shirley Murphy evidently appreciates the 
need for similar means of distinguishing between class 
and class in London ; for, in the present report he 
presents a table showing the degree in which the dwellers 
in common lodging houses suffer from pulmonary tuber¬ 
culosis, in contrast with other inhabitants of the metro¬ 
polis. Since the year 1902 the administrative control 
of London common lodging houses has devolved on the 
County Council; and the medical officer of health has 
taken pains to inform himself as nearly as practicable con¬ 
cerning the effect of residence in buch dwellings on the 
health of the lodgers. But in this attempt he is met by the 
difficulty that the mortality from separate diseases cannot 
satisfactorily be presented in terms of population, because 
of the extreme variations in the numbers living, from time 
to time ; he therefore prefers to rely on the deaths from 
specified diseases in proportion to the deaths from all causes. 
From a table in which this alternative has been adopted we 
learn that of the total deaths of inmates of common lodging- 
houses, at ages 25-35 years, 54 per cent, were attributed to 
pulmonary tuberculosis, as against 40 per cent, in London 
generally; at ages 35-45 the percentages were 53 and 31 
respectively; at ages 45-55 they were 48 and 23; and at 
ages 55-65 they were 31 and 12 ; whilst at ages above 65 the 
proportions were 11 per cent, in common lodging-houses as 
against 3 per cent, elsewhere in London. 

As regards measures either in operation or in contempla¬ 
tion for limiting the prevalence of tuberculous disease, this 
report contains a section that will amply repay perusal. 
Abundant evidence is produced to show that there is a grow¬ 
ing demand for really effectual methods of dealing with the 
disease over and above the ordinary expedients of isolation 
and disinfection usually adopted for the suppression of the 
acute infectious disorders. A system of voluntary notifica¬ 
tion of pulmonary tuberculosis obtains in many of the 
sanitary districts and this is generally followed by disin¬ 
fection and by visits to the house, with advice as to pre¬ 
cautions to be taken by the sufferer. In a few instances 
compulsory notification, with compulsory removal of advanced 
cases, has been advocated by medical officers of health. 
But on this point Sir Shirley Murphy insists, in our opinion, 
most justly, that the "latter view is more advanced than 
that which is actually held. It becomes therefore very 
necessary to examine the grounds for such a demand, 
which, if fully acted upon, would deprive of their liberty 
many thousands of persons in London.” The current theories 
concerning infection on the one hand and heredity on the 
other which have been advanced to account for the in¬ 
cidence of pulmonary tuberculosis are ably discussed in the 
report. Reference is made to the opinions of Professor Karl 
Pearson who has specially studied this subject, utilising for 
this purpose the facts relating to 384 families in which cases 
of pulmonary tuberculosis had occurred. Professor Pearson 
found that the number of tuberculous married persons who 
had a tuberculous mate was not sufficiently great to require 
an appeal to infection in order to account for this number; 
but what he did find was that the condition which governed 
the liability to attack was heredity of the diathesis of pul¬ 
monary tuberculosis. "A theory of infection,” he writes, 
“does not account for the facts. I am inclined to think that 
the risks run, especially under urban conditions, are, for 
tuberculosis as for a number of other infectious diseases, so 
great that the constitution or diathesis means almost every¬ 
thing for the individual whose life cannot be spent in self- 
protection ; 1 feel fairly certain that for the artisan class the 
inheritance factor is far more important than the infection 
factor, because in a very large proportion of cases it does not 
lie in the power of the individnal to maintain, in the stress 
of urban life, a wholly safe environment." 

The passage in which Sir Shirley Murphy summarises his 
own conclusions on this important snbject is worthy of 




446 The Lancet,] 


NOTES UPON HEALTH RESORTS. 


[Feb. 8, 1908. 


quotation here. He says: “The acceptance of the view 
that under conditions which exist in urban populations, the 
susceptibility of the individual, and not the exposure to 
known cases of phthisis, govern the probability of attack 
does not of itself negative the theory of the infectivity of 
tuberculous phthisis. It does, however, raise serious question 
aa to the practicability of reducing the rate of phthisis 
mortality by efforts to segregate persons suffering from this 
disease, even if the theory of infection from person to person 
is accepted as the common way in which susceptible persons 
are infected. However this may be, it may undoubtedly be 
stated that our knowledge of the subject at the present time 
is insufficient to justify the introduction into London of a 
system of compulsory segregation. ” 

The London statistics of mortality from cancer or 
malignant disease agree generally with those of other parts 
of the United Kingdom in that they indicate a continuously 
increasing fatality from this terrible malady, from the 
earliest recorded dates to the present time. From a table in 
the report it appears that whilst in 1851- 60 the average loss 
of life in the metropolis from malignant diseases was equal 
to 42 in each 100,000 of the population at all ages and of 
both sexes, in the year 19C6 the proportion had risen to 98 in 
the same number living. 

In order to obtain precise information concerning the local 
incidence of cancer factors have been calculated for correct¬ 
ing as far as possible the rates of mortality for the several 
sanitary areas of the metropolis ; but owing to changes in 
these areas caused by the London Government Act of 1899 
the death-rates since 1900 are alone available for comparative 
purposes. The average death-rates from cancer in the years 
1901-05 are presented in another table which shows that the 
highest mortality (1 • 10 per 1000) occurred in the City of 
London, the lowest rates obtaining in Finsbury and in Green¬ 
wich, where they were 0 • 84 per 1000. In yet another table 
an attempt is maue to ascertain the relation of overcrowding 
to cancer incidence in various districts of London, the object 
being to compare the death-rates of sections of the people 
differently circumstanced socially. But although the 
numbers dealt with are considerable the differences in the 
local death-rates, compared according to this method, are 
less pronounced than might have been expected. 

Puerperal fever, under which name are included the deaths 
from pyaemia and septicaemia occurring in connexion with 
the puerperal state, was fatal to 187 women in the course of 
the year 1906, the number notified as suffering from affec¬ 
tions of this nature being 298. The subject of puerperal 
sepsis has oome to assume additional interest because of the 
steps that are now practicable under the Midwives Act of 
1902 for diminishing the perils of childbirth. From data 
in the report it appears that in the year 1906 the number of 
midwives on the London registers was 2350, less than 8 per 
cent, of whom are returned as “uncertified.” The actual 
proportion, however, must be greater than this, for the 
majority of enrolled midwives are not practising. Many of 
them are engaged as monthly nurses and many more are on 
the staffs of hospitals. Interesting details are given in the 
report as to the number of female medical inspectors 
appointed under the Midwives Act and also as to the duties 
which they perform. In the administration of this Act in 
London the authorities appear to have been assiduous. 

All cases of puerperal fever where a midwife is known to 
have been in attendance are investigated. For this purpose 
early intimation of all cases of puerperal fever is received by 
telephone from the Metropolitan Asylums Board and weekly 
lists of deaths from puerperal sepsis are obtained from the 
Registrar-General. Of the 187 deaths registered as from 
puerperal fever 68 referred to cases that had not been 
notified as suffering from that disease; it would therefore 
appear probable that in spite of the compulsory nature of the 
Notification Act many cases of puerperal fever, in its 
wider sense, which do not prove fatal, are never officially 
notified. Incidentally the investigations under the Act 
have served to ascertain the proportion of stillbirths to total 
children born. For the metropolis this is seen to average 
from 3 to 4 per cent. 

( To be continued .) 


Death of a Centenarian.— Mrs. Honor 

Coleman, who died recently at Yatton, Somersetshire, 
celebrated the 106th anniversary of her birth on Feb. 22nd, 
1907. The old lady’s mother and grandmother were also 
centenarians. 


NOTES UPON HEALTH RESORTS. 

ALGECIRAS AND ITS CLIMATE. 

By A. W. \V. Dowding, M.D. Durh., M.R.C.P. Emn. 


The Algeciras Gibraltar Railway, which has its sea 
terminus at the quaiDt old town of Algeciras, Spain, right 
opposite Gibraltar, and its capital entirely English, has been 
the means of opening up the neighbouring district not only 
by its railway and steamer communications but also by 
means of the new Hotel Reina Cristina, Algeciras, which was 
built in 1901 and has since been enlarged. The district 
itself for its climate, scenery, and objects of archaeological 
interest is difficult to surpass, and within three hours by rail 
is the inland town of Ronda, situated on a lofty plateau 
about 2400 feet above the sea level and practically sur¬ 
rounded at a distance with a panorama of high mountains. 
Here the air is very dry and bracing. And the company is 
bnilding another hotel in conjunction with the Reina Cristina 
which will be opened shortly. 

As regards the climate of Algeciras—the most southerly 
health resort in Europe—it is milder, warmer, and more 
equable than that of the Riviera, Algiers, and Morocco. In 
north latitude 36° 6' 20” and in west longitude 5° 20' 53” it 
is practically in the line of latitude with Algiers and Malta 
and is about 4° north of Madeira and further south than 
the Riviera. Beautifully situated on the Bay of Gibraltar, 
the surrounding country is undulating and the soil is light 
and porous so that the roads soon dry up after rain. Being 
located near the junction of the Mediterranean and the 
Atlantic Ocean at a point where two great continents meet 
it naturally follows that its climate must be influenced more 
or less by each of these elements. The water-supply is 
excellent, and Algeciras has the reputation of being one of 
the most healthy towns in Spain. 

The following are certain observations taken at an altitude 
of about 52 feet above the sea level and for an average of five 
years ;— 


Mean annual barometric pressure . 

Mean pressure for the six months (October to April) 

Mean annual temperature in the shade. 

Mean shade temperature for the six mouths (October 

to April) ... .. .. 

Absolute minimum temperature . 

Mean annual daily range of temperature . 

Mean relative humidity of the air . 

Annual average rainfall . 

Average number of days when fog exists . 

Average number of days when rain falls . 


29 987 
29-99 

64*0° FaJir. 

59 1° „ 

36-8° ,, 

12 - 8 ° 

70 per cent. 
32 22 inches. 
1 
74 


Both snow and frost are alien to Algeciras and its- 
immediate neighbourhood. At Algeciras, and indeed all 
along the coast for many miles on either side, cold weather 
is a thing unknown and it is the experience of winter 
visitors who have tried the Riviera, Algiers, and other places 
on the Mediterranean that it is the warmest and most 
equable of the lot. East and west are the prevailing winds, 
with slight variations. From the W.S.W. it is protected by a 
range of beautiful hills commonly called the “ Palm 
Mountains.” The E S.E. wind comes right across the 
Mediterranean from Gibraltar but it is only prevelant in the 
summer. During the winter months the winds are generally 
from the W.S.W. orW.N.W. and for the remainder of the 
year, chiefly in summer and autumn, the E.S.E. and E.N.E. 
winds predominate. Gales are of rare occurrence and 
taking the whole year through the number of stormy days 
can be counted on one’s fingers. In fact, with rare exceptions 
the winds are always light and warm. 

The rainfall for a warm climate is a moderate one and 
generally occurs at intervals between the months of 
September and April inclusive, so that practically from May 
to August the weather is perfectly dry. The average rainfall 
throughout the year is 32 inches, but as sometimes several 
inches fall in 24 hours it will be understood that the rain is 
anything bnt continuons, and, another thing, as the greater 
proportion descends in the night time the days as a rule are 
clear and bright. The consequence is that during what is 
commonly called the wet season the sun comes out during 
the day and the sky generally is cloudless. It is very 
seldom, therefore, that the weather keeps people indoors. 
Indeed, for the last few years the scantiness of rain 
has been the great drawback. This fact also accounts for 



The Lancet, ] 


MEDICINE AND THE LAW, 


[Feb. 8, 1908. 447 


the uncommonly large amonnt of sunshine which is one of 
the outstanding features of the climate of Algeciras and its 
neighbourhood. Taking the number of hours of sunshine 
per annum it averages 3000, or fully 1000 more than can be 
practically had at the very best English health resorts. All 
this is very important to visitors who have to leave their 
own countries to escape the rigours of the winter and who 
teek after warmth and snnshine. The best months for 
invalids are from October to June. The mean winter 
temperature is 55° E. in the shade. The air is dry and 
bracing and there are no sudden changes of temperature. 

The English Hotel Reina CriBtina, with its 22 acres of 
beautiful grounds outside the town, is an ideal winter place 
for delicate people and invalids able to move about. There 
are also the Hotel Anglo llispano and smaller Spanish hotels 
and a few furnished houses and Hats to be bad for the 
season, bnt there is a lack of good accommodation for 
people of moderate means. All kinds of outdoor sports and 
amusements can be obtained in the neighbourhood, but 
except at Gibraltar one has to be satisfied with a quiet 
country life free from excitement. 

From my experience of Algeciras since 1904 I am con¬ 
vinced that in many respects its climate is unequalled in 
Europe. I have noted marked improvement in cases of 
neuritis, insomnia, and other nerve troubles. Also goaty, 
cardiac, bronchial, and kidney cases as a rule are greatly 
benefited by residence in Algeciras. It is excellent also 
simply for a rest cure. Algeciras is not only a health resort 
but it is a convenient centre for visiting the most important 
and interesting places in Andalusia and Morocco, such as 
Honda, Granada, Seville, and Cordoba on the one hand, and 
Tangier and Ceuta on the other. A splendid service of 
passenger steamers ply between it and Gibraltar daily (six 
miles). Gibraltar as a sea port if nothing more is one of the 
most convenient in Europe for visitors, as the liners of the 
P. and O., Orient, Norddeutscher Lloyd, White Star, 
Dominion, Canard, and other great shipping companies 
call weekly, both on their outward and inward cruises, so 
that passengers can get to or from England and America on 
the one hand, and from and to Algiers, Marseilles, Genoa, 
Naples, and Egypt on the other, with the greatest ease and 
comfort. Visitors can either find their way to Algeciras 
overland by the express trains or by the P. and O. and other 
steamers in about four days from London and three days 
from Southampton. 

Algeciraa. _ 


MEDICINE AND THE LAW. 


Kitting the Book . 

In a recent appeal to the Divisional Court against a 
judgment delivered in the Brompton county court a new and 
curious point was raised with regard to the taking of the 
oath in the usual form by kissing a Testament. For this 
reason we refer again to a topic which has been so much 
discussed already in our columns and elsewhere. A medical 
man called as a witness had refused on sanitary grounds to 
kiss the Testament provided and had also objected to taking 
the oath in the Scottish form on the ground that he was a 
member of the Church of England. He had, however, pro¬ 
duced a Testament on which lie was willing to be sworn but 
the county court judge had refused to allow him to avail 
himself of it, saying that he would not permit the oath to be 
taken upon any book except the one in ordinary use in the 
court. As a result the witness was not sworn and his 
evidence was lost to the party on whose behalf he had been 
called. Argument took place on the question whether the 
judge had decided wrongly in this matter and it was urged 
on behalf of the appellant that there was no suggestion that 
the Testament produced was not a perfect copy. This was 
in reply to a suggestion by Mr. Justice Phillimore that there 
were persons who would consider an oath less binding if it 
was taken upon a Testament nob complete in every respect 
or in some other irregular manner. It was further argued 
by counsel that all that was necessary was that the judge 
should be satisfied that the Testament was one regarded by 
the witness as imparting a binding nature to his oath and 
that there was no legal obligation to use a volame provided 
by the court for the purpose and no other. Mr. Justice 
Phillimore is reported as having said that there could not be a 
new trial “because of a silly wrangle on the part of the 
doctor.” It was his view that the question involved a matter 


of the discipline of the court, although the county court 
judge might have been wiser to admit the evidence, and the 
appeal was eventually dismissed. The objection raised to- 
the Scottish form, which is to be administered without 
question to any who may prefer it, is not very easy to follow, 
bub at the same time it seems highly unreasonable that a 
witness in the position of a medical practitioner who chooses 
to provide his own Testament should not be allowed to be 
sworn upon it. To suggest that he would be likely to 
commit perjury, solacing his conscience with the knowledge 
that the volume was defective and so was not a Testament, 
is little short of absurd. 

Is a Matter Liable for Medical A ttendanoe on Servantt ? 

The question of the liability of a master for medical 
attendance on his servants is one of considerable importance 
to the medical profession. A master is not bound to provide 
medical assistance for his servant but the obligation (if any) 
must arise from contract ; nor will such a contract be 
implied simply because the servant is living under the 
master’s roof, nor because the illness of the servant has 
arisen from an accident met with in the master’s service. 
Thus where a servant who had been hired at the yearly 
wages of £3 10.?. and victuals had his arm broken while 
driving his master’s team, and was carried to his mother's 
house and attended by his master’s surgeon, who was acci¬ 
dentally passing such mother's house at the time and was 
called in, it was held in Wennall v. Adney (3 B. & P. 247) 
that the surgeon could recover nothing from the master on 
an implied promise to pay for the attendance. Where such 
accidents take place the parish officers are bound to assist 
and the law will so far raise an implied contract against 
them as to enable any person who affords that immediate- 
assistance which the necessity of the case usually requires 
to recover against them the amount of money expended. Se 
in all cases where a servant falls ill and is unable to pay for 
necessary medical assistance the parish is bound to supply 
such assistance, although the servant may not have pre¬ 
viously to bis illness received or stood in need of parish 
relief. In Newly v. Wiltshire (2 Esp. 739) the defendant, a 
farmer, sent his wagon to Cambridge, and in returning a 
boy who had been sent with it fell from the shafts and broke 
his leg. The boy could not be removed out of the parish 
where the accident happened on account of the danger 
which it might occasion. The plaintiff was overseer of the 
parish where the accident happened and took the charge 
of getting the boy cured upon himself. It was neces¬ 
sary to amputate the leg and the overseer expended 
in and about the cure £32. Afterwaids the boy served the 
remainder of the year with his master and the action was 
brought to recover from the defendant the expenses of the 
boy’s cure. Lord Mansfield, Chief Justice, said: “I da 
not applaud the humanity of the master in this case ; he 
does not inquire after his servant for six weeks after the 
accident; and when he does he passes on the other side. 

I think, in general, a master ought to maintain his servants 
and take care of them in Bickness ; but the question now is, 
What is the law ? There is, in point of law, no action 
against the master to compel him to repay the parish for the 
cure of his servant; no authority whatsoever has been cited ; 
and it seems to me that it cannot be. The parish is bound 
to take care of accidents.” And Mr. Justice Heath, in 
Wennall v. Adney, said: “I am perfectly sure it is more 
for the advantage of servants that the legal claim for such 
assistances should be against the parish officers rather than 
against their masters, for the situation of many masters 
who are obliged to keep servants is not such as to enable 
them to afford sufficient assistance in cases of serious illness.” 
Where, however, a father left his children under the care of 
servants, in a house at some distance from his own, and one 
of Buch servants was attacked by illness, vfrhich was caused 
by suckling one of the children, and called in a medical 
man who was not known to her master to attend her, and 
where the master's wife knew of such attendance and ex¬ 
pressed no disapprobation, and, after this, the master sent 
his own surgeon to see such servant, it was held in Cooper 
v. Phillips (4 C .Sc P. 584) that the surgeon who had been 
originally called in by the servant could recover the amount 
of his bill from the master. A master is, however, bound to 
provide an apprentice with proper medicines and medical 
attendance (R. v. Smith, 8 C. & P. 153). It is not inci¬ 
dent to the employment of a guard or the superintendent 
of a station of a railway to enter into a contract with 
a surgeon to attend a passenger injured by an accident 




448 Thb Lancet,] EXPERIENCE OF A RECEPTION HOUSE FOR RECENT CASES OF INSANITY. [Feb. 8, 1908. 


on each railway, and the railway company are not therefore 
liable to the surgeon for services rendered to such passenger 
uDder a contract so entered into (Cox r. The Midland Railway 
Co., 18 L J.Ex., 65). Nor does the new Workmen’s Compen¬ 
sation Act make the master liable for medical attendance on 
a servant in case of accident. Of coarse, some masters insure 
their servants in such a way as to cover medical expenses 
up to £5 but the law does not impose any obligation on them 
to do so. Suppose a caretaker of a country house falls down¬ 
stairs in the absence of the family and is laid up for some 
weeks with concussion of the brain. A medical man is called 
in by one of the servants to attend her. Is the master liable? 
The answer is “No.” There is no doubt that as time goes on 
the provisions of the Workmen’s Compensation Act will be 
extended to cover medical expenses. If the principle of 
compensation for injuries is once admitted it seems absurd to 
limit the compensation to particular employments, as was the 
case before 1906, and if compensation has now to be paid to 
all servants for accidents it seems anomalous not to make the 
master liable for medical expenses. In the above case 
supposed the caretaker might have become unconscious and 
seriously ill for four or five days, but if she recovered and was 
able to do her work again by the thirteenth day she would 
only be entitled to recover compensation for one week which 
in no case can exceed £1 a week and yet the medical 
expenses she had to pay may have far exceeded that 
amount. 

The Health and Safety of Young Children. 

Several cases affecting the health and the lives of little 
children have recently been reported in the newspapers 
showing a strong intention on the part of those administer¬ 
ing the law to protect this helpless section of the community 
from the various dangers always threatening it. In the 
recent bitterly cold weather Mr. Denman had before him at 
Marlborough-street a man, 30 years of age, who was charged 
with exposing his son, aged four and a half years, in a way 
ljkely to cause injury to his health. The child was placed 
on an organ which his father and another man were wheeling 
about for the purpose of obtaining money. Mr. Denman 
called attention to the number of children thus made use of 
in severe weather for the iniquitous purpose of extracting 
alms from kind-hearted but mistaken persons and to the law 
which enabled him to punish the conduct of adults who so 
subjected them to danger and suffering. He expressed his 
determination to make the case an example and a warning 
to parents and others and sent the defendant to prison for a 
month with hard labour. A street organ formed the means 
by which the male defendant in another case “earned” his 
living. He and his wife were charged with neglecting four 
children whose ages ranged from six years to 14 months. 
Their plan was not to take them out in the streets 
but to leave them locked up without food, fire, or sufficient 
clothing. A story was told apparently involving conjugal 
infidelity on the part of both parents, and there was 
an allegation of fear of her husband on the part of the 
wife, but the learned magistrate looked on the cruelty 
proved as sufficiently serious to warrant the infliction of 
sentences of six months’ imprisonment on the man and 
of four months on the woman. At Bradford James 
Taylor, a labourer in the employment of the corporation, 
had beaten with shocking brutality his little girl, seven 
years of age, and his son, 13 years of age, besides nearly 
strangling the latter. He received sentences amounting to 
12 months’ hard labour, accompanied by the expression of 
the opinion of the chairman of the bench that he was a 
dastardly blackguard. In the first case mentioned above the 
police are to be congratulated upon the vigilance of a 
constable; in the second and third the National Society for 
the Prevention of Cruelty to Children conducted the prosecu¬ 
tion and obtained well deserved success. Among recent 
inquests showing the dangers which beset children may be 
noted one at St. Pancras at which it was proved that Daisy 
Bell, six years of age, owed her death to her flannelette 
nightdress catching fire at a grate not protected by any fire¬ 
guard. Mr. W. Schrdler, the coroner, called attention to 
the Bill which proposes to make the omission to provide a 
fireguard punishable as criminal neglect where a child lias 
died in consequence and expressed a hope that the measure 
might be reintroduced with success during the coming session. 
At another inquest held at Kingston it was proved that a 
little girl, aged eight weeks, had been fed on boiled bread 
when her mother found that the child would not take the 
breast. The body of the infant thus starved to death 
weighed 6i pounds and the coroner, Mr. Michael H. Taylor, 


after referring to the number of deaths of children from 
malnutrition as “ appalling,” expressed the wish that girls 
might be taught at school more that would be useful to them 
in domestic life, even if they learnt less about other subjects 
of a more strictly scholastic character. While the sympathy 
of all is rightly invoked for children wantonly neglected and 
ill-treated allusion may be made to the observations of Sir 
Horatio Davies uttered recently at the Guildhall police court 
in connexion with the generous efforts of strangers to aid 
children and others whose cases are made prominent through 
the evidence of their destitution given in the law courts. In 
thanking the press and the public on behalf of a case of 
genuine poverty and suffering, he pointed out with reference 
to it and to that of several children then before him who 
had been found wandering in the City that there was a risk 
of encouraging evilly disposed parents to send out their 
children to beg with a view to their being brought 
to the police court and so exciting sympathy. Two 
other recent cases serve to illustrate the difficulties 
against which the National Society for the Prevention of 
Cruelty to Children and those who sympathise with its efforts 
have to contend where deliberate cruelty can hardly be attri¬ 
buted to the parents but rather physical and mental incapacity 
to fulfil their duties. In the first instance the mother of 
two children of the respective ages of six and three years 
was said to be blind and quite incapable of cleansing 
or taking care of them. She spent her days sitting about 
in the streets, presumably in order to excite sympathy and 
to collect alms, and it was further stated that her husband, 
a man 62 years of age, ill-treated her and refused to look 
after his offspring. Summoned at the North London police 
court he was sentenced to three months' hard labour for his 
neglect. In the other case an inquest was held upon an 
infant, three months old, one of twins, who, according to the 
evidence of Dr. Henry S. Souttar, house physician at the 
London Hospital, had been starved to death by the mother's 
neglect. The other child present at the inquest in his 
mother’s arms was shown to the coroner, Mr. Wynne Baxter, 
who expressed horror at his condition, and finding the 
mother’s answers to his questions unsatisfactory, pursued his 
inquiries with regard to her until he discovered that she had 
recently been an inmate of Claybury Asylum. He expressed 
the opinion that she was on the borderland between sanity 
and insanitv and expressed his intention of communicating 
with the National Society for the Prevention of Cruelty to 
Children. 


FIVE YEARS’ EXPERIENCE OF A RECEP¬ 
TION HOUSE FOR RECENT CASES 
OF INSANITY. 

By Hamilton C. Mark, M.D. Glasg., F.F.P.S. Glasg., 

MF.D1CAL SUPERINTENDENT, GLASGOW DISTRICT ASYLUM, WOODILEE, 
LENZ1E; MACKINTOSH LECTURER ON INSANITY, 

ST. MUNGO'S COLLEGE, GLASGOW. 

Tub question of the provision of increased accommodation 
at Woodilee Asylum was brought before the Glasgow District 
Lunacy Board in the latter part of the year 1900. In a 
report submitted to the board it was urged, among other 
considerations, that the required accommodation should 
embrace (1) a reception house ; (2) a sanatorium for the 
consumptive insane ; and (3) a nurses’ home. This 
accommodation the board decided to provide. The recep¬ 
tion house and sanatorium, which are similar in design, 
were opened for the admission of patients on Dec. 25th, 
1902 and the nurses' home for 110 nurses was opened 
on Sept. 15th, 1904. Of the two former buildings I con¬ 
fine my description to the reception house as my main 
object in writing this paper is to give an account of the 
work that has been and is being done in it. 

The reception house is situated about a quarter of a mile 
from the main administrative centre and is about 200 feet 
above sea level. It is, in some respects, unique, and has been 
the object of much interest duriDg the five years in which it 
has been in operation. It presents those special features ; 
(1) its construction is that of an ordinary hospital; (2) the 
provision of verandahs permits cf the advantages of the 
open-air treatment ; (3) all newly admitted patients are 
received into it; (4) patients whose illness is of short dura¬ 
tion are allowed to remain and thus avoid the necessity of 
their being sent to the main asylum ; and (5) the nursing is 
mainly done by women. The building consists of three 






sshas* r ■ 


■» ■ ■ 1 • 




The Lancet,] EXPERIENCE OF A RECEPTION HOUSE FOR RECENT CASES OF INSANITY. [Feb. 8,1908. 449 


Fig. 1.—Reception house from south-east. 


Flo. 2.—Open-air treatment of recent admissions. 
















450 The Lancet,] 


VITAL STATISTICS. 


[Feb. 8, 1908. 


blocks connected to an administrative building by open 
corridors. The blocks are one storey in height. The 
administrative department has a second storey containing 
bedrooms for nurses. The structure of the building is of 
corrugated iron and wood with a brick foundation; the inner 
walls are lined with '* compo ” boarding and are painted in dis¬ 
temper. The buildings are arranged one on each side and one 
behind the administrative block. All the wards face the 
south. The block behind the administrative department 
consists of two wards, each containing 12 beds. The total 
number of beds in the reception house is 62, and the cubic 
space allowed for each is 1500 cubic feet. The two other 
buildings have each one ward of 12 beds, one ward of six 
beds, and three single rooms. All the wards and rooms are 
provided with French windows and round the sides of each 
block there are verandahs. The beds can be wheeled from 
the wards to the verandahs with the greatest ease. Special 
provision has been made against lire. There are no fires in 
any of the wards and the heating is by water under a low 
pressure. Each ward has attached to it a bathroom and the 
necessary lavatory and water-closet accommodation. All the 
baths are so arranged that they can be used for the electrioal 
treatment of the patients. 

Reference has been made to the upper storey of the 
administrative block in which nurses' rooms are situated. 
The lower storey consists of a reception room, bathroom, 
and examination room for newly admitted cases, a room well 
furnished with the latest electric therapeutic apparatus, 
medical officers' quarters, kitchen, scullery, and dining hall 
for the staff. The verandahs, which are on the south, east, 
and west sides of the wards, were purposely introduced. For 
several years previous to the erection of the reception house 
and sanatorium newly admitted and phthisical cases were 
kept as much as possible in the open air with manifest 
advantage. It was thought that the extensive use of 
verandahs would, in the prevalent climatic conditions, afford 
the greatest facility for carrying out the open-air treatment. 
In practice this has actually occurred. Since the opening 
of the reception house the freest use of open-air treatment 
has been employed, not only for the consumptive but for all 
the newly admitted cases. 

1425 patients (737 males and 688 females) have been 
admitted since the reception house was opened. It has 
not been necessary, on account of inability to deal with 
them, to admit any of the patients to the main asylum 
or remove them shortly after admission from the recep¬ 
tion house to the asylum. This is more remarkable in 
view of the fact that the reception house does not 
possess the means of restraint or seclusion. No day 
nurse has keys, and the ward doors are open all day. 
The windows are open night and day. All patients on 
admission are bathed and subsequently examined by the 
medical officer and by medical clerks who are senior students 
of medicine. The patients are kept in bed until their con¬ 
dition has been diagnosed. As a rule they are then removed 
to the respective buildings in the asylum which are most 
suited for their condition; thus, an infirm or senile 
case is sent to the infirmary of the main asylum; 
the phthisical patient is sent to the sanatorium ; 
chronic cases with fairly good physical health are, in the 
first place, admitted to the wards of the main asylum where 
they are placed at occupations suited for their condition 
both of body and mind, and from there they are drafted to 
the farms where, if they do well, they may ultimately be 
boarded out in the country. In this way, from the point of 
classification, the reception house has many advantages. 
From the points of diagnosis and treatment the conditions 
are, in my mind, ideal. No patient is removed until a com¬ 
plete report of the physical and mental characteristics of 
his case is detailed in the case books of the asylum and the 
course of care and treatment decided. Those patients who 
have a likelihood of early recovery are detained in the 
reception house until convalescence has been established. 
The number of patients who have been discharged recovered 
in this way is 216 (108 males and 108 females). There are 
three bedrooms in each of the southern blocks which are 
used in several ways. Any patient who is very excited and 
restless is plaoed in one of them with a nurse. The beneficial 
effects of this treatment have often been noticed. The 
rooms are also used for the moribund, and when available 
one is given as a privilege to a convalescent. These rooms 
are bright and attractive and so situated as to give the 
maximum amount of peace and quietness. 

The nursing of the patients is mainly done by women. I 


have seen nothing to prevent the whole of the nursing being 
done by women, but I think this would be objectionable 
because we have not yet reached, nor shall we probably reach, 
the stage when all the patients in asylums will be nursed by 
women. I think it only fair to give male attendants, who 
have charge of working parties of patients, all facilities in 
the early stages of their asylum career for acquiring a sound 
knowledge of their profession, and adapting this knowledge 
to the advantage of the patients of whom they may ulti¬ 
mately be in charge at outdoor work. In the reception 
house I have followed the practice I have been accustomed 
to in the asylum hospitals for men. Two male attendants 
are regularly on day duty and two on night duty. The 
object I have in mind is thus acquired. Many objections to 
women nursing male patients, especially newly admitted 
male patients, have been urged. None of these will be found 
in practice, though experience has taught me to exercise the 
greatest care in the selection of nurses to male patients. 
This has reference solely to matters of staff discipline and 
does not affect primarily the welfare of the patients. 

The following are some extracts from reports by His 
Majesty’s Commissioners in Lunacy :— 

By Dr. John Fraser. 5th May, 1903 .—The reception house produced 
a most favourable impression. Its arrangements are devoid of any 
asylum features, being identical in every respect with those of a small 
general hospital. It is staffed by nurses aud is under the charge of a 
trained hospital nurse. Every patient on admission is treated in this 
house and the length of residence there depends on the mental con¬ 
dition. The comfort, rest, skilful treatment, and good nursing which 
newly admitted patients receive in this house are most favourable to 
the early recovery of the curable and to the well-being of those who 
are incurable. 

l!,th April, 190 /,.—The reception house and convalescent wards con¬ 
stitute a valuable and important advance in the treatment and 
classification of the patients. 

By Dr. John Macoherson. 15th Nov., 190 /,.—The arrangements for 
the reception, nursing, and medical treatment of newly admitted 
cases in this asylum are now probably unsurpassed by those in any 
institution in this country. The facilities for the clinical investigation 
and the medical treatment of nervous diseases have been provided by 
the district board with unstinted liberality. It is right to add that Dr. 
Marr and his large staff of assistants are sedulously observing facts 
and carefully recording them, and that a mass of clinical material of 
great value is being gradually accumulated in the medical records of 
the asylum. 

Wood!lee Asylum, Lenzie. 


VITAL STATISTICS. 


HEALTH OP ENGLISH TOWNS. 

In 76 of the largest English towns 8781 births and 5680 
deaths were registered during the week ending Feb. 1st. 
The mean annual rate of mortality in these towns, which had 
been equal to 20 • 0 and 18 ■ 5 in the two preceding weeks, 
further declined to 18 • 2 in the week under notice. During the 
first live weeks of the current quarter the annual death-rate 
in these towns averaged 18 6 per 1000; the rate during 
the same period in London did not exceed 18 • 0. The 
lowest annual death-rates in the 76 towns laBt week were 
7'3 in Hornsey, 7 6 in Smethwick, 8'7 in Northampton, 
and 9 7 in Burton-on Trent ; the rates in the other towns 
ranged upwards to 26 4 in Newport, 26 7 in Liverpool, 
27 7 in Merthyr Tydfil, and 29 '3 in Warrington. The rate 
in London last week did not exceed 17'2. The 5680 
deaths registered in the 76 towns during the week under 
notice showed a further decline of 69 from the numbers 
returned in the two preceding weeks, and included 441 
which were referred to the principal epidemic diseases, 
against 501 and 409 in the two previous weeks; of these, 
190 resulted from whooping-cough, 83 from measles, 66 
from diphtheria, 46 from diarrhoea, 35 from scarlet fever, 
21 from “fever” (principally enteric), but Dot one from 
small-pox. The deaths from these epidemic diseases in the 
76 towns were equal to an annual rate of 1 • 4 per 1000, 
tbe rate from the same diseases in London being 
1-3. No death from any of these epidemic diseases was 
registered last week in Wolverhampton, Huddersfield, Wigan, 
Hornsey, or in six other smaller towns; tbe annual death- 
rates from these diseases ranged upwards, however, in the 
other towns to 3 • 1 in Bootle, in Bolton, and in Aston 
Manor, and 7 '3 in Warrington. The fatal cases of whoop¬ 
ing-cough iu the 76 towns, which had been 164 and 154 in the 
two preceding weeks, further rose last week to 190; they 
caused annual death-rates equal to 2 3 per 1000 in Bootle 
and in South Shields, 2 S in Aston Manor and in Bolton, and 
5'1 in Warrington. The 83 deaths from measles showed a 
further decline from the numbers in the three previous 




VITAL STATISTICS—THE SERVICES. 


[Feb. 8,1908. 451 


The Lancet,] 


weeks; this disease, however, caused a death-rate of 1'3 in 
Southampton. 1‘7 in Barrow-in-Furness, 1-8 in York, and 
2 0 in Willesden. The 66 deaths referred to diphtheria, on 
the other hand, showed an increase upon recent weekly 
numbers, and included 24 in London, three in Liverpool, 
three in Manchester, three in Reading, and two in Bary ; 
these deaths in the two last mentioned were equal to an 
annual rate of 1 • 9 and 1 ■ 8 per 1000 respectively. The 
46 deaths attributed to diarrhoea showed a slight increase, 
whereas the fatal cases of scarlet fever had slightly declined ; 
the highest rates from scarlet fever last week were 1 • 1 in 
St. Helens and 15 in Warrington. The 21 deaths referred 
to “fever” were fewer than in any recent week; four, 
however, occurred in Birmingham, four in Manchester, and 
two in Portsmouth. The number of scarlet fever patients 
under treatment in the Metropolitan Asylums and London 
Fever Hospitals, which had steadily declined in the eight 
preceding weeks from 5581 to 4044, had further fallen to 
3913 on Feb. 1st; during the week ending on that day 405 
new cases were admitted to these hospitals, against 469 and 
380 in the two previous weeks. The deaths in London 
referred to pneumonia and other diseases of the respiratory 
organs, which had been 499 and 465 in the two preceding 
weeks, farther declined to 432 in the week under notice, but 
exceeded by 35 the corrected average number in the corre¬ 
sponding week of the five years 1903-07. The causes of 54, 
or 1 • 0 per cent., of the deaths registered in the 76 towns 
last week were not certified either by a registered medical 
practitioner or by a coroner. All the causes of death were 
duly certified in Mancheeter, Leeds, West Ham, Bradford, 
Newcastle-on-Tyne, and in 45 smaller towns ; and the causes 
of all but one of the 1584 deaths in London were duly certi¬ 
fied. No fewer than ten of the causes of death in Birming¬ 
ham, eight in Liverpool, four in South Shields, and three in 
Warrington were uncertified. 


health of scotch towns. 

The annual rate of mortality in eight of the principal 
Scotch towns, which had been equal to 24 ■ 3 and 22 • 2 
per 1000 in the two preceding weeks, was 22 • 3 in 
the week ending Feb. 1st, and exceeded by 4 1 the 
mean rate during the same week in the 76 English towns. 
Among the eight Scotch towns the death-rates ranged 
from 17 • 6 and 17 • 9 in Dundee and Aberdeen to 23 9 
in Glasgow and 25‘4 in Greenock. The 785 deaths in 
these eight towns exceeded by three the number in the 
previous week, and included 123 which were referred to the 
principal epidemic diseases, against 158 and 142 in the two 
preceding weeks ; of these, 64 resulted from measles, 26 
from whooping-cough, 11 from diarrhoea, eight from “ fever,” 
seven from scarlet fever, six from diphtheria, and one from 
small-pox. These 123 deaths were equal to an annual rate 
of 3 ■ 5 per 1000, which exceeded by no less than 2 • 1 
the mean rate last week from the same diseases in the 
76 English towns. The fatal cases of measles, which had 
been 92 and 81 in the two preceding weeks, further declined 
last week to 64, of which 54 occurred in Glasgow, three in 
Edinburgh, three in Aberdeen, and two in Greenock. The 26 
deaths from whooping-cough exceeded the number in the pre¬ 
vious week by one, and included 12 in Glasgow, six in Leith, 
three in Edinburgh, three in Greenock, and two in Perth. 
The 11 deaths attributed to diarrhcea, of which seven were 
returned in Glasgow, were fewer than in any recent week. 
Five of the Beven fatal cases of scarlet fever occurred in 
Glasgow. The eight deaths referred to “ fever ” included 
six certified as cerebro spinal meningitis, and two as enteric 
fever; four were returned in Glasgow, and three in 
Edinburgh. The six fatal cases of diphtheria included two 
in Glasgow and two in Dundee. The death trom small pox 
was registered in Leith. The deaths referred to diseases of 
the respiratory organs in these eight towns, which had 
been 205, 199, and 178 in the three preceding weeks, were 
179 in the week under notice, and exceeded by 53 the 
number from the same diseases in the corresponding 
week of last year. The causes of 22, or 2"8 per cent., of 
the deaths in these towns last week were not certified or 
not stated; in the 76 English townB the proportion oi these 
uncertified deaths last week did not exceed 1-0 per cent. 

HEALTH OF DUBLIN. 

The annual rate of mortality in Dublin, which had been 
equal to 31'2 and 29 5, per 1000 in the two preceding 
weeks, further declined to 25'5 in the week ending 
Feb. 1st. During the first five weeks of the current 


quarter the death-rate in the city averaged 27 "5 per 
1000; the rate during the same period did not exceed 
18 0 in London and 19'1 in Edinburgh. The 193 
deaths of Dublin residents registered last week showed a 
further decline of 30 from the high numbers in the 
two previous weeks, and included six which were re¬ 
ferred to the principal epidemic diseases, against three 
and nine in the two preceding weeks ; these six deaths 
included two from measles, two from whooping-cough, two 
from diarrhoea, but not one either from scarlet fever, 
diphtheria, “fever,” or small-pox. These six deaths from 
epidemic diseases were equal to an annual rate of 0 - 8 
per 1000, the death-rate from the same diseases last 
week being 1 ■ 3 in London and 1 ■ 9 in Edinburgh. The 
193 deaths in the city last week from all causes included 
34 of infants under one year of age and 70 of persons 
aged upwards of 60 years; the deaths of elderly persons 
were again exceptionally numerous. Five inquest cases and 
three deaths from violence were registered during the week, 
and 75, or 38 8 per cent., of the deaths occurred in public 
institutions. The causes of 12, or no less than 6 2 per cent., 
of the deaths in the city last week were not certified; in 
London the causes of all but one of the 1584 deaths were 
duly certified, while in Edinburgh 3 • 3 per cent, of the 
causes were uncertified. 


THE SERVICES. 


Royal Navy Medical Service. 

The following appointments are notified:—Staff Surgeons: 
W. It. Center to the President, additional, for three months’ 
course at West London Hospital ; W. H. Pope to the 
Philomel , on commissioning; H. P. Jones to the Topaze; 
M. P. Jones to the Attentive: E. S. Tuck to the Foresight, on 
recommissioning ; C. C. Macmillan D.S.O., to Malta Hos¬ 
pital ; and R. F. Clark to the Victory. Surgeons; G. M. 
Kastment to the Wildfire: and C. J. O’Connell to the 
Magnificent. 

Surgeon J. H. Lightfoot has been promoted to the rank of 
Staff Surgeon, with seniority of May 15th, 1907. 

Royal Army Medical Corps. 

Lieutenant-Colonel George Coutts retires on retired pay 
(dated Feb. 5th, 1908). 

Volunteer Corps. 

Jtoyal Garrison Artillery ( Volunteers ) • 2nd Devonshire: 
George Douglas Kettleweli to be Surgeon-Lieutenant (dated 
Jan. 1st, 1908). 1st Glamorganshire : Surgeon-Lieutenant 
F. G. Thomas to be Surgeon-Captain (dated Jan. 9th, 1908)/ 

Jlifie: 1st Volunteer Battalion, The Sherwood Foresters 
(Nottinghamshire and Derbyshire Regiment): Surgeon- 
Captain A. B. Chambers resigns his commission (dated 
Dec. 20th, 1907). 

Royal Army Medical Corps (Volunteers). 

Western Com mand : Manchester Companies: Honorary 
Lieutenant in the Army John William Smith (late Captain, 
Royal Army Medical Corps (Volunteers) ), to be Captain 
(dated Nov. 21st, 1907). John O’Sullivan to be Lieutenant 
(dated Dec. 19th, 1907). Captain A. T. Lakin resigns his 
commission (dated Jan. 9th, 1908). Lieutenant W. E. 
Rothwell resigns his commission (dated Jan. 9th, 1908). 
Argyll and Sutherland Bearer Company : Lieutenant W. C. 
Murray to be Captain (dated Deo. 25th, 1907). Lancaster 
and Border Bearer Company ; Surgeon-Captain Henry 
Dodgson, from the 3rd (Cumberland) Volunteer Battalion, 
The Border Regiment, to be Captain (dated Jan. 1st, 1908). 
Sussex and Kent Bearer Company ; Lieutenant-Colonel 
and Honorary Colonel J. Turton is borne as supernumerary 
whilst bolding the appointment of Brigade-Surgeon- 
Lieutenant-Colonel, Senior Medical Officer, Sussex and 
Kent Volunteer Infantry Brigade (dated Dec. 17th, 1907). 
Henry Arthur Clifton Harris to be Lieutenant (dated 
Dec. 17th, 1907). 

Deaths in the Services. 

On Jan. 25th, at the Royal Naval Hospital, Chatham, 
Staff Surgeon Harold Edgar Fryer, R.N. lie joined the 
Royal Navy in 1897 as surgeon and was promoted to Staff 
Surgeon in 1905. The deceased, who was only 34 years of 
age, had been suffering from pulmonary tuberculosis. 



452 The Lancet,] THE SERVICES—PLEURAL EFFUSION AND ITS TREATMENT. 


[Feb. 8, 1908. 


Indian Medical Service. 

The result of the January examination was announced on 
Feb. 1st. There were 58] candidates, of whom 51 ulti¬ 
mately entered for the examination ; of these, 48 qualified, 
the first 16 beiDg admitted as lieutenants-on-probation, 
while one withdrew during the examination. The names of 
the successful candidates, with the marks obtained by each 
out of a possible maximum of 5100, are given below :— 


Name. 

Marks. 

W. B. Brlerley 

. 3988 

B. Knowles 

. 3962 

J. B. Lapaley ... 

. 3796 

J. A. Shorten ... 

. 3722 

B. B. S. Sewell 

. 3680 

W. L. Watson ... 

.. 3652 

C. H. Fielding 

. 3627 

W. J. Simpson 

. 3621 


Name. 

Marks 

F. R. Coppinger ... 
A. de C. C. Charles 

. 3610 

. 3575 

J. W. Barnett. 

. 3574 

F. Stevenson . 

. 3554 

S. H. West . 

. 3534 

Madan Lai Puri 

. 3506 

Satya Charan Pal ... 

. 3501 

R. S. Townsend 

. 3483 


The Royal Navy List. 1 

This most excellent handbook has now been before the 
public for more than 30 years and each year demon¬ 
strates the care with which the book is compiled 
while everything is done to facilitate ready reference. 
Over ZOO pages are devoted to the record of the 
war and meritorious service of officers both active and 
retired, and there is a complete list of ships of the 
Royal Navy with details relating to each ship. Under 
the heading of the “Naval Recorder” are an article 
on the current history of the Royal Navy, a list of the 
commissions and services of first- and second-class ships 
on the active list, a list of the fleets and squadrons in 
commission since 1878, and a chronological table of notable 
events from the year 1219 to the present time. A valuable 
feature of the Navy List is a bibliography of naval literature. 
The book should find a place in the library of everyone who 
is interested in our first line of defence. 


(tampithnn. 


11 Audi alteram partem.” 

PLEURAL EFFUSION AND ITS 
TREATMENT. 

lo the Editor of The Lancet. 

Sir,—S ir James Barr affects to think that in agreeing to 
accept the term “ pulmonary traction ” and to substitute for 
my hypothetical case of fibroid phthisis with non-adherent 
pleune an actual one with adherent pleurae I have made 
important admissions. This is a little ungallant of him, as 
these concessions were for the purpose of humouring Sir 
James Barr and with the full knowledge that they did not 
affect one way or the other the main issue between us, which 
is whether it is, or is not, necessary for the student of 
pulmonary physics to keep separate in his mind the concep¬ 
tion of pulmonary tautne6S and that of pulmonary elasticity. 
I may at once say that after doing my best to get at Sir James 
Barr’s meaning I do not find that he advances in his last 
letter a single valid argument against any of the statements 
made in my two previous letters. I shall once more 
endeavour to convince him that my contentions are as easy 
of proof as they are simple. 

I, of course, recognise that the factor of resistance is an 
essential ingredient in our conception of pulmonary elasticity, 
that the lungs cannot be made to manifest their elasticity 
as regards a stretching force without being stretched, and 
that when they are stretched they pull on the visceral 
pleura and so exert traction on the circum-pulmonary struc¬ 
tures ; but it is not by virtue of their elasticity that the 
lungs exert this traction but by virtue of their tautness. It 
is quite true, as Sir James Barr insists, that the elasticity of 
the lungs enables them to retain their tautness and thus to 
exercise a continuous traction during the entire respiratory 
cycle, and I am ready to admit that this is a prime function 
of pulmonary elasticity, but we have no more right to say 
that the elasticity causes the traction than we have to say 
that the elasticity in the hangman’s rope causes the death of 
the condemned man, or that the elasticity of the traces 
attached to a waggon causes the waggon to be pulled along. 


1 The Royal Navy Li«t and Naval Recorder, No. 121, January, 1908. 
Wlutherby and Co., 326. High Holborn, London, W.C., and 4, Newman'i- 
court, Cornhill, London, B.C. 


Even Dr. D. W. Samways, for whose support, though 
qualified, I am gratefnl, fails, eminent physicist though he 
is, to make the necessary distinction between tantness and 
elasticity. “Consider, ” he writes, “ the thorax and the respira¬ 
tory mnscles at rest. The lungs remain stretched; they support 
by their elastic recoil a certain fraction of atmospheric 
pressure to which the intrapleural space (if space it may be 
called) is not subjected in consequence. In that sense, as 
Sir James Barr states, ‘there is a slight negative pressure 
in the pleurse owing to the elasticity of the lungs.’” I 
submit that the negative pressure at this moment when 
the chest is kept fixed and when we may . assume 
the intrapulmonary pressure to equal the extra-corporeal 
pressure is due to the tautness of the pulmonary tissue 
pure and simple and that the factor of “ elasticity ” 
or “elastic reooil” has nothing to do with it. Let 
us for argument’s sake suppose the lungs in the case 
in question suddenly to be rendered perfectly non-elastic, 
their tantness, however, remaining unaltered. In such 
a case the negative pressure in the pleurse produced by 
pulmonary traction would undergo no change. Is it not 
therefore evident that we must keep the idea of pulmonary 
tautness and that of pulmonary elasticity distinct 1 I shall 
presently show that this is not merely theoretically necessary 
but that in actual life it is possible to get a great increase in 
pulmonary tautness and a corresponding augmentation of 
pulmonary traction though pulmonary elasticity be consider¬ 
ably subnormal. 

But first a word as to the factors which determine 
“pulmonary traction.” They are two—pulmonary tautness 
and intrapulmonary air pressure. Pulmonary traction varies 
directly with the one and indirectly with the other. These 
two factors are not only distinct but may at one and the 
same time work in opposite directions. Thus if at the end of 
a deep inspiration when pulmonary tautness is at the 
maximum a powerful expiratory effort be made with closed 
glottis, the increment in intrapulmonary pressure thus pro¬ 
duced more than obliterates the traction effect of pulmonary 
tantness, and consequently the lungs no longer exert traction 
upon, but actually press against, the surrounding parts. 
Contrariwise, if at the end of a deep expiration, when the 
pulmonary tissue is relaxed and the lungs cease to exercise 
traction, a powerful inspiratory effort be made with closed 
glottis, the greatly lowered intra-pulmonary pressure thus 
effected will give rise to considerable pulmonary traction. 

Pulmonary tantness then plays an important part in deter¬ 
mining pulmonary traction, the two tending to rise and fall 
together. Pulmonary tautness, however, bears no constant 
relation to pulmonary elasticity. I shall prove this pro¬ 
position by reference to two diseases—hypertrophous 
emphysema and fibroid phthisis. Dr. Samways remarks on 
the fact that the elastic tissne of the long “ strangely chooses 
from birth onwards never to assume the nnstretched condi¬ 
tions.” This stretched condition of the pulmonary tissne is 
effected by the inspiratory mnscles. As I have elsewhere 
pointed oat, the inspiratory muscles are throughout life ever 
on the watch to maintain pulmonary tautness at a certain 
mean level, with the object of maintaining a constant 
suction or (as Sir James Barr prefers to call it) 
" traction ” on the heart, and thus facilitating diastole ; 
the inspiratory muscles, in fact, play a considerable 
part in effecting cardiac diastole—constitute, in fact, an 
important diastolic force. Now let us take a simple uncom¬ 
plicated case of hypertrophous emphysema insidiously 
coming on, as it so frequently does, without any bronchitis 
or cough about middle life. The lungs gradually lose their 
elasticity much in the same way as the skin loses its 
elasticity. Suppose, now, the mean size of the chest to 
remain the same ; it is obvious that the tautness of the lungs 
will fall below the normal and that there will be a 
corresponding fall in pulmonary traction. But the mean 
size of the chest does not remain the same. The ever- 
watchful inspiratory muscles, in obedience to the physio¬ 
logical necessity just referred to, cause an increase in 
mean thoracic capacity and thus tighten the pulmonary 
tissue up to the normal, much as the violinist is compelled 
from time to time to tighten np the strings of his instrument. 
And thus, as the pulmonary tissue loses in elasticity with 
every advancing month and year, the thorax is made to 
increase in size and for a long time the tautness of the 
pulmonary tissue, in spite of steadily diminishing elasticity, is 
kept at the normal and mith it the resulting pulmonary 
traction until at length a point is reached at which the 
increase in the size of the thorax can no longer keep pace 












Thb Lancet.] 


PLEURAL EFFUSION AND ITS TREATMENT. 


[Feb. 8, 1908. 453 


with the decrease in the elasticity of the lungs, with the 
result that pulmonary tautness and pulmonary traction sink 
below the normal. What better instance can I give of the 
need to distinguish between tautness and elasticity : 

I now come to the case of fibroid phthisis. It is quite 
easy to prove that in this disease—in which all will admit 
there is an enormous diminution of elasticity—there may be 
a great increase in pulmonary tautness with a corresponding 
increase of pulmonary traction. Sir James Barr denies that 
the lungs are taut in fibroid phthisis. “Try and you will 
find that the fish does displace the water and the lungs are 
not taut and the intrathoracic pressure is not lowered.” If 
the lungs are not taut, and if pulmonary traction is not 
increased, how are we to account for the “sinking in” of the 
upper part of the chest not infrequently met with in chronic 
phthisis as well as in the more acute forms of the disease 1 
Instead, i.e., of the lungs exercising moderate traction on 
the upper part of the chest so that the impiratory muscles 
have no difficulty in keeping that portion normally expanded, 
the lungs exercise a traction so great that the inspiratory 
muscles, strive how they may, are powerlesB to contend 
against it and the chest flattens in consequence. 

It is needful to remember that pulmonary tautness is not 
necessarily equal throughout the entire extent of the lung. 
Under normal conditions, with non-adherent pleura: and 
normal pulmonary texture, it tends to be. Thus when a 
purely abdominal breath is taken the lower part of the lungs 
expand first, but owing to the mobility of the lungs, rendered 
possible by the pleurae, and owing to the uniform elasticity 
of the pulmonary tissue, the augmented tautnese tends 
rapidly to diffuse itself throughout the entire lungs. When, 
however, the pleurae are adherent, or when the structure of 
the lungs is profoundly modified as by the abundant deposit 
of fibrous tissue, one portion of the lung may be super- 
normally stretched while another part is only moderately 
taut. Suppose, for instance, that in its upper part the lung is 
highly fibrotic and the pleura is adherent, while in the lower 
parts there is emphysema, pulmonary tautness might be 
supernormal in the one part and subnormal in the other. 

“Try and you will find that the intrathoracic pressure is 
not lowered.” It is not clear whether Sir James Barr here 
means intrapulmooary or intrathoracic extrapulmonary 
pressure—two very different things. In another passage he 
refers to intrathoracic or intrapleural pressure, and pre¬ 
sumably Sir James Barr is here referring to intrapleural 
pressure. Sir James Barr appears to assume that it is 
possible to measure pulmonary tautness and pulmonary 
traction by means of intrapulmonary pressure, but we 
have already seen that the two factors which determine pul¬ 
monary traction—pulmonary tautness and intrapulmonary 
pressure—may simultaneously operate in opposite directions. 
Sir James Barr not only denies that the lungs may be super- 
normally taut in fibroid phthisis but actually argues, or 
appears to argue, that pulmonary traction is necessarily 
lowered in this disease because the intrapulmonary pressure 
cannot in Muller’s experiment be reduced to anything like the 
normal extent, say, only — 8 Hgmm., as against — 80Hgmm. 
I freely admit that it may he possible to produce a higher 
degree of pulmonary traction in the normal individual 
by Muller’s experiment than in the case of a patient 
suffering from fibroid phthisis. But people do not spend 
their lives in making Muller’s experiment. Further, if Sir 
James insists upon dwelling upon the difference just referred 
to, 1 may point with equal force to the fact that in the con¬ 
trary experiment of expiring with closed mouth and nares, 
the normal individual is capable of producing a very much 
higher intrapulmonary pressure than the patient with fibroid 
phthisis, and that therefore pulmonary traction is much 
more effectually obliterated and converted into pulmonary 
pressure in the former case than in the latter. Sir James’s 
argument here cuts, in fact, both ways. What we have to 
do with, however, is not a temporary condition, voluntarily 
induced, but with habitual conditions, and, as a matter of 
fact, there is very little difference between the habitual mean 
intrapulmonary pressure of the normal individual and of 
the patient with fibroid phthisis. If, therefore, the average 
degree of pulmonary tautness is greater in the latter case 
than in the former the average degree of pulmonary traction 
must be greater. 

Regarding my assertion that in cases of phthisis the mean 
size of the thorax may be increased, Sir James Barr Eays : 
“ 1 always thought that fibroid tissue occupied less space 
than the portion of the lung which it replaced. I am afraid 
there is some confusion in Dr. Campbell's mind between 


fibroid tissue and the accompanying emphysema.” Of course, 
fibroid tissue tends to occupy less space than the portion of 
lung which it replaces. For this reason, if the atrophied 
fibroid lungs are to increase in size and thus adapt them¬ 
selves to the thoracic cavity, the mean size of which is con¬ 
stantly tending to be increased by the powerfully acting 
inspiratory muscles, something must give, and this giving 
involves not only the alveoli with the production of the 
emphysema to which Sir James refers, but also (what Sir 
James neglects to mention) the bronchi (causing bronchiec¬ 
tasis) and often also the tubercular cavities which tend to be 
pulled out by the taut lung tissue into spheroidal form ; 
these yieldings manifestly all result from supernormal 
pulmonary tautness. 

Sir James Barr asks why in fibroid phthisis my “ heightened 
tautness of the lungs should allow the fingers to become 
bulbous ” ? the inference being (I presume) that by augment¬ 
ing pulmonary traction it should facilitate, not impede, the 
circulation. The answer is surely obvious : in so far as the 
bulbous condition of the fingers in fibroid phthisis is due to 
obstructed circulation it results from the widespread destruc¬ 
tion of the pulmonary blood vessels. No amount of aug¬ 
mented traction on the heart could adequately compensate 
for this. 

Commenting on my assertion that “comparatively non¬ 
elastic lungs, such as those seamed with scar-tissue, are 
capable of being rendered more taut, and thus of exerting 
more traction on circumjacent parts than normal, highly 
elastic lungs." Sir James Barr says : “ This reasoning 

is that of tbe academician in his study and not that 
of the clinician who views facts and reasons there¬ 
from. I shall now," he continues, “proceed to prick the 
bubble.” This is his modut operandi : “Non-elastic fibroid 
lungs cannot be taut both in inspiration and expiration 
and therefore a constant negative pressure cannot thus 
be maintained.” Quite true. Lungs wholly non-elastic 
could only become taut at the extreme limit of inspiration, 
and this to all intents and purposes means that with such 
lungs there would be no pulmonary traction, hut, on the 
contrary, a positive pressure on the heart, and this would so 
interfere with the circulation, already sorely embarrassed by 
the block in the pulmonary circuit, that death would soon 
ensue. I admit that Sir James has pricked the bubble, but 
please note, Sir, that I am in no way responsible for the 
blowing of that poor bubble. Sir James himself is responsible 
for that, for it will be observed that in the passage he 
quotes from me I refer not to “non-elastic” but to 
"comparatively non-elastic” lungs—two very different things. 
While I believe it is possible for certain portions of the lung 
in fibroid phthisis (the apex, for instance) to be at one and 
the same time practically non-elastic, supernormally taut, 
and immobile, yet other portions must, if life is to continue, 
retain sufficient elasticity to remain taut during the ordinary 
respiratory movements. 

To my contention that the enlargement in the mean size 
of the chest which may occur in fibroid phthisis is brought 
about by the inspiratory muscles, Sir James replied in his 
first letter that any stretching of the lungs that might occur 
was caused by the pressure of air within them and not by 
the inspiratory muscles. Referring to this I said in my last 
letter: “ What has the average intrapulmonary air pressure 
got to do with the stretching of the lungs when the 
pleurae are adherent 1 Manifestly nothing whatever,” 
seeing that the pressure of the intrapulmonary air 
is counterbalanced by the extracorporeal air pressure. 
Dr. James Barr thus comments on this passage: 
“The question and answer coming from a physicist are 
really very funny. Does he not know that whether the 
lungs are adherent or not tbe thoracic parietes intervene 
between the external atmosphere and the lungs, and any 
force which expands the thorax beyond the expansile power 
of the lungs must exercise a force of 15 pounds to the square 
inch, and this the inspiratory muscles could not do over such 
a large surface as the chest though they tugged and pulled 
like Dr. Campbell at Cleopatra’s Needle. The inspiratory 
muscles, like Dr. Campbell, often expend a lot of useless 
energy. How often do we grieve at the struggles of a poor 
asthmatic doing nothing ? ” Surely these remarks are beside 
the question. I nowhere made any mention of an “expan¬ 
sion of the thorax beyond the expansile power of the lungs,” 
but simply referred to the moderate increase in the mean sizeof 
the chest which may sometimes be observed in cases of fibroid 
phthisis. Sir James’s objections apply to such an expansion of 
the thorax as should separate the chest walls from the lungs 




454 The Lancet,] 


THE RESPONSIBILITY FOR THE ANESTHETIC. 


[Feb. 8 , 1908. 


and leave a vacuum between the two, and not only would the 
inspiratory muscles be incompetent to do this, but no force 
which can be imagined, not even one equal to 15,000.000 
pounds or 15,000,000 tons to the square inch of chest surface, 
would be competent to do this, for in the process of expansion 
the thoracic walls or the lungs would rupture long before 
such a vacuum could be brought about. As a matter of fact, 
the inspiratory muscles are competent to expand the chest 
to its potential maximum, as may be observed in advanced 
cases of hypertropbous emphysema. 

May I, Sir, in concluding this long letter venture to express 
the hope that this time the energy expended may not bo 
entirely lost on Sir James Barr. Certain it is that I shall be 
more than content if it proves as profitable to him or to 
others as are the respiratory struggles of the unfortunate 
asthmatic profitable to the latter, convinced as I am that those 
struggles, blind and purposeless as they may appear to the 
casual observer, are yet wisely directed towards a useful end, 
and that but for them no patient could battle through a 
severe asthmatic paroxysm. Nature is not always such a 
fool as some seem to think. 

I am. Sir, yours faithfully. 

Wimpole-atreet, Feb. 2nd, 1908. HARRY CAMPBELL. 


THE CAUSE OF THE PREVALENCE OF 
ADENOIDS. 

To the Editor of The Lancet. 

Sir,—I am glad Dr. J Sim Wallace does not “ put any 
importance on” his figures, for even more startling 
deductions might be made from them. As his five shut- 
window families have 26 children and his five open window 
families but 19 he might have argned that closed windows at 
night increased the number of children born, and closed 
windows might be recommended to the President of 
the United States as a cure for race-suicide! But joking 
apart, I do not think Dr. Wallace will find that his 
theory is supported by facts. I think the explanation of his 
numbers, if one is needed, is that adenoid families see a lot 
of the doctor and where the doctor rules the windows are 
open at night. If adenoids are on the increase it cannot be 
due to open windows, for windows that really shut are of 
qnite recent introduction. The old leaded glass always 
leaked and it is only since it was superseded that the bed- 
curtains and night-caps of our parents have been done away 
with. I am. Sir, yonrs faithfully, 

O. Clayton Jones, M.B. Oxon. 

Silverton, Exeter, Jan. 29th, 1908. 


THE RESPONSIBILITY FOR THE 
ANAESTHETIC. 

To the Editor of The Lancet. 

Sir,—I t is to be hoped that Dr. Dudley W. Buxton's paper 
in The Lancet of Jan. 18th, p. 151, and your leading 
article thereon have been very carefully read not only by sur¬ 
geons and anaesthetists but also by general practitioners. It 
happens far too commonly that a practitioner who calls in a 
surgeon to perform an operation—whatever the nature of 
this may be—suggests, and even requests, that be or his 
partner or assistant may give the anaesthetic, although there 
may be no adequate reason for not engaging a skilled 
anaesthetist. When such a request is made to a surgeon it 
is, of course, not easy for him to refuse, although he may 
have grave misgivings as to the result of his consent and 
although he may be well aware that the operator who 
permits a person of small experience to give an anaesthetic 
accepts a very serious responsibility. 

I have no doubt such an arrangement is usually suggested 
in all good faith, for the majority of practitioners whom I 
have met do not seem to realise that for the proper conduc¬ 
tion of a large proportion of the operations done at the 
present time special skill and experience are as needful in 
the anaesthetist as in the surgeon, and that the average prac¬ 
titioner cannot expect to be any more capable of replacing 
the one than the other. It is necessary not only to know the 
kind of amcsthetic best suited to the patient and to the 
operation but also to be well acquainted with the surgical 
procedure in order that pitfalls may be avoided. This is 
especially the case with operations on internal organs and 
above all with those (even ‘ 1 trivial ” ones) on the upper air- 
passages, where safety and success can only be attained by 
a knowledge of the operator's methods and a perfect 


cooperation between him and the anesthetist. So many 
instances have come to my knowledge where want of special 
experience in a self-constituted anesthetist has led to in¬ 
convenience and even disaster that I venture to trouble you 
with this letter. I am, Sir, yonrs faithfully, 

J»u. 25th, 1908. F.ll.C.S. 


THE PRESENT PROSPECTS OF THE 
MEDICAL PROFESSION. 

To the Editor of The Lancet. 

Sir.—T he remarks of “ Inspector-General ” in yonr issue of 
Jan. 25th are worthy of the very greatest consideration, and 
call for more than ordinary passing comments in your corre¬ 
spondence columns. Indeed, a change of government in the 
whole attitude and conduct of modern professional manners 
is sadly needed. Kverytliing is moving too quickly now¬ 
adays and this is not foreign to ourselves. There is a rash, 
a congestion, and a competition in onr ranks which is 
decidedly tending to disorganise the enthusiasm and high 
aims of those who formerly filled the ranks of the profession. 
There is, in fact, disorder. That this is the outcome of 
education and general social changes is clear. But to stave 
off this wave of socialism in medicine needs a stronger 
bulwark than the lean-to wall of your valuable professional 
journal or any other medical publication of your standard. 

Thus, Sir, my fragmentary remarks in The Lancet in 
support of " Inspector-General ” may possibly only react pro¬ 
portionately as a grain of sand. But medicine is full of 
hope and, although slow in results, nevertheless a number 
of grains of sand may affect the whole problem before us— 
viz., the present, nay probably the futnre, prospects of the 
medical profession. We are apt to throw stones at glass 
windows and to blame others for a great deal that befalls the 
profession when, if we weighed the matter thoughtfully, 
perhaps we ourselves are sore. There are hundreds of men 
in the profession striving to aim at good deeds but they are 
batiled by those whose methods and practice are not pleasant 
to behold. If we despise the lay advertiser why should this 
not apply to ourselves, may I ask! Is not personal adver¬ 
tisement contrary to the ethics of the profession of medi¬ 
cine ! Why, then, do gentlemen send open postcards and 
the like through the post seeking patients ! Are there no 
censors in the profession ! And, what is worse, how few of ns 
have the courage of their opinions and perhaps are too sby to 
utter condemnation on personal advertisement! But is not 
the canker worm of self-advertitement a sign of stress—an 
ominous warning for the future of the profession for which 
some drastic measures will have to be devised sooner or 
later ! It is impossible for a whole body of men to travel 
along a cordnroy road for a length of time without several 
falling out of the ranks. 

Again I will draw attention to another lapse in medicine 
among the present generation—namely, the using of pro¬ 
prietary drugs and other medicaments foreign to the order 
of the British Pharmacopoeia. What has become of the good 
old pill may 1 ask ? And if we do not actually practise 
empiricism do not we sail very close to the wind and 
encourage that class of the laity who deal in such things ? 
Altogether, from the drug point of view, are we not getting 
very muddled ! 

As concerns onr practice, there is no definite ruling as to 
what constitutes the exact duties of the general practitioner, 
because his need to earn a living wage encourages him to 
be Jack of all branches of the profession. Hence arises 
specialism, bat truly there is more dabbling in the specialties 
of the profession by its members than is justified. And it is 
questionable whether this dabbling by the recently qualified 
is not indirectly an explanation of the oft-repeated public 
censure which the profession as a whole has to endure. In 
the army we see things are differently managed, for there is 
a stage of probation, then successive periods, including an 
examination, before the young man reaches the title of a 
colonel. And in general civil practice we ought to see some¬ 
thing similar, so that a junior should not rank as high as his 
senior who has practised for many years. The licensing 
bodies might renew by fresh reception, at varying periods, an 
extension to practise, gradually weeding out those who by 
age, incompetency, or irregular practice rightly cease as 
practising members. Above all, before a candidate qualified 
to practise leaves the threshold of the licensing body, be 
it the Royal College of Physicians or the Royal College of 
Surgeons, there should not be the slightest doubt as to 



The Lancet,] 


THE SPREAD OF CHOLERA IN THE NEAR EAST. 


[Feb. 8,1908. 455 


what are his duties to himself and his professional brethren. 
This should be empanelled in a thoroughly bound document 
with the stamp of the College detailing their methods and 
manners of practice and all matters likely to lead to contro¬ 
versial dispute in the future of the recipient. 

We have no regular scale of fees, but the most important 
point for all thoughtful men is the spirit of trade-unionism 
which has been discussed so much in the medical journals. 
Once and for all let us at ODce knock such nonsense on the 
head. Until there is a revolution or a break up of the empire 
no such practice can be adopted in the care of the sick and 
wounded. How can we regulate hours of labour in war, and 
the practice of medicine iB war against disease. There is 
also another spirit which is equally increasing in the rising 
generation which affects the nobility of our calling. As is 
the caBe of the servants of the Church, poverty to a great 
extent must befall the rank and file of medicine. There 
is only room for a certain number of bishops and of 
physicians and surgeons in ordinary and the rest must 
be satisfied with their lot and be content with a life 
of love for their follow creatures. 1 do not know of any 
calling in life in which a love of medicine with a private 
income coaid be better fulfilled and do at the same time 
much signal service to the medical profession. Parents of 
the well-to-do might well consider this and put their sons 
into the profession of medicine instead of other callings. 
How cowardly seems the way in which we sometimes neglect 
our right when we stoop to the power of money. 

I would remark that the rise and fall of our profession or 
of a nation will always be dependent upon its leaders, and I 
would emphasise the great importance of this leadership and 
example from those who are officers in the great army of 
medicine and surgery. I mean our teachers and professors 
at the schools for medicine and surgery, the authorities 
at the Iloyal Colleges, and all to whom the student 
of physic looks for his education and guidance. Tf I 
have confined myself to a particular groove of thought 
perhaps some other members of the profession will take a 
different line and give assistance in this difficult question of 
the present prospects of the medical profession. Perhaps he 
will confine himself more strictly to what may seem to be 
the text, but I hope he will at least remind the great leaders 
of medicine and surgery of their enormous ethical responsi¬ 
bilities. For such leaders may stave off the effects of the 
wave of discontent in the medical profession. 

I am, Sir, yours faithfully, 

J«T1.25th, 19G8. _ VlRTUTKM SEQUOR. 


To the Editor of The Lanobt. 

Sir, —In The Lancet of Jan. 25th “Inspector-General” 
mentions several reasons for the alleged present serions 
financial condition of many of the general practitioners of 
this country. “Inspector-General,” however, gives no 
remedy. I do not think we have far to seek to find the 
cause and therefore the cure. The cause, to my mind, is the 
ignorance or lethargy, or both, of a large number of the 
general practitioners. On H. R.H. the Prince of Wales’s 
return from his colonial tonr, when speaking at the 
Guildhall, his message to Great Britain was to “ wake up.” 
The same message, to my mind, might with advantage be 
taken to heart and acted upon by a vast number of the 
general practitioners scattered through our land. 

“ Inspector-General ” mentions “quackery ”as one cause— 
granted ; and undoubtedly legislation ought to come to our 
aid in this respect, not mainly to protect us, however, but to 
protect the public. Your correspondent mentions “preventive 
medicine,” but not as a cause ; it certainly is not a cause, for, 
granted a proper knowledge of preventive medicine, our 
incomes would be quite as large from the exercise of that 
humane branch as from the treatment of disease, and 
certainly with greater satisfaction to onrselves. “Inspector- 
General ” gives two other reasons for the present serions 
financial condition of many members of our profession—vis., 
(I) that railways have brought the rural districts “into 
touch with towns where patients can consult some medical 
man renowned for special knowledge of their ailments ”; 
and (2) “ the abuse of medical charities.” The first of these 
causes he says is “ entirely non-medical ”—I disagree. The 
second cause undoubtedly exists. I maintain that both are 
the fault of the general practitioners to a very large extent. 
If the mass of general practitioners of this country knew 
their work well they would treat the cases themselves and 
not send them to “ specialists, ” nor would their patients go 
to “ specialists.” 

The medical student before lie leaves fats hospital ought to 


hold at least one appointment in every branch of his profes¬ 
sion, so that when he goes into practice he is able to remove 
tonsils, adenoids, turbinates, polypi, and other nasal obstruc¬ 
tions ; to treat diseases of the throat, nose, ear, &c.; to correct 
errors of refraction and deal with astigmatism ; to properly 
treat displacements of the uterus, be able to curette the 
uterine cavity, amputate the cervix, &c., and Boon through 
all the thousand-and-one minor operations. His knowledge, 
however, should not cease there, but nowadays with surgery 
so simplified by aseptic methods he ought to be able to do 
abdominal surgery and other major operations. 

Where does the “specialist” come in'! In his proper 
place, to diagnose really obscure cases, to operate on those 
cases which this or that general practitioner is not justified 
in doing because he is unable to get sufficient practice in 
this or that particular operation. If the general practitioner 
knew his work, as I maintain he ought to know it, the 
wealth of the “ specialists ” would to a large extent be dis¬ 
tributed over the medical community, the number of 
“ specialists ” would be reduced, and the medical profession 
would once more be flourishing. It is, I think, forgotten by 
many that each patient sent by them to a “specialist” 
means the loss to them, only too frequently, not only of that 
patient but of all that patient’s friends who have, or think 
they have, any disease affecting that particular region of the 
body. 

I say again, let the general practitioners of this country 
‘ ‘ wake np ” ; let those who do not know their work properly, 
learn it; and those who do, awake from their lethargy and 
do the work themselves. Personally, I have been in general 
practice many years and now am half a general practitioner 
and half a consultant, although not being on the staff of 
a hospital I am aware that some would deny me the right of 
calling myself a consultant at all—but in that case they 
must call me a general practitioner who is consulted 
frequently by his fellow practitioners. How have I acted in 
the past? Whenever necessary to consult a “specialist” I 
have gone with my patient, have kept my eyes open, and 
any operations I did not know how to do I very soon learnt 
the way and in the future did them myself as long as I felt 
justified by my knowledge to do so. To my mind there lies 
the principal remedy, and if the general practitioners will 
only exercise it we should soon hear less of these financial 
difficulties. I am, Sir, yours faithfully, 

London, Jau. 25th, 1908. HALF-AND-HALF. 


THE SPREAD OF CHOLERA IN THE NEAR 
EAST. 

(From the British Delegate on the Constantinople 
Board ok Health.) 


As reported in my last letter 1 this year’s pilgrimage to 
Mecca and Medina iB very seriously infected with cholera. 
From Mecca the following daily returns have been ieceived 
since the beginning of January (these figures are in continua- 

L.: in tVtO lot.tPT lllRt, TftfftlTpd :- 


Jan. 1st ... 

52 deaths . 

15 cases isolated. 

„ 2nd ... 

52 „ 

4 

,, 3rd ... 

56 ,, 

14 

,, 4th ... 

67 ,, 

. 17 

„ 5th ... 

86 „ 

■ 12 

,, 6th ... 

98 „ 

■ 20 

,, 7th ... 

127 „ 

. 46 

„ 8th ... 

185 ,, 

. 48 

,, 9th ... 

177 „ 

■ 42 

, r 10th ... 

241 „ 

. 27 

„ 11th ... 

257 ,, 

6 

„ 12th* ... 

121 ,, 

— 

„ 13th ... 

62 ,, 

. — 

„ 14th ... 

16f ,, 

. — 

,, 15th ... 

31+ „ 

. — 

„ 16th ... 

143§ „ 

— 

„ 17th ... 

486 ,, 

18|1 cases isolated. 

,, 18th ... 

394 „ 

. — 

„ 19th ... 

350 „ 

— 

,, 20th ... 

246 ,, 

• — 


" L»n tnib any uic pn^nmo iciu iuouu« .v. -*»-"““7 -roc' 

[ina 82 deaths. J At. Mina 201 deaths. $ At Mina 195 deaths. 
The pilgrims had now returned to Mecca. 

The above figures are interesting. Up to Jan. 11th there 
as a steady rise in the number of deaths, corresponding 


•i The Lancet, Jan. 18th, 1908, p. 1 









456 Th* Lancet,] 


THE SPREAD OF CHOLERA IN THE NEAR EAST. 


[Feb. 8,1908. 


with the steady accumulation of pilgrims as the fetes 
approached. The telegram of Jan. 5th states that the rise 
in the number of deaths on that day was due to the arrival of 
infected caravans from Medina and Jeddah. On the 12th, 
the eve of the first day of Kurban Bairam, the pilgrims were 
Hocking out to Arafat and Mina ; the town of Mecca would 
be largely deserted, and the number of deaths from cholera 
there underwent a corresponding diminution. Then, after 
the fetes, the pilgrims flowed back to the city, and there was 
an explosive rise in the curve of the outbreak, followed by a 
slight but steady fall. It is almost certain that the returns 
were very incomplete during the days that the fetes lasted, 
when the pilgrims were in more or less constant movement, 
and distributed over a relatively large area. It may, there¬ 
fore, be assumed that the true figures, could they have been 
ascertained, would have considerably exceeded those here 
given. The total number of cases reported from Mecca has 
been 4373, and that of deaths 3992 down to Jan. 20th. 

In Medina the numbers have been less, as was to be antici¬ 
pated, for, whereas all the pilgrims visit Mecca, only a 
certain proportion of them go to Medina ; and, of these, 
perhaps the majority go there after, rather than before, the 
fetes. It is unnecessary to quote the daily returns from 
Medina. They may be summarised as follows :— 

Between Dec. 18th and Dec. 24th ... 78 cases ... 74 deaths. 

„ „ 25th ,, Jan. 3rd ... 133 ,, ...113 „ 

,, Jan. 4th ,, ,, 7th ... 73 „ ... 32 ,, 

„ ,, 8th „ „ 15th ... 46 „ ... 41 „ 

The returns from Medina have, however, been very incom¬ 
plete ; on many days the bulletin has been altogether missing. 

In Yanbo 107 cases of cholera, with 69 deaths, were 
recorded between Dec. 20th and 24th ; and 148 cases, with 
91 deaths, between Dec. 25th and Jan. 3rd. Since the last- 
named date no news has been received of the course of the 
outbreak in Yanbo. 

In Jeddah it will be recalled that two cases of the disease, 
both fatal, occurred on Dec. 26th and 29th respectively. 
Then, between Dec. 30th and Jan. 4th, there were 20 cases 
and 19 deaths ; between Jan. 5th and 9th, 8 cases and 8 
deaths ; and between Jan. 10th and 19:,h. 4 cases with 3 
deaths. Finally, the latest telegrams from Jeddah show that 
the pilgrims are now flowing back there from Mecca and 
bringing the infection with them. Thus, on the 19th it was 
reported that one case of cholera had occurred in a caravan 
arriving from Mecca ; on the 20th 8 deaths from the disease 
were recorded there; and on the 21st there were 26 deaths 
and 3 cases isolated. 

In the meantime the outbreak of cholera in the Abu-Saad 
lazaret (Jeddah) has diminished but has not come wholly to 
an end. It will be recalled that several ships arrived there 
from Yanbo with large numbers of hajjis suffering from the 
disease. Between Dec. 21st and 29th as many as 128 cases 
with 53 deaths occurred among these pilgrims. Between 
Dec. 30th and Jan. 4th there were 46 fresh cases and 36 
deaths; between Jan. 5th and 9th 12 cases and 9 deaths; 
and between Jan. 10th and 18th 4 cases and 4 deaths. In 
addition, the French pilgrim ship from Sinope and Con¬ 
stantinople which was mentioned in my last letter arrived at 
the Abu-Saad lazaret on Jan. 3rd and reported that 19 
deaths from cholera had occurred on board during the 
voyage. Possibly all these deaths were not due to cholera, 
as of three fatal cases from her landed at the Wells of Moses 
and originally reported as cases of cholera it has now been 
shown that only in 1 was death due to that disease, the 
others having died from pneumonia and pneumonia with 
dysentery respectively. However this may be, it appears 
that a further death from cholera occurred on Jan. 4th 
among this ship’s pilgrims at Abu-Saad, and 7 more cases 
were landed from her on the 5th. 

A pilgrimage so seriously contaminated with cholera as 
the present one offers an obvious and very real danger for 
the rest of the world ; and for the next few weeks and 
months the sanitary defences of countries in close proximity 
to Arabia—and later possibly those of countries farther 
removed—will be put to a serious strain. On the present 
occasion a new factor, which did not exist during former 
epidemics, has to be taken into consideration by those 
responsible for the sanitary control of the dispersing 
pilgrims. This is the Hedjaz railway. A detailed scheme 
of measures for the sanitary defence of the line during 
the present Haj has been drawn up; and some, if not 
all, of the-e measures are already being executed. 1 hope 
to recur to this subject in greater detail in a later letter. 
The measures imposed by the Constantinople Board of 
Health on pilgrims returning from the Hedjaz by sea may 


be summarised as follows. Pilgrim ships coming to the 
Mediterranean will, after undergoing the measures prescribed 
by the Egyptian regulations at the lazaret of Tor, be subject 
to a further five days' quarantine and disinfection in one of 
the Turkish lazarets of Clazomene (Smyrna), Beirut, or 
Tripoli (Africa). In addition, those destined for Constanti¬ 
nople will be subject to a medical visit on passing the 
Dardanelles and again on arriving at Constantinople. Russian 
pilgrims are to be carried on ships exclusively reserved for 
their direct transport to Russian ports. Such ships will first 
do the regulation quarantine at Tor and will then be allowed 
to transit the Dardanelles and Bosphorus in quarantine. 
They will, however, be permitted to provision, under strict 
sanitary surveillance, at the Clazomene lazaret. Should 
cases of cholera occur on any of these ships they will be 
sent to the Clazomene lazaret for the necessary measures of 
quarantine and disinfection, after which they will still have 
to pass the Straits in quarantine. 

As will have been gathered from earlier letters, the 
city of Constantinople has been menaced with a possible 
invasion of cholera from Russia through the latter part of 
the year just closed. Down to the last day of the year it 
was hoped, apparently with reason, that it would escape, in 
spite of the constant passage of pilgrim ships past its shores 
and in spite of the actual occurrence of one case among 
pilgrims in Stamboul in November. 2 This hope has now, 
unfortunately, been falsified. On Jan. 1st a case of disease 
presenting all the symptoms of cholera occurred in the 
Yenishehir quarter of the town. This is really a suburb of 
Pera. The patient died and the bacteriological evidence 
showed that death had in fact been due to cholera. This 
case has been followed at intervals by eight others, making 
nine in all ; and eight out of the nine cases have ended in 
death. In every case the diagnosis of cholera based on the 
clinical history and appearances after death has been con¬ 
firmed by the results of a bacteriological inquiry. The cases 
have been scattered over a large area, extending from the 
northern Bosphorus to the Marmora and including Pera, 
Stamboul, and both shores of the Bosphorus. Thus, in 
addition to the first case mentioned above, there have been 
two cases at Beicos, near the northern end of the Bosphorus 
on the Asiatic side ; one at Kumeli Hissar, about half way up 
the Strait on the European side; two of boatmen in the 
Golden Horn ; one in the Balata quarter of Stamboul (near 
the Golden Horn); one in a boatman at Haidar Pasha, 
opposite Stamboul, on the Asiatic shore of the Bosphorus 
and the terminus of the Bagdad Railway ;• and, finally, 
one at Zeitun Bournou, on the Marmora shores of Stamboul. 
It is not known how these persons contracted the infec¬ 
tion, nor has any connexion between the successive cases 
been traced. Passengers leaving Constantinople by sea or 
land are now subjected to a medical visit and disinfection 
on depar'ure, and to a medical visit on arrival in 
another Turkish port. The weather in this city is at present 
cold, the thermometer varying between 0° and 4- 5°C. 
This may possibly explain the sporadic character of the out¬ 
break up to the present and may countenance the hope that 
the infection will die out before the spring. 

In Russia the epidemic has apparently completely come 
to an end. Since Dec. 18th (31st) no cases of the disease have 
been returned from any part of the Empire. The following 
figures complete those published in former letters :— 



Prom 

Nov. 28th to 
Dec. 4th. * 

From 

Dec. 5th to 
11th * 

From 

Dec 12th to 
18th.* 

Cases 

Deaths 

Cases 

Deaths 

Cases 

Deaths 

Penza (government) ... 

17 

8 

13 

6 

13 

4 

Samara (town). 

— 

— 

1 

1 

— 

— 

Samara (government) ... 

— 

— 

3 

1 


— 

Yaroslavl (town) . 

2 

1 

1 

1 

— 

— 

Kief (town) . 

9 

— 

5 

1 ’ 

— 

— 

Kursk (government) ... 

7 

1 

6 

2 

2 

— 

Orenburg (government) 

2 

— 

3 

3 


— 

RoBtof on Don. 

4 

— 

— 

— 

- 

— 

Kuban Territory . 

3 

1 

3 

6 

i 

— 

Tomsk (government) ... 

- 

— 

3 

10 

i 

1 

Akmnlinak Territory ... 

1 

— 

5 


- 



* The dates in the above table are according to the Old Style. 


3 The Lxjtcrr, Jan. 4tb, 1908, p. 52. 





Tm Lanoet,] 


SANITATION AT SKA. 


[Feb. 8 , 1908. 457 


The total number of cases of cholera registered in the Russian 
Empire since the beginning of the epidemic down to 
Dec. 18th (31st) was 12,109 and that of deaths 5800. 
Constantinople, Jan. 23rd. 


SANITATION AT SKA. 

The Ventilation and Drainage of Some Liverpool 
Passenger Ships. 

(From our Special Sanitary Commissioner.) 


The newest developments in shipbuilding may inspire the 
hope that real progress will be accomplished in securing 
sanitation at sea ; nevertheless, the fact remains that there 
is still much to be done. Undoubtedly the rivalry in running 
great and luxurious liners is a force that makes for sanitary 
improvements. It is now very generally acknowledged that 
special machinery must be employed to propel the necessary 
amount of air into a ship : therefore the newer and best 
ships have machinery for this purpose. This is a great 
step forward. There now remain the regulation of such 
supply and its even distribution over all parts of the ship 
without, however, causing injurious draughts. HaviDg seen 
on the Mauretania and the Lutitania the latest efforts that 
have been made in this direction, I visited the White Star 
liner Cedric, which is not a new boat nor can it be con¬ 
sidered an old boat. Again, it is not one of the more recent 
and extravagantly luxurious ships, while, on the other band, 
it is a very large and comfortable vessel. It was in the early 
morniDg of Nov. 21st last that I went on board this ship 
while still in dock at Liverpool, though she sailed that after¬ 
noon for New York. My first experience was to assist at 
the examination of the crew and steerage passengers by 
the Board of Trade medical inspectors. The crew marched 
past in Indian file as their names were called out, for they 
had already been placed in line and in order along the 
promenade deck. Then followed some 350 steerage passengers. 
An interpreter helped the medical officer to ask questions. But 
as all these persons had previously been carefully examined 
by the ship's surgeon this was more a formal matter and only 
doubtful looking passengers were stopped and questioned 
anew. Some of the emigrants were rather rough in manner 
and appearance. They were taught their first lesson of 
ship’s discipline by being made to take off their 
hats and to remove their cigarettes from their mouths 
when passing before the inspectors. But the manner 
in which this lesson was conveyed was at times as rough as 
the behaviour it was intended to correct. There was more 
trouble with the women. The Board of Trade instruction is 
that nothing must be taken on board that might be the cause 
of hurt or injury. Consequently, a dead set was made 
against hatpins. These sharp points protruding from the 
sides of women’s hats are undoubtedly dangerous on a 
crowded deck, particularly when, as the ship rolls, 
passengers stumble up against one another. The examining 
medical officer explained that recently in a Liverpool 
omnibus a lady moved her head in such a manner that 
she drove her hatpin into a gentleman’s eye. The lady 
thereupon had a fit of hysterics in the omnibus but this did 
not restore the wounded gentleman's sight. Consequently 
all the women had to remove their hatpins before they were 
allowed to proceed, but as these dangerous implements were 
not confiscated I do not see what is to prevent their using 
them again once the ship is out of port. The stewards will 
have a hard time of it if they are going to watch all these 
women and see that they never use their hatpins again 
daring the whole voyage. Still, it is undoubtedly dangerous 
to wear hats from which protrude long and sharp pins when 
the sea is rongb and it is impossible to walk straight and 
steadily. Some curious incidents occur during these examina¬ 
tions. Thus one woman was kept back to be examined more 
thoroughly because she persisted in saying that she did not 
know the age of her own child. Perhaps she was afraid of 
being charged a higher fare, though this bad nothing what¬ 
soever to do with the medical officer. All he could do was to 
insist on the child showing the vaccination marks. The 
chief thing was the eyes. Four passengers had been refused 
by the ship’s surgeon and the Board of Trade medical in¬ 
spector again re-examined the eyes of several passengers. 
Some looked very wretched specimens of humanity, but there 
was no organic defect, so they were allowed to pass. 

The Cedric iB a very large ship of 21,000 tons and could 


carry 1835 third-class passengers. It possesses in all ten 
steam and six electrical ventilating fans bnt also relies 
largely on natural ventilation. There are numerous mush¬ 
room cow] ventilators in the sheltered parts of the promenade 
deck. How far these work satisfactorily I had but few 
opportunities of ascertaining. One thing I may venture to 
say. The lavatories are badly situated ; indeed, they are in 
so unsuitable a position that it is absolutely necessary to 
employ mechanical force to prevent a nuisance arising. 
They are just in the very centre of the ship, as far awsy 
from the sides or from natural ventilation as it is possible 
to place them. Now there is in this a distinct advantage. 
The Criterion was. I believe, the first theatre in 
London to be ventilated scientifically and this simply 
because being built entirely underground there could 
be no natural ventilation whatsoever. In the lavatories of 
the Cedric there are air shafts or trunks along the ceiling 
with openings over each closet seat and the Buction, 
mechanically produced, is so strong that a piece of paper 
will be held against the wire netting by the force of the out- 
rushing air current. In the third-class dining-room I also 
found the suction within the ventilating trunks strong 
enough to hold paper fast against the apertures for drawing 
oat the air. The system here is to draw away the air, leaving 
it to find its way in by the accident of doors and portholes. 
The electric fans employed are of the “ sirocco ” type ami 
they are very powerful. They are reserved for the passenger 
part of the ship. But the very word “ sirocco ” suggests the 
principal difficulty. Something like a sirocco might be 
useful for a blast furnace but no one would desire to have 
a sirocco in bis cabin. Perhaps when applied for suction 
only it may not cause much inconvenience but if the air is 
blown into the cabins with great force the ventilators will 
be closed. Thus though there were many air shafts or 
trunks travelling along the ceiling, notably in the sleeping 
compartment of the steerage, the currents of air coming 
through the apertures which I examined seemed to me much 
too strong for anyone to sit or to lie down near them. There 
is great need of a more systematic means for delivering the 
air so as to avoid cutting draughts. In the hospital 
1 could not find any mechanical ventilation, though 
it is more needed there than elsewhere. There was what 
is called a torpedo ventilator communicating with the very 
badly situated hospital closet. This is a sort of cowl which 
catches the air as the ship moves along and is of little or no 
use when the ship is not moving. But it should be in the 
open air, whereas in this case it was between decks and near 
the descent to the hold. There were, of course, portholes, 
and some of them have an air inlet but this is natural ventila¬ 
tion. Undoubtedly, the lavatories are the best ventilated part 
of the ship and the hospital should have been treated in the 
same manner. In the smoke room there was a double dome. 
Some of the glass panes of the inner dome were removed and 
replaced by ornamental fretwork. As a suction is produced 
between the outer and inner dome the air is drawn away 
through the fretwork. In a word, it seemed to me that 
though the Cedric possesses a considerable amount of 
mechanical power this is not utilised in a systematic 
manner. The means are there but their application is 
defective. Too much is left to accident, there is no well- 
thought-out organised method. But probably much about 
tbe same thing could be said of almost every ship afloat. 

The Board of Trade insists that there shall be means of 
ventilation, but what indication is there as to how these 
are to be applied ? If the result is far from perfect 
even on palatial liners what happens on ships of more 
modest pretensions? While in Liverpool I had the oppor¬ 
tunity of visiting a few of the latter kind of ships 
belonging to other and to different companies. This experi¬ 
ence was neither pleasant nor encouraging. One was a big 
cattle ship which was to sail in abont 24 hours. The filth 
that still remained on board was so abundant that I failed to 
see how the ship could possibly be cleaned in time. Of course, 
this was due to the cattle which had been on board, and though 
these had been landed some time ago it does cot seem to me 
that the decks had been properly scoured out. In dark corners 
there were still accumulations of nondescript filth and refuse. 
Where some of tbe cattle men sleep there is a gutter 
running along the side of the ship. Liquid manure 
and water travels and with the pitching of the 
ship sometimes rushes along this gutter. It passes 
nnder some of the bunks occupied by cattle-men. It used 
to be uncovered and caused a very bad smell. The only 
reason for not doing away with it altogether is the desiie to 



458 The Lancet,] 


SANITATION AT SEA.—BIRMINGHAM. 


[Feb. 8.1908. 


preserve this drain in case the place where these cattle-men 
now sleep should on some occasion be required for cattle. 
Then the drain would be useful. In the meanwhile the 
only concession made is the introduction of a few planks so 
that manure still continues to pass to and fro inside the 
men's cabin but it is boarded over. There are steam-pipes 
all round and these are much needed in the winter for heat¬ 
ing the cabins but they also help to increase the odour of 
the manure. Obviously the manure from the cattle should 
not be allowed to penetrate the cabin where men sleep. The 
quarters for the cattle-men are more extensive than the 
seamen's quarters and there are many bunks, but if anything 
there is even less provision for ventilation. The seamen 
occupy a cabin where there is no order, no principle, no 
sign of any scientific effort whatsoever to procure ventila¬ 
tion, though there are several pipes leading down to their 
cabin. One of the pipe ventilators had evidently been closed 
up. This will inevitably happen, for it does not suffice that 
there should be a pipe to admit the air, there must also be 
means so to regulate this inlet that it shall not cause an 
injurious or unpleasant draught. Then in the seamen’s 
quarters there was the chain pipe down which the anchor 
chain rattles and makes a great noise, rendering sleep 
difficult. It is true that all hands are generally on deck 
when the anchor is weighed. 

Some of the closets were locked and it is curious how often 
the keys are mislaid when a ship is unexpectedly visited. 
However, I succeeded in seeing a trough closet, with 
three seats and no privacy. A pipe communicating 
with the donkey-engine discharges water that would clear 
out the bottom of the trough, but the splashings on the side 
of the trough would not be effected by this occasional 
flush. They are suDposed to be scrubbed away by a 

brush, but it is doubtful if this is done, and then 

if it is done what becomes of the brush ? This brush, 
impregnated with ftecal matter, might be a source 
of danger if any of the persons using the closet were 
carriers of typhoid or cholera bacilli. That the clearing 

out of a closet with three seats should depend on 

hand labour and a brush properly and frequently applied to 
the sides of a trough is a most rudimentary and dangerous 
arrangement. To find such an insanitary closet on a ship 
shows how little attention is given to these matters. The 
washing accommodation also was absolutely insufficient. In 
“the glory hole,”a term which derisively designates the 
stewards’ quarters, 1 found near the entrance a small wooden 
shelf. In this a round hole had been cut just the right size 
to hold a wooden bucket. This receptacle was half full of 
water in which, to judge from appearances, more than one 
person had already washed. It was necessary to go out on 
deck to pour the dirty water away and to get a clean supply. 
The stewards are crowded together in a very small space and 
are left to do the best that they can. If they wash at all it is 
greatly to their credit considering the few facilities afforded. 
Nevertheless, some passengers are carried on this Bhip, and 
it iB high time that the travelling public should insist that 
those who wait upon them must have all the necessary con¬ 
venience to keep themselves clean. 

On another and smaller ship which does not carry 
cattle but only cargo and passengers I likewise found very 
miserable conditions among the firemen and sailors. Over 
one bunk in a very small and unventilated cabin there 
passed the soil-pipe from a closet which was on the 
deck above. The pipe came across the angle from 
the deck just above this upper berth and the side of 
the ship. During the last voyage this pipe burst and the 
soil fell on the fireman's bed. Never before have I seen a 
soil-pipe above and within a few inches of a bed. Instead 
of removing this or at least putting in a new and sound 
pipe, it had only been roughly mended with soldering 
and a patch. The same accident may therefore occur 
again. Though I found no ventilator in the firemen’s 
quarters there was an air-pipe coming down into the 
Beamen's quarters. The cabin was loftier than usual but very 
crowded and there was not floor room enough for two or 
three sailors to dress at one and the same time. Another 
ship of the same type offered somewhat similar dis¬ 
advantages. The firemen's quarters had just been scrubbed 
and washed out and still did not smell sweet. I noticed here 
that the doors of the small food lockers had in many 
instances been wrenched off. These food lockers are a source 
of trouble and of danger especially in respect to the rats 
which they attract. In any case they ought not to be in the 
sleeping compartment. If there is a mess room there might 


be food lockers but these should not be allowed in the over¬ 
crowded sleeping cabins. Now that the law insists on 120 
instead of 72 cubic feet per head this will be more easily 
managed ; but a ship was pointed out to me which, though 
built quite recently, had only allowed 72 cubic feet for the 
crew and therefore there was no room for washing, yet the 
men have to eat and to sleep in their small cabins. As 
for washing, an iron bucket was provided and it was used 
either on deck or in the stoke-hole. This, however, was a 
Channel boat, whereas the other ships I have described are 
all engaged for ocean traffic and make prolonged journeys. 


BIRMINGHAM. 

(From our own Correspondent.) 

The Quarterly Report of the Medical Officer of Health. 

The medical officer’s report upon the last quarter of 1907 
may on the whole be looked upon as indicating a fairly satis¬ 
factory condition of the health of the city during the latter 
part of last year. The death-rate was 16 ■ 1 per 1000, a 
little worse than in the corresponding quarter of 1906, and 
the birth-rate unfortunately was extremely low—26 • 6 per 
1000, which is a slightly lower rate than in the last quarter 
of the previous year. The most unsatisfactory features of 
the quarter were the continued prevalence of scarlet fever 
and measles. The cases of scarlet fever reported numbered 
904, or almost double the number recorded in the same 
period of 1906, and the deaths caused by the disease 
were more than double those of the same period last 
year—that is, 39, as contrasted with 18; yet even this un¬ 
satisfactory condition is better than that which has prevailed 
in some of the past years. The cases of diphtheria, although 
far too prevalent, were not so numerous as in the last quarter 
of 1906, and the deaths which resulted from it were compara¬ 
tively few, the death-rate being only 91 per cent. There 
were only 70 cases of typhoid fever, a new record for the 
quarter, and the history of some of the cases pointed so 
strongly to infection by means of mussels that an inquiry 
into the matter has been commenced but as yet no results 
have been published. 

The Cost of Medical Inspection of School Children. 

There is a growing sense of irritation in this district 
against the expense which the new Act is goiDg to throw on 
the ratepayers, more particularly in densely populated areas 
where the cost will fall most heavily. It is pointed out that 
increased adminstrative expenditure will be necessitated, but 
the increased administrative expenditure does not strengthen 
a claim for a special grant for educational purposes, for the 
Board of Education has decided not to allow special grants 
for expenditure on administrative purposes which exceed the 
produce of a penny rate. It is becoming more and more obvious 
that administrative expenses must increase if the new rules 
and laws are to be carried out, and in these circumstances 
the opinion is becoming more and more plainly expressed 
that if Parliament and Government departments make rules 
and regulations which must cause increased expenditure and 
if that expenditure is to be incurred for national purposes 
then the ruling authorities should at the same time make 
arrangements to provide a considerable proportion of the 
necessary money. 

The Milk-supply of the City and the Midland Farmers' 
Association. 

At the recent annual meeting of the Midland Farmers’ 
Association attention was directed to Dr. J. Robertson's report 
that 14 per cent, of the milk sent into Birmingham was con¬ 
taminated with tubercle bacilli. The association recom¬ 
mended all its members to exercise great care in the exa¬ 
mination of their cows, particularly as regards the udders, 
and advised them to take steps at once to remedy any 
abnormal conditions. The executive committee expressed 
its willingness to cooperate with the health committee of the 
city in every possible way. In moving the adoption of the 
report Lord Harrowby expressed the belief that the Bill 
dealing with the question of milk-supply which is to be 
brought before the House of Commons contains no provision 
for the payment of compensation for animals slaughtered for 
the public good, and a motion was carried stating the con¬ 
viction of the association that legislation requiring the com¬ 
pulsory slaughtering of infected cattle should be associated 
with provision for proper compensation. 





The Lancet,] 


BIRMINGHAM.—MANCHESTER. 


[Feb. 8,1908. 459 


St. John Ambulance Association. 

The report presented at the annual meeting of the 
Birmingham centre of the St. John Ambulance Association 
shows that the work of the centre continues at a high level. 
24 classes were held daring the year and most satisfactory 
examination results were secured. It was stated that the 
appeal made for funds for the Birmingham corps of the 
brigade had not met with a satisfactory response, and 
further support is needed to enable the brigade to attain 
its full development. In proposing a vote of thanks to the 
Lord Mayor, who presided at the meeting, Dr. T. Nelson, the 
chief surgeon of the brigade, pointed out that new head¬ 
quarters would be required, for those at present held have to 
be given up during the year, and he expressed the hope that 
provision might be made in the new municipal buildings. If 
Dr. Nelson’s hope is realised the brigade will be fortunate, 
but no doubt whether in the municipal buildings or elsewhere 
suitable headquarters will be found. 

The Analyst's Report. 

The analyst's report is always interesting reading for it 
gives us a general idea of the possible purity of the food we 
consume. Apparently during the last quarter of 1907 our 
milk-supply was less tampered with than during the same 
period of the previous year, and the cases of addition of 
poisonous preservatives were both very few and compara¬ 
tively unimportant. Butter also, so far as the samples taken 
were concerned, showed less evidence of adulteration than in 
the same quarter of 1906. We may therefore congratulate 
ourselves that during the latter part of 1907 our food was a 
little more pure than usual and that may be looked upon as 
some compensation for its increased cost. 

The late Sir William Cook. 

By the death of Sir William Cook Birmingham is deprived 
of a man who took the greatest interest in, and gave freely 
of his services to, everything which appertained to the good 
health of the city. He was chairman of the health committee 
for the long period of 34 years. He was closely associated 
with, and took an active part in, every important movement 
for the sanitary reform of the city during that time 
and we have to thank his skill, foresight, and energy for 
many of the advantages which we enjoy to-day. One of the 
last efforts which he made for health purposes was that by 
which he induced the council to acquire Salterby 
Grange for a sanatorium, and, in the opinion of many 
people, he was the only man who could have in¬ 
duced the council to take the step at the time when the 
motion was brought forward. From 1880 till his death he 
was chairman of the Hospital Saturday Fund and he had the 
pleasure of seeing the annual income of the Fund gradually 
increase till last year it attained to the amount of £20,000, a 
sum upon which he had set his heart. He was a governor of 
the General Hospital and a supporter of the New LyiDg-in 
Charity. He worked hard for both institutions ; indeed, he 
was a man who will alwayB be honoured as one who gave his 
best work for the good of his fellow citizens. 

Feb. 4th. _ 


MANCHESTER. 

(From our own Correspondent.) 

Anthrax in the Market. 

A case brought before the stipendiary magistrate on 
Jan. 29th shows how necessary it is that skilled inspection of 
food should be carried out by those who are qualified and 
alert. Two quarters of beef were exposed for sale in the 
meat market on Dec. 12th last. The chief veterinary inspector 
said it was “rough-looking” and took a Bample. Micro¬ 
scopical examination, confirmed by others, showed that it 
was a case of anthrax. There does not seem to have been 
any attempt at concealment In this case, for when the in¬ 
spector said that he should have to seize the whole of it the 
butcher told him he had sold the other half but kept this for 
the inspector to see. He also showed a letter from the 
person who had sent the carcass saying that the heifer 
had been accidentally hanged and was not bled till an 
hour after it happened. “ But run no risk; have it 
inspected before exposing. I expect it is all right.” This 
looks as if the sender's suspicions were excited. Happily the 
portions already sold were recovered before any had been 
used for food. The defendant had been in business for 30 


years and was a past-president of the Manchester and Salford 
Butchers’ Association ; he had “an unblemished business 
reputation,” so that he had every motive for not attempting 
any concealment of the facts. He had, however, to pay a 
fine of £10 and costs, and the magistrate said, “if he had 
been of opinion that the defendant sold the meat knowing 
it to be affected with anthrax he should have been obliged 
to send him to prison.” This may seem to be rather a hard 
case for the batcher but the food-supply must be carefully 
guarded. 

Useful and Unobtrusive. 

Though our charities are no doubt often abused, yet those 
who know most as to the condition of the patients in the 
Manchester hospitals acknowledge that on the whole they 
are as to means in a state of poverty, and from that 
point of view’ worthy of help. One of the most useful 
ways of affording help is to give them suitable garments 
for use in hospital or on leaving. The Manchester 
Hospital Work Society is an association that year by 
year distributes garments, made by the associates them¬ 
selves, to the poor sick in the hospitals. It has 
been correctly described as a society for work and not 
for collecting money, and this description was justified 
by the statements made at the annual meeting presided over 
by the Lady Mayoress on Jan. 29th. But like most other 
organisations, its prosperity ebbs and flows, and this last year 
the tide of its success was low. Dr. A. M. Edge said that 
fewer garments had been received for distribution, far short 
of two garments per bed which is aimed at. New hospitals 
and hospital enlargements are being built, so that the out¬ 
look is serious as they mean more patients. There is one 
point named in the report of the committee which will be 
appreciated by those who deplore the deaths from burning 
so often occurring where flannelette is worn. The committee 
pleaded for the use of flannel and not flannelette in making bed 
jackets. Dr. W. Walter read the financial statement which 
showed the year’s income as £103 and the working expenses 
as £19 14s. The lady associates had contributed 2228 
garments, while the funds only allowed of 448 being pur¬ 
chased. This special charity is one that appeals more 
particularly to the active benevolence of women and should 
be more successful than it is. The l.ady Mayoress, who 
must be acknowledged to speak with authority on such a 
subject, considered that ‘ ‘ two garments a year were really a 
very small contribution from one woman,” and she seemed 
to think that fancy work was more attractive than plain 
sewing, but ventured to predict that the day of the former 
would go by and good plain needlework come to the front. The 
value of the work was testified to by Mr. Andrew Boutflower 
and other medical men. Surely there are many ladies in the 
district who would gladly join in this work if it were 
brought to their notice. Apropos of the mention of 
flannelette, on Jan. 29th the city coroner held inquests on 
four children in different parts of Manchester who had died 
from burning. The usual accounts were given—the absence 
of the mother for a few minutes, no fireguards, and playing 
with matches. The coroner said that “ it was most heart¬ 
rending to have to hold inquests on so many little children.” 

Convocation of the University of Manchester. 

A meeting of the Convocation was held on Jan. 29th, when 
Professor R. B. Wild was unanimously elected chair¬ 
man of Convocation. Dr. George Ashton, Captain R.A.M.C. 
(Volunteers), moved :— 

That in the opinion of Convocation ft is the duty of the Manchester 
University authorities to give every support to Mr. Haldane's 
Territorial Army scheme. 

The meeting, he said, was not asked to discuss the scheme 
politically or to consider its merits or demerits. It had 
passed through Parliament and would come into force on 
April 1st next. In East Lancashire the county associa¬ 
tion was expected to provide a division—i.e., about 
19,600 men. Dr. Ashton thought that the University 
had not in the past shown the interest in the 
Volunteer movement which he could have wished. “There 
were about 1100 students and only 135 volunteers,” and 
among the teaching staff—about 200—only three held 
commissions, and he wanted to see more of the students 
and more of the teaching staff engaged in the scheme. 
One gentleman, ;as an American “ outlander,” thought 
that all the students would be the better for “military 
drill and discipline,” and there is no doubt whatever that he 
gave utterance to a truth. Whether his further view that 
“fora large number of students military drill would be of 




460 The Lancet,] 


WALKS AND WESTERN COUNTIES NOTES.—SCOTLAND. 


[Feb. 8,1903. 


considerably more value than any two courses of lectures 
they were likely to get in one week ” is a matter which need 
not be considered here. The voting showed pretty clearly 
the feeling of the meeting, 19 rotes being for the motion 
and 4 against. A certain amount of satisfaction at this 
result in favour of preparation for defence may perhaps be 
allowed, even in these days of cosmopolitanism. 

Feb. 4th. 


WALES AND WESTERN COUNTIES NOTES. 

(From our own Correspondents.) 

Health Report of Cardiganshire. 

Although the insanitary conditions which prevail in 
certain parts of Cardiganshire have been the subject of 
investigation by the medical inspectors of the Local Govern¬ 
ment Board upon various occasions the county council has 
never taken any steps in the direction of remedying those 
conditions. It is possible that individual members of the 
council may excuse this inaction on the plea of ignorance of 
the circumstances ; such excuse will, however, no longer 
avail, for there has recently been issued a summary of the 
annual reports for 1906 of the district medical officers of 
health which has been compiled by Mr. Evan Evans, D.P.H. 
The very forcible manner in which attention is drawn in the 
summary to the prevalence of pulmonary tuberculosis in the 
county ought to awaken the council to a sense of its responsi¬ 
bilities. During 1906 the death-rate from this disease in the 
whole county was 2 6 per 1030, compared with 16 in 
Merionethshire and 0 1 8 in Monmouthshire. In Aberystwith 
rural district the death-rate was as high as 4 ■ 3 per 1000 
and in the Cardigan rural district it was 3 • 2 per 1000. 
Mr. Evans considers that the migration of the healthiest 
and most vigorous individuals to other districts and the 
return home of those infected elsewhere is a considerable 
factor in this high death-rate. Other causes are insanitary 
dwellings and an insufficient dietary, for from nearly all 
districts comes the same tale—closed windows at night and 
staple dietary of bread and butter. There does not appear to be 
any form of disinfection of the dwellings of patients suffering 
from pulmonary tuberculosis either before or after a death. 
Now that the attention of thecounty council has been drawn to 
the very unenviable position occupied by Cardiganshire with 
regard to the prevalence of this disease the claims of the 
Allt y-mynydd Sanatorium ought to be responded to 
generously. It is difficult to believe that the chief ad¬ 
ministrative body, which includes among its members four 
medical practitioners, will remain inactive after the dis¬ 
closures which have now been made public. 

Medical Inspection of Schools in Cardiff. 

Upon the recommendation of the medical officer of health, 
Dr. E. Walford, a subcommittee has advised the Cardiff 
education committee to appoint two medical assistants, each 
at a salary of £250 per annum, to devote the whole of their 
time to the services of the committee, acting under the 
direction of the medical officer of health who, as chief 
medical officer to the education authority, will organise, 
supervise, and assist in the work of medical inspection, 
report upon the results of the inspections, and be generally 
responsible to the committee for all the medical and sanitary 
matters connected with the public elementary schools in the 
town. Two women inspectors, each of whom is a trained 
nurse and a certificated inspector of nuisances, have been 
employed for some time past in the health department of the 
Cardiff corporation and Dr. Walford suggests that they could 
assist in filling in the schedules connected with each medical 
examination and without attempting anything like medical 
treatment could be most useful in visiting the houses of 
defective children and bringing home to the parents a full 
sense of their responsibilities with regard to their children. 
Dr. Walford thinks that in most canes tactful advice and 
useful counsel are most urgently required and that generally 
the parents of defective children would be ready and willing 
to take steps themselves to bring about the physical improve¬ 
ment of their children if they only knew what steps were 
necessary. He further pointed out to the committee that 
without any direct medical treatment on the part of the 
education authority much physical improvement might be 
effected by a greater attention to the sanitation of the school 
buildings and by the improvement in the environment of the 


scholar which would result from the more frequent visits of a 
medical man. 

Tuberculosis in Herefordshire. 

For several years past a branch of the National Association 
for the Prevention of Consumption and Other Forms 
of Tuberculosis has been doing good work in Hereford¬ 
shire. Popular lectures have been given in different parts 
of the county and in other ways there has been dis¬ 
seminated information as to the means by which tuberculous 
disease may be prevented. The death-rate from pulmonary 
tuberculosis in the county, as a whole, is not high, for many 
years past having averaged 1 • 0 per 1000, but in some 
parishes the rate is as high as 2 • 5 per 1000, and it has 
been estimated that there are at the present time about 500 
persons suffering from this disease in the county. At the last 
meeting of the county council the general purposes com¬ 
mittee was instructed to report as to the practicability of 
establishing a sanatorium for incipient cases of tuberculosis. 
The suggestion appears to be that a sanatorium should be 
established by the various boards of guardians in the county 
and that they should pay to a central fund the cost of main¬ 
taining pauper patients in the sanatorium. 

Breathing Apparatus in Coal Mines. 

The colliery owners of Monmouthshire and South Wales 
have recently been considering a scheme for establi»hing 
central rescue stations in various parts of these coalfields. 
It has been suggested that there should be 13 such stations 
in the Rhondda valleys, the Merthyr and Aberdare valleys, 
Garw and Ogmore valleys in Glamorgan and in the eastern 
and western valleys in Monmouthshire. The estimated cost 
of each station is £2000 and £500 for the equipment 
together with £500 annually for the maintenance. The 
particular apparatus to be used has not been decided upon, 
for it is hoped that inventors of different forms will demon¬ 
strate their usefulness to a committee of the coalowners 
which has been formed for the purpose of giving practical 
effect to the project. 

Typhus Fever in Monmouthshire. 

When reporting upon a fatal case of typhus fever which 
had occurred in the urban district of Et>bw Vale in Mon¬ 
mouthshire, Mr. J. W. Davies, the medical officer of health, 
stated that in his opinion it was due to overcrowding and 
filthy surroundings. There was only one bedroom in the 
house occupied by the patient, the other occupants being a 
man and his wife and threo children. It appears that the 
house concerned, together with those adjoining, had already 
been condemned as uninhabitable and the tenants were 
living in them rent free until other dwellings could be found. 

Feb. 4th. _ 


SCOTLAND. 

(From our own Correspondents.) 

Friction at Ruokill Fever Hospital. Glasgow. 

Considerable disquietude has been aroused in the public 
mind in Glasgow owing to the evidences of seriou3 iriction 
which have become apparent recently among the staff at 
Racbill Hospital. 14 months ago a new matron was 
appointed to the hospital and it seems that subsequently to 
that the nurses, of whom there are about 150 employed in 
the institution, made complaints, alleging that the hospital 
was understaffed and that the nurses were overworked. 
These complaints were embodied in a letter addressed on 
tiept. 30th by the five assistants forming the resident medical 
staff to the physician-superintendent of the hospital. The 
main allegations put forward in the letter were : (1) an 
insufficient number of nurses in certain wards; (2) an 
insufficient number of sisters, or charge nurses: (3) in¬ 
experienced nurses in charge of wards; and (4) inefficient 
ambulance administration. The superintendent is thereupon 
alleged to have informed them that in the domestic and nursing 
department of the hospital he had no jurisdiction over the 
matron. A letter of complaint was then addressed to the town 
clerk on Nov. 27th. Soon thereafter a notice was posted at 
the hospital intimating that an inquiry would be held by the 
sub-committee of the hospital which stated that it would 
receive any statement which a sister or nurse wished to 
make regarding the conduct of the hospital. Thereupon 105 
of the nursing staff wrote offering to testify and a number of 
these were examined. Before Christmas the inquiry was 



j&a: 

ZXL\ i 


/a 2 


r'; o 




-lit 

fcr: 


• V- } 


] 

■3 II 
•U*!. 




i*. 

If 


'l 


* l! 
c: 






The Lancet,] 


SCOTLAND. 


[Feb. 8,1908. 461 


stopped and efforts were made to restore harmony, but with¬ 
out effect. Later, it is stated, the sub-committee informally 
requested the physician-superintendent to dismiss three of 
the assistants and that be declined to do so, as he had no 
complaint against them. On Jan. 7th, however, the three 
assistants received a letter from the medical officer of 
health of Glasgow dismissing them. This “dismissal” the 
resident physicians refused to accept but eventually left the 
hospital under protest. The final stage in the episode so far 
is an intimation to the town clerk from the Local Govern¬ 
ment Board stating that the Board has received a memorial 
from the resident physicians at Ruchill Hospital praying the 
Board to institute an inquiry into the conditions existing at 
the hospital. The statements in the memorial appear to the 
Board to constitute a prima facie case for inquiry by it in 
the interests of public health. Before coming to a decision, 
however, it has deemed it advisable to hold a preliminary 
investigation with the view of ascertaining whether the 
circumstances call for a full and detailed inquiry. With 
this object it has appointed Dr. Henry H. Littlejohn, pro¬ 
fessor of forensic medicine in the University of Edinburgh, 
a commissioner to inquire and report. As a result of Professor 
Littlejohn's preliminary report the Local Government Board 
has intimated that it has appointed Mr. Donald Crawford, 
K.C., sheriff of Aberdeenshire, a commissioner “to inquire 
and report upon the complaints of overcrowding and under- 
staffing of Ruchill Fever Hospital and on the administration 
and management of the hospital.” 

The Epidemic of Enteric Fever in Glasgow. 

The epidemic of enteric fever in the west-end of Glasgow 
seems to be now on the wane and it is not expected that 
many more cases will be reported. At the time of writing, 
however, there are 156 cases of enteric fever in the city as 
compared with 139 in the previous week, and of these 90 
have been traced to the same source, a contaminated milk- 
supply. 

The New Convalescent Home at Edzell. 

On Jan. 13th a meeting of the managers of the Montrose 
Asylum and Infirmary was held to discuss an un¬ 
fortunate hitch which has occurred in connexion with the 
building of the new convalescent home at Edzell. The 
meeting, which lasted about one and a half hours, was held in 
private. Considerable progress has already been made with 
the building, which was estimated to cost £2500. The 
building operations are, however, at present suspended and 
at the meeting the managers heard lengthy correspondence 
on the subject and also a report by Mr. John Sim, the 
architect. After free discussion the managers unanimously 
decided that no arrangement would satisfy them which did 
not involve the pulliDg down of the building. 

Sea forth Sanatorium, Ron-shire. 

This institution was formally opened on Jan. 16th in the 
presence of a large and representative gathering and of the 
■own councils of Dingwall and Tain. A message from the 
King wishing success to the sanatorium was received, and 
also one from the Local Government Board of Scotland 
offering congratulations to Colonel and Mrs. Stewart 
Mackenzie of Seaforth, the donors of the institution. Mrs. 
Stewart Mackenzie was presented with a gold key by Mr. 
Macbeth, the architect, with which she opened the main 
entrance and declared the Seaforth Sanatorium open. The 
foundation-stone of this institution was laid rather more 
than a year ago by Mrs. Stewart Mackenzie. It is situated 
over 200 feet above sea-level, about two miles from Dingwall, 
and just behind the village of Mary burgh. It has been 
endowed by the donors to the extent of £100,000. and they 
have also given the site, large grounds, building, and equip¬ 
ment. The institution is available for both sexes ; one-third 
of the accommodation is reserved for the Island of 
Lewis, and the other two-thirds for the mainland of 
Ross and Cromarty. The total accommodation in the 
meantime consists of 12 beds but this may materially 
be enlarged by the addition of outside cubicles. Anyone 
resident in the county who cannot afford to go to a com¬ 
mercially conducted sanatorium may be admitted and it is 
hoped that an educational as well as a curative work may be 
done throngh the institution. The building is divided into 
two blocks with the administrative department in the centre. 
The patients’ rooms are uniform with the exception of the 
end rooms which are larger and intended for the treatment 
of special cases. While in the meantime each patient will 
have a room, any of the rooms might be used for two beds 
and the larger ones for four. The rooms open on to a broad 


plat which runs along the entire length of the structure and 
on to which beds can be drawn and a constant current of air, 
regulated at will, can be had in each room. The floorings 
are of pitch pine ; all the corners of the rooms are rounded 
and all the furnishings are on the most approved principles. 
The building is three storeys high in the centre and contains 
matron’s and nurses’ rooms, dispensary, and pathological 
researoh rooms for the resident physician. During the life¬ 
time of Colonel and Mrs. Stewart Mackenzie the institution 
will be managed by them. Afterwards it will be controlled 
by a body of trustees and a local committee. 

The Notification of Births Act and Scottish Medical Men. 

An influential deputation of the Aberdeen Medico- 
Chirurgical Society, representing nearly the whole of the 
medical profession in Aberdeen and the immediate neigh¬ 
bourhood, waited upon the town council of that city on 
Jan. 20th to express the views of the society on the proposed 
adoption of the Notification of Births Act by Aberdeen. The 
deputation, which consisted of Dr. G. Williamson (president), 
Dr. J. Marnoch (secretary). Dr. A. H. Lister (treasurer), Dr. 
John Gordon, Dr. G. M. Edmond, and Dr. K G. Mackerron, 
advanced in a very able manner arguments against its adop¬ 
tion such as have been laid before the readers The Lancet 
more than once. They did not oppose the objective of the Act 
but only the method of its proposed administration—namely, 
by means of gratuitous certificates supplied under penalty 
by medical men attending births. They pointed out that 
in this matter no exercise of professional Bkill is involved 
and that the notification could be made by tbe father or 
nearest relative attending the mother, as only a simple state¬ 
ment of fact was required. It was contrary to the usage of 
the profession to give any information regarding patients, 
except such as the law required for the public welfare and 
which could only be supplied by a medical man. Further, if 
a mother wished to conceal a birth she would be less likely 
than formerly to su rnmon medical aid in a place where the Act 
had come into operation. Finally, the injustice to medical 
men of expecting them to perform another gratuitous service 
to the State was shown and the case of Manchester, the 
council of which city has rejected the Act after its adoption 
by the sanitary committee, was cited. The deputation was 
heard very courteously by the Aberdeen bailies and in con¬ 
sequence Councillor Kendall Bnrnett withdrew his motion 
to accept the Act and substituted one to send it back to the 
public health committee for further consideration in the 
light of the expression of medical opinion which the council 
had heard. This vigorous defence of professional rights may 
be commended to the notice of medical societies elsewhere. 
—At the first meeting of the newly elected Laurencekirk 
district committee of Kincardine county council a circular 
was submitted from the Local Government Board explaining 
the Notification of Births Act, 1907, and inclosing a form of 
application for its adoption. The chairman moved that the 
Act be not adopted. Mr. Low seconded the motion and 
pointed out that the Act was an injustice to the medical pro¬ 
fession, because it imposed a penalty for neglect of duty for 
which they received no payment. Tbe motion was agreed to 
unanimously. 

Crathie and Braemar Parish Council: Medical Ofticership. 

In The Lancet of Jan. 4th, p. 60, some details were given 
of a conflict of opinion which has arisen in the parish 
council of Crathie and Braemar in Aberdeenshire with refer¬ 
ence to the appointment of Dr. William Brown of Braemar 
as medical officer to the council. Some of the members are 
very hostile to Dr. Brown and at the meeting held on 
Dec. 13th, 1907, a majority of 6 votes to 2 were in favour 
of dismissing him. The subject was again discussed 
at a meeting of the parish council held on Jan. 29tb. 
The chairman said that he had communicated with tbe 
Local Government Board for Scotland, giving a statement of 
the various steps which had been taken during tbe past year 
in connexion with the appointment of the medical officer, 
and that the Local Government Board had replied, stating 
that Dr. Brown’s appointment was in order, and that 
there was no good reason for doubting its legality. The 
Local Government Board also stated that a medical officer, 
unless his agreement specially provides to the contrary, holds 
office for one year and his engagement may be terminated, 
at the end of that year if due notice, say, of six weeks or 
two months be given to him. If no such notice be given he 
holds office by “tacit relocation” for another year. The 
Board also strongly deprecated the removal of a medical 





462 The Lancet,] 


SCOTLAND.—IRELAND. 


[Feb 8, 1008. 


officer from office unless for good and sufficient reasons. It 
was then moved and seconded— 

That in view of the resolution carried at last meeting with reference 
to the medical officer and without prejudice to the pleas of the council 
as to the regularity and validity of his appointment the council 
resolve to dispense with the services of Dr. Brown on three months’ 
notice, and the clerk be, and hereby is. instructed to give Dr. Brown, 
under reservation of the said pleas, three months’notice of dismissal; 
and further that the council direct the clerk to advertise the vacancy 
lii terms of the regulations. 

This motion was carried. The chairman thereupon handed in a 
protest stating that the dismissal of Dr. Brown constituted a 
breach of the council’s contract with him. The protest, 
further stated that, on behalf of Mr. A. H. Farquharson of 
Invercauld, and on his own behalf, he protested against the 
parish assessments being employed in expenditure connected 
with any action which might be taken as a result of this 
breach of contract, and held those who voted for the motion as 
liable to recoup him in any Iobs or damage which he might 
sustain. Two other members of the council also handed in 
protests. Dr. Brown laid on the table a protest which was 
read by the chairman. In this lie declined to accept notice 
of dismissal from the council on the ground that he held his 
appointment from Feb. 23rd, 1907, and that the council had 
failed to give him the six weeks' notice which was declared 
by the Local Government Board to be necessary. He also 
declined to take delivery of any letter containing such notice 
of dismissal. 

Feb. 3rd. 


IRELAND. 

(From our own Correspondents.) 

The late Lord Kelvin. 

Lord Kelvin was certainly one of the most distinguished 
men to whom Ireland has ever given birth and it is fitting 
that a statue should be raised to him in his native city of 
Belfast. A sum of nearly £1000 has been subscribed for the 
purpose as the result of a public meeting. 

Ihe Royal College of Surgeons in Ireland. 

The annual dinner of the College took place on Feb. 1st 
at the College, Sir Henry R. Swanzy, the President, being 
in the chair. The toast of “ The College ” was proposed by 
Dr. J. Magee Finny, President of the Royal Academy of 
Medicine of Ireland, and was responded to by Sir Henry 
Swanzy who took legitimate pride in pointing out the many 
improvements that had reoently been made in the medical 
school attached to the College. 

Death of Professor Antony Roche. 

The death is announced of Mr. Antony Roche, proFessor 
of medical jurisprudence in the Catholic University and 
examiner at the Royal University of Ireland. Professor Roche 
took great interest in sanitary science and made many 
interesting communications to The Lancet. 

Sanatorium for the County of Cork. 

In the year 1902 the various public boards of the county of 
Cork agreed to submit to a rate of Id. in the £ for the 
erection and maintenance of a sanatorium for consumptives. 
Since then the project has undergone many vicissitudes. The 
conjoint boaid first selected a site at Mareytown, near 
Macroom, but the Local Government Board refused to 
approve of it on the grounds that it was unsuitable for the 
purpose. The next site proposed was Myshall, but as a river 
from which some of the water-supply comes for Cork would 
bound the proposed grounds of the sanatorium the Cork town 
council appeared by counsel at the Local Government Board 
inquiry and offered strenuous opposition to the adoption of 
the site. Again the Local Government Board entered 
a non possumvs. Then Mr. Brazier-Creagh, a member 
of the conjoint board, offered a free site at Streamhill, near 
Doneraile, and his colleagues, mindful of their previous 
experiences, decided on casting as far as possible on 
the shoulders of the Local Government Board the 
onus of selecting a site and accordingly requested that 
body to send two of its inspectors to visit the lands 
offered by Mr. Brazier-Creagh. The Local Government Board 
acceded to the request and a week ago an inquiry was held by 
Dr. E. C. Bigger and Mr. Cowen, O.E., the two inspectors who 
had visited the proposed site and had apparently approved of 
it. It was not considered necessary to produce any medical 
evidence in favour of the site but it was soon found that a 
number of people residing in the neighbourhood of Streamhill 


were opposed to the project, and It was urged that the 
expectorations of the patients could find their way into an 
adjoining river and spread the disease amongst the in¬ 
habitants and their cattle. Lord Castletown and Mr. Harold- 
Barry of BallyvoDare, landlords who have extensive holdings 
near Streamhill, also objected on the ground that their 
properties would be injured. An engineer gave evidence 
thut ilie soil on which it is proposed to build the sanatorium 
is peaty and retentive, and Mr. Harold Barry said that it is 
bog over which he shot snipe. Professor H. Corby stated 
that the fact of it being a bog would at once condemn 
it. He also expressed the opinion that the sanatorium treat¬ 
ment is so comptratively valueless that it is a pity a large 
sum of the ratepayers’ money should be expended on the 
erection of a sanatorium in any part of the county. Some 
witnesses were then examined who gave evidence in favour of 
the site and the inquiry terminated. It is believed that the 
recent report of the Local Government Board of England on 
the sanatorium treatment of consumption will influence the 
Cork conjoint board in abandoning the project of erecting a 
sanatorium for the county. 

Poor law Administration in Belfast. 

At a meeting of the Belfast board of guardians on 
Jan. 14bli it was reported by the clerk that the estimates for 
the vear ending March 31st, 1908, showed an increase of 
£3959, due to the large number of inmates, especially infir¬ 
mary patients, there being an increase of nearly 400 
patients. There was an increase of 200 in those requiring 
medical treatment and an increase of 72 in children. In 
clothing the average weekly cost had gone up from 6 id. per 
week to 9 d. Then outdoor relief would reach £1870 tor the 
current half-year and a total of £3601 for the year, and 
taking the increase to go on progressively it would be 
almost £4000 and a rate of Is. Id. in the pound would be 
needed in the forthcoming year. It must be candidly 
admitted that such figures raise among maty the sus¬ 
picion that the Poor-law system i6 not what it should be 
in Belfast. Why should pauperism increase in Belfast 
where for the past three or fonr years trade has been brisk ? 
It would seem as if among some of the poor the spirit of 
independence, which formerly at least prevailed and which 
prevented them accepting assistance from the workhouse 
unless sheer want drove them into it, is gone. Then the 
workhouse system really encourages pauperism owing to the 
fact that the inmates are now better housed, better fed, and 
better cared for than a large proportion of the poorer rate¬ 
payers. Such a state of affairs is really a direct incentive to 
many lazy, idle people to join the pauper ranks and it 
imposes an almost unbearable burden on those who are just 
on the border line of pauperism. Again, the increase in the 
infirmary patients is one of those weak points in the Poor- 
laws that require to be remedied, as it is surely wrong 
that struggling ratepayers should have to pay for the 
treatment of those who might reasonably be called upon to 
discharge their own liabilities. An increase in the cost of 
clothing—almost to one-third—is very extraordinary, and 
considering the industrial conditions of Belfast an outdoor 
bill of £3600 is really preposterous and contrary to the 
recommendations of Mr. Agnew, the Local Government 
Board inspector. In the Belfast workhouse there is the 
population of a small town (4028 inmates were in it a week 
ago). How many of the lazy, idle men and women in this 
institution do anything (as occurs in Switzerland and other 
continental countries) for their upkeep 7 The ratepayers of 
Belfast are beginning to see that the guardians must 
exercise much more discrimination in the administration of 
relief. 

The Consumption Dispensary in Belfast. 

At a meeting of the city council of Belfast in committee 
held on Jan. 20th it was decided after some discussion to 
agree to an arrangement by which the Forster-green Hos¬ 
pital for Consumption will undertake to open a dispensary 
in the city or, in other words, an out patient department, on 
the understanding that the corporation takes ten beds in 
addition to the 25 already provided and pays at the rate of 
£1 15s. a week for each additional bed, with the proviso that 
in case any of the said ten beds should be vacant the 
corporation is to be given credit for each such bed at the 
rate of 15*. per week for the time such vacancy shall 
continue, the agreement to be for one year with the option 
of renewing it at the end of that period. This new 
development will cost, it is said, almost £3000 per annum. 

Feb. Ath. 


•J 

r 

2 


el 

I 


■~x 


Xi 


z* 

u 


• l 


•4 

Cjj 


•*r 




Vi 







464 The Lancet,] 


ITALY.—VIENNA. 


[Feb, 8,1908. 


ITALY. 

(From our own Correspondent.) 

The Italian Beil Crest: A School for Female Helps. 

THE otherwise admirably equipped Red Cross of Italy is 
admittedly defective in one important adjunct to its 
efficiency—an adjunct long possessed by the sister societies 
of the Red Cross in other countries—that of female helps. 
These helps are recruited from the class of ladies of good 
social position, whose education, already productive of refine¬ 
ment in manner and demeanour,has been specially enhanced by 
training in the mitier of nurse. During the sanguinary Russo- 
Japanese war the lady-helps ( dame infermiere) of both 
belligerents gave memorable proof of their good offices not 
only on the battlefield but on other occasions involving 
disaster—explosion or similar accidents in camp or quarters 
—inseparable from military operations. Of these offices, on 
the Russian side, the Italian representative Count Camperio 
was an assidnous witness and the account which he gave of 
them in a lecture delivered last year in Rome profoundly im¬ 
pressed the many interested in Red Cross organisation. The 
regional subcommittee of the ‘ * Croce Rosea Italiana ” at once 
utilised the interest thus evoked by putting itself in com¬ 
munication with the central committee, and its initiative has 
now fructified in a “school” specially equipped for the 
training of lady-helps on the lines of the Russian 
and Japanese organisations—a school which will be 
officially opened to-day in the buildings of the military 
hospital on the Caelian Hill. Her Majesty Queen Elena is 
the patroness and at her instance an appeal has been 
addressed to the ladies of Rome to give the institution all 
the encouragement in their power. The response has already 
been more than gratifying and the present year will 
witness the start of a corps of “ infermiere voluntarie ” 
(volunteer lady-helps) which will place Italy on a level with 
her sisters in the one branch of Red Cross equipment in 
which she has hitherto been defective. The appeal—a 
lengthy but none the less impressive document—sets 
forth the programme of special instruction to be given 
on the Thursdays and Sundays of successive weeks 
throughout five months of the year between the 
hours of 3 and 6 p.m. The subjects taught will be 
essentially practical in their tenour, divided into four 
courses, and the teachers will be four officers, two of 
whom will be supplied by the War Office and two by the 
Red Cross Association. A final examination will give the 
successful examinee the right to the “ Diploma di Infermiera 
della Croce Rossa Italiana,” together with a “medagliadi 
riconosclmento ” (medal of recognition) bearing the emblem 
of the Geneva Convention and the name of the holder of the 
diploma. Every such holder will be morally obliged to be 
in readiness for every call in case of the mobilisation of the 
Italian Red Cross. Other duties are specified in the pro¬ 
gramme of qualification but as these are identical with those 
imposed by the Red Cross societies of other nations they 
need not be detailed here. The school, I may add, will be 
under the direction of Lieutenant-Colonel Parisi, director of 
the military hospital of Rome ; of Dr. Postemski, principal 
medical inspector of the Italian Red Cross; of Colonel 
Fanara, medical officer of the Reserve ; of the Duchess 
Amalia Tortonia, of the Countess Camerana, and of the 
Countess Pelagallo di Marazzano. As I write, I am informed 
that the teaching staff will consist of the Chevalier Professor 
Giovanni Memmo and Dr. Umberto Riva of the Army Medical 
Department, and of the Chevalier Dr. Augusto Bisso and the 
Chevalier Dr. Bonaventura Pasca, medical captains of the 
Red Cross. 

“ Frost-bite and Wolf-bite.” 

If up to now the winter on the Italian slopes of the Alps 
has been comparatively mild—so mild as to tempt some of 
the Piedmontese Alpine Club to arduous expeditions— 
the same cannot be said of the southern ranges of the 
Apennines. This time last year The Lancet, under the 
above title, recorded the disastrous incursion of famished 
wolves into the haunts of man—one heard of them in the 
Abruzzi having, under stress of cold and hunger, assailed a 
linesman on the highway, and, in spite of his armed defence, 
torn him to pieces, leaving little besides his blood stained 
sword to attest bis fate. Further south last week in the 
Basilicata, not far from the town of Fotenza, a similar 
tragedy well nigh befel a wood cutter and his son driving 
home on a cart from the plantation. It was broad day—not 


the dusk of the evening, as in the former instance—when the 
two were assailed by wolves, the fiercest of which remained 
in single combat with the wood-cutter, while the others were 
being scared away by his son. The father, a man of powerful 
build and dauntless courage, grappled with the brute, and after 
a desperate struggle succeeded in pinning it to the ground. 
The wolf, however, still made formidable fight, and to such 
effect that the wood-cutter, already severely bitten and losing 
blood, might have got the worst of it had not his son 
opportunely fetched him an axe from the vehicle. With this 
he dealt the brute a decisive blow and the struggle was at 
an end—leaving him, however, as stated, horribly lacerated, 
particularly in the hands, a proper subject for the Pasteur 
Institute. The Government, it is suggested, might offer a 
prize for each of these dangerouB animals brought in dead, 
and this would be a finer, and also a more serviceable, sport 
than the steady destruction of the chamois, which is rapidly 
disappearing from Alpine Italy, till it bids fair to live only 
in Carducci's magnificent ode, entitled “ II Piemonte.” 

Feb. 2nd- _ 


VIENNA. 

(From our own Correspondent.) 


Medical Inspection of Schools. 

The Ministry of Education, in which medical influence is 
undoubtedly active, has again issued an order dealing with 
hygienic measures to be adopted in regard to the supervision 
of schools. School hygiene is to be regarded as an integral 
part of the sanitary administration of the different counties 
and the reports sent in by the respective boards will have to 
show clearly to what extent schools are visited by medical 
men at regular periods. The order enables the local 
authorities to appoint visiting medical officers for the 
schools, especially for the so-called elementary schools, in 
which children from six to 14 years of age receive instruc¬ 
tion. The order empowers them also to institute medical 
supervision in infants’ schools (where the ages of the children 
are from four to six years), in technical schools, and in com¬ 
mercial schools. A suggestion as to the time of inspection 
of the children is given. The medical officer must examine 
new pupils on their first arrival and must afterwards 
visit the schools at intervals of about four or six 
months, unless a local outbreak of epidemic disease, such 
as parotitis, measles, scarlet fever, or diphtheria, makes it 
advisable to pay more frequent visits. Special attention 
is to be given to diseases of the eye, ear, throat, and teeth, 
as well as to the ventilation and the lighting of the class¬ 
rooms. The expenditure will be borne by the ratepayers 
and the Government. The school medical officer will not 
undertake the treatment of the little patients but his work 
will be rather of a preventive nature. The fees for treat¬ 
ment have to be found by the parents or friends. Another 
memorandum just issued deals with the care of feeble¬ 
minded or crippled children and with the proper treatment 
and care of the deaf and dumb. There is good provision 
for this class of defectives in Austria and the Ministry of 
Education only calls the attention of teachers to its exist¬ 
ence. For the higher classes of the public schools gym¬ 
nastics are recommended as an antidote to the 111-effects of 
the demands made by modern education on the mental 
faculties. 

A Case of Lymphatic Leuheeviia n-ith Chylothorax. 

At a recent meeting of the Medical Society Dr. Strasser 
showed a man who had been suffering from diarrhoea and 
swollen glands for some time previously to his admission to 
hospital. A cubic millimetre of his blood contained 
4.000,000 erythrocytes and 437,000 leucocytes, of which 
98 per cent, were lymphocytes. A few weeks after admis¬ 
sion the haemoglobin index, which had been constantly 
74 per cent., sank still lower, and he had a sudden attack of 
dyspnoea, caused by accumulation of fluid in the right 
pleural cavity. Puncture had to be performed twice, 
the fluid which was withdrawn beiDg turbid and 
yellowish in colour with a specific gravity of 1 • 16 ; 
it contained 7 per cent, of albumin and 3 per cent, 
of fat with some sugar, and was, in fact, typical chyle. 
Although the exudation reached to the level of the third rib 
the heart was not displaced, a condition which Dr. Strasser 
thought was due to infiltration of the pleura making it 
rigid. The chylothorax was caused either by bursting of the 




The Lancet,] 


VIENNA.—NEW YORK. 


[Feb. 8,1908. 465 


thoracic duct consequent on the pressure of leukmmic glands 
or by injury of the duct through sarcoma. The patient was 
submitted to a course of x ray treatment. The long bones, 
the spleen, and the glands were exposed to the rays, and the 
leucocytes fell to 5000 per cubic millimetre after a few 
weeks. Such cases where the lymphocytes were so abundant 
were liable to develop malignant disease, mostly of a sar¬ 
comatous nature. An interesting property of the pleuritic 
effusion was that it counteracted the effect produced by 
adrenalin on the pupil of the eye, whether that of the patient 
or of an animal. This fact might perhaps in future be made 
use of to ascertain the nature of doubtful pleuritic effusions^ 

Cerebrospinal Meningitis and Deafness. 

The epidemic of cerebro-spinal meningitis which occurred 
in Vienna in 1907 gave Dr. Alt an opportunity of studying 
its effects on the auditory organs and he recently communi¬ 
cated his results to the Gesellschaft der Aerzte. He exa¬ 
mined 60 patients, of whom 9 died without a functional 
examination being possible. Of the 51 remaining patients 
12 became completely deaf, 15 died later, 15 regained full 
health and hearing, and 9 suffered more or less serious 
damage. Deafness appeared as an early symptom within 
the first four days, but in a few cases it came on later ; in 
three cases it supervened after the disease was practically 
over. The vestibular organs were affected in a high degree. 
All those who became deaf had an unsteady gait, with 
vertigo and other disturbances of coordination, until they 
learned tocontrol their gait thiough the medium of the other 
senses, especially that of sight. Microscopic examination 
of the internal ear constantly showed purulent disease of the 
labyrinth, the cochlea and the semicircular canals, whilst 
the nerves were infiltrated and the bony labyrinth was in 
many cases filled with newly formed connective tissue. The 
patients who survived and became deaf showed not the 
least change in the tympanic membrane and functional 
examination of these patients revealed complete absence of 
perception of spoken words, musical sounds, or noises, 
deafness being complete in consequence of the destruction 
of the inner ear. 

Primary Syphilitic Sore of the Nose. 

A very rare case of extra-genital syphilis was shown by 
Dr. Menzel at the same meeting of the above society. The 
patient was a young man who had for three weeks been 
complaining of a swelling of the nose. The appearance of 
the affected part suggested simple abscess or furuncle. 
Examination of the nares revealed an elliptic, hard, well- 
defined, prominent nodule, with an ulcer of a lardaceous 
appearance on the top of it. The infiltration measured 
about three-quarters of an inch in all diameters. The 
relative absence of pain, the short duration and the presence 
of hard indolent glands in the submaxillary region con¬ 
firmed the diagnosis of specific ulcer. A few days later a 
typical syphilitic exanthem appeared on the trunk, whilst no 
trace of any other primary lesion was discoverable. Spiro- 
chsetae were found in some of the particles removed for that 
purpose from the ulcer, so that the diagnosis was unquestion¬ 
able. Only 25 cases of similar primary infections have been 
recorded and it was remarkable that nearly all of them were 
after a short time followed by severe syphilis of the brain ; 
in fact, most dermatologists were agreed that extra-genital 
syphilis, especially in the head and face, often led very 
quickly to cerebral lesions. This has been explained by 
Fournier and Mobl as being due to the fact that in these 
cases the virulence of the spirochseta was not attenuated as 
it otherwise was by passing through glands. 

Influenza in Vienna. 

During the month of December, 1907, and January of the 
present year, when changes of weather were unusually rapid 
and frequent, influenza was very prevalent in Vienna, but 
as a rule the disease ran a very mild course, either because 
the virulence of the micro-organism was diminished or 
because the population was already to some extent immunised 
The infection was present everywhere and assumed a bron¬ 
chitic type with complications affecting not only the acces¬ 
sory sinuses of the nose but also the intestinal canal. About 
11,000 cases were reported in one week, but the diagnosis 
was hardly ever confirmed by bacteriological examination. 
The disease took the shape of a pandemic, all the larger 
towns in Central Austria suffering alike, so that public 
offices, schools, and even post-offices had to be closed tem¬ 
porarily. The attack, however, generally passed away in 
from fonr to six days. 

Feb. 1st. 


NEW YORK. 

(From oub own Correspondent.) 


Bank of Medical Officers in the Navy. 

The resignation of the chief officer of the Bureau of 
Navigation makes public a controversy in official naval 
circles in regard to the rank of medical officers in charge of 
hospital ships. It appears that the head of the Bureau, a 
rear admiral, contended that these ships should be in com¬ 
mand of a line officer and the surgeon should be in charge of 
the sick only. The Surgeon-General of the Navy endeavoured 
to have the rule established that a hospital ship should be. in 
command of the surgeon who should have a corresponding 
rank A joint board of the army and navy medical officers 
convened more than a year ago by executive order to unify 
the medical services as much as possible recommended that 
hospital ships should be commanded by medical officers, and 
the recommendation was approved by both the Secretary of 
War and the Secretary of the Navy in general orders. 
Accordingly, in the army all hospital shipB and medical 
transports are placed under the Surgeon-General but in the 
Davy the opposition has continued, and iu the preparation of 
the naval medical supplies for the fleet now on the way to 
the Pacific the question of the position of commander of 
hospital ships assumed an acnte form which was closed by 
the decision of the President in favour of the Surgeon- 
General of the Navy and the retirement of the head of the 
Bureau of Navigation. 

. Public Medical Lectures. 


The Faculty of Harvard Medical College has organised a 
course of public lectures to be given on Sunday evenings and 
Saturday afternoons, which are holidays for the working 
public. The subjects selected for each lecture are of a 
papular character and are designed to entertain and to instruct 
the common people. The following are examples: Common 
Salt; Fatigue, its Effects and Treatment; Alcoholism and 
Insanity ; Infant Feeding; Preventable Diseases of the 
Skin ; and Foods in Health and Disease. The lectures are 
exciting popular interest and will result in stimulating 
other medical schools to undertake similar work and thus 
meet a great public want. 

Hospital for Nervous Diseases. 

The Department of Charities of New York has established 
a hospital for the exclusive treatment of diseases of the 
nervous system on Blackwell's Island. Its capacity is 
250 beds. It is reported that there are more than 1000 
patients in the hospitals of the city awaiting admission, all 
of whom are suffering from various forms of nervous 
diseases which unfit them for treatment in general hos¬ 
pitals. The new hospital will be equipped with laboratories 
and all necessary appliances for diagnostic and therapeutic 
research, and for lectures and demonstrations in neurological 
science. This is the first hospital of the kind established in 

this country. , . . 

Use of Nostrums by Phyncians. 


At a meeting of the Philadelphia branch of the American 
•barmaceutical Association a discussion arose on the 
,revalence of the custom of physicians to prescribe 
•dvertlsed nostrums the ingredients of which were un- 
nown. The editor of a leading magazine, which excludes 
rom its columns all nostrums, stated that the present 
.citation against advertising nostrums bad the effect upon 
he public to make thousands of people absolutely opposed 
o them. The result is that in three years 18 nostrum 
aanufacturers have gone out of business and two of the 
argest concerns are for sale. He added that to-day it is 
.radically impossible to get nostrum advertisements into 
ny reputable magazine and within a short time it will 
.e almost impossible to get patent medicine advertisements 
nto the religious weeklies. The next effort is to be centred 
n the provincial and urban daily newspapers. Dr. H. D. 
Vood attributed the continuance of the evil of nostrum 
medication to the leading members of the profession. It 
ppeared on examination of 5000 prescriptions made in the 
ear 1906 that there was 6 per cent, more patent medicine 
.nsn.ihmi Ystt loQ/iino- nhvsir.ians of Philadelphia than m 


New Board to decide on Pure Food Itules. 

Dr. Harvey W. Wiley of the United States Agricultural 
Department has heretofore made and enforced the rules 



466 The Lancet,] 


NEW YOEK.—AUSTRALIA. 


[Feb. 8. 1908. 


governing the manufacture of foods under the “ Pare Food 
Laws.” But his rulings have been severely criticised by 
dealers in foods. It is alleged by the fruit driers of 
California that the quantity of sulphur specified as the 
maximum by Dr. Wiley’s decision is one-third that allowed 
in Germany which has the strictest food regulations of all 
countries. The complaints against Dr. Wiley’s decisions are 
so numerous and urgent that the President has determined to 
appoint a commission of expert chemists who shall constitute 
a board to make a final decision on all of these questions. In 
order to secure the most competent chemists the President has 
requested the presidents of the universities of Johns Hopkins, 
Virginia, California, Yale, and the Northwestern of Chicago 
each to recommend a chemist whom he will appoint on a 
board which shall determine finally all questions arising under 
the law. 

General Immigration statistics. 

Recently published statistics by the Immigration Restric¬ 
tion League show that during the year 1907 there were 
landed in this country 1,285,349 immigrants, the largest 
number received in any one year since 1821. The change in 
the national groups of immigration since 1369, a period of 
37 years, is interesting. The percentage of immigrants, from 
Austria-Hungary, Italy, and Russia in 1869 was 0• 9, and from 
the United Kingdom, France, Germany, and Scandinavia it 
was 73'8 ; in 1907 the former group was 71’3 per cent, and 
the second group 17 • 1 per cent. The change in the relative 
percentage of these two groups of immigrants began in 1896. 
The largest elements in immigration at present are as 
follows : Southern Italian, 242,497; Hebrew, 149,182; 
Polish, 138,033; German, 92 936 ; Magyar, 60,071; and Scandi¬ 
navian, 53,425. The percentage of illiterates in total immigra¬ 
tion was 23 • 9 ; the lowest percentage in each 100 immi¬ 
grants over 14 years of age who cannot write and cannot 
read and write their own language was Scotch 1 0, and the 
highest percentage was Portuguese, 76 ■ 6. The present 
immigration law excludes the following classes:—The 
mentally unfit—viz., idiots, imbeciles, feeble-minded, and 
insane: the physically unfit—epileptics, tuberculous, and 
persons afflicted with a loathsome or contagious disease ; the 
morally unfit—prostitutes, procurers, polygamists, anarchists, 
and convicts ; the economically unfit paupers, persons likely 
to become a public charge, professional beggars, contract 
labourers, and assisted emigrants. The number debarred and 
deported in 1907 was 14,059, or 1 ■ 1 per cent, of the total 
number of arrivals. 

The Federal Employers' Liability Lam Void. 

For more than 20 years the railroad men of the United 
States have been struggling to secure a law which protected 
them from the accidents to which they are especially liable. 
The President urged the passage of such a Bill and at the 
last session of Congress it was finally passed and became 
law. The law was brief and provided for the extension of 
the employers' liability to all common carriers engaged in 
interstate commerce and practically abolished the “Fellow 
Servant ” rule. The doctrine of contributory negligence was 
modified so as not to bar recovery where the negligence of 
the employee was slight and the negligence of the employer 
was gross in comparison—the newer doctrine of “ compara¬ 
tive contributory negligence.” On the passage of the law 
several railroads united to test its constitutionality, with the 
result that it has been declared unconstitutional by the 
highest court and is now void. 

Jan. 25tli. _ 


AUSTRALIA. 

(From odr own Correspondent.) 


Melbourne Hospital. 

The question of a site for rebuilding the Melbourne Hos¬ 
pital remains unsettled, although it provides a topic for 
newspaper correspondence and has been the subject of 
several conferences between various bodies interested. Dr. 
J. W. Springthorpe is energetic in support of the proposal to 
rebuild on the present site, while Dr. R. R. Stawell expresses 
the opinion of the advocates for removal. At a meeting of 
the hospital medical staff a motion affirming the desirability 
of procuring a larger site was carried by 11 votes to five. 
The present block is about four acres in extent and the 
proposed new area, which is at present occupied by the 
pig and horse market, would be something between 12 


and 14 acres, but it is about a mile farther out of 
the city. The opponents of removal assert that this 
extra distance is a serious drawback and that the site itself 
is dusty and exposed to the north winds. The advocates 
for a new site affirm that the present situation is too 
small for a modern self-contained hospital and clinical 
school, and that the “pig-market” block has the advantage 
of being in the immediate vicinity of the University Medical 
School. Under the terms of the gift of £100,000 for 
rebuilding purposes made by the trustees of the Wilson 
estate, the question of site had to be decided upon within 
six months. About four months of the term have already- 
elapsed. The trustees also retained the right of approval of 
any site determined upon. 

The Danysz Microbe. 

Sir William Lyne is determined to carry out the Federal 
policy of “ Australia for the Australians” even to denying 
admission to imported microbes. Dr. F. Tidswell has shown 
that the Danysz microbe, or one indistinguishable from 
it, is already known in New South Wales and has caused 
epizootics among rabbits. Sir William Lyne admits that 
this places a new aspect on the question of trying the 
Danysz method on the mainland, but states that it is certain 
that Parliament would never permit the liberation of the 
microbe introduced to Australia by Dr. Danysz. Mean¬ 
while the pastoralists demand that a trial shall be made in 
the rabbit-infested areas of the interior. 

St. Vincent's Hospital. 

The engineering inspector of the Board of Public Health 
has reported that St. Vincent’s Hospital, Melbourne, is 
“ excessively overcrowded.” St. Vincent’s is the most recent 
hospital building in Australia and is fitted with every modern 
improvement. The present structure forms only a part of 
the whole design and under the Board's standard is available 
for 76 patients. At the time of the inspector's visit 124 
patients were under treatment, patients being ‘ ‘ placed in 
the balconies, in the lobbies, and other parts of the building 
not set apart for such a purpose.” Dr. Norris (chairman of 
the Board of Health) remarked that the state of affairs was 
“nothing short of scandalous” and immediate action was 
ordered in the direction of a peremptory letter to the 
hospital authorities and a communication with the Board’s 
solicitors. The hospital authorities have replied that so 
great has been the demand in urgent cases that they have 
been unable to turn them away and that the hospital is so 
equipped with balcony and corridor space that some patients- 
can be temporarily accommodated there without incon¬ 
venience. 

Infants’ Food. 

Recently at the Richmond (Victoria) police court trades¬ 
men were fined with costs for selling well-known brands of 
infants’ food in contravention of the Pure Foods Act. The 
editor of the Chemist and Druggist has written to tlfe press 
to point out that the prosecution was for failure to state that 
the foods must not be used for infants under six months. 
The Pure Foods Act requires that infants’ foods containing 
starch must be labelled or sold with the statement that they 
are not intended for children under the age of six months. 

Home for Consumptives. 

On Dec. 14th last the sanatorium for consumptive women 
was opened at Thirlmere, New South Wales, by the State 
Governor, Sir Harry Rawson. The site was devoted to the pur¬ 
pose originally by a Mr. Goodlet. but subsequently was placed 
under the management of the Queen Victoria Home for 
Consumptives. Eventually the site was purchased and with 
the new buildings has cost £10,000. It will accommodate 
50 patients. Since the male wing was opened at King’s 
Tableland the practice of mixing the sexes at Thirlmere has 
been abandoned. The medical supervision will be in the 
hands of Dr. Eric Sinclair. 

Action for Libel. 

Mr. S. B. Helwig who is registered as M.D. Univ. of Heidel¬ 
berg, 1899, recently brought an action against the pro¬ 
prietors of the Ballarat Echo , claiming £1000 damages 
for alleged libellous paragraphs stating that the plaintiff had 
victimised a resident of Ballarat in respect to an alleged cure 
for gall-stones. The plaintiff has practised for some time at 
Pakenham, a small village near Melbourne. He is alleged to 
have claimed by advertisement in the public press to be able 
to remove gall-stones by means of a special medical treat¬ 
ment. The paragraphs complained of had reference to a 
patient who had undergone the treatment without benefit. A. 


Jj 

tit 

mi 

tin 
is x 


era. 

UKK 

scri 

rsiei 

21: j 

zselh 


Via 

uai 

ra 4 
zad 
^staa 

-* 3 , 

i^aij 
» S!Q! 

-Qti 



- bi 

• •s; | 

Vjj 

- i. 1 
He 

~F. 

■a ; 
•’ T, 


-Tar 

-V: 


<2^ 



'•4 


* *i 


' ^ 


*>! 


The Lancet,] 


AUSTRALIA—BUDAPEST. 


[Feb. 8, 1908. 467 


strong bar appeared on both sides. The jury found generally 
for the defendants and Mr. Justice Cussen said that be would 
appoint a future day to hear arguments as to how the verdict 
should be entered and as to costs. On a subsequent applica¬ 
tion judgment was entered for the defendants with costs 
upon one count, and as to the other count a new trial was 
ordered. 

Diphtheria Patient Fined. 

An unusual prosecution in this part of the world was made 
in the case of a woman who was charged under the Health 
Act that she was, while knowing she was suffering from 
a dangerous infectious disease—to wit, diphtheria—in¬ 
tentionally in a public place. The patient had been an 
inmate of the infectious diseases hospital and though conva¬ 
lescent left the institution against the order of the medical 
superintendent. In going home to her family she called at a 
friend’s house and sat on the verandah. The magistrates 
imposed a line of 10s. with £3 3*. costs. 

State Relief. 

The annual report of the State Children’s Relief Board of 
New South Wales shows that 7049 children are under super¬ 
vision, 4024 being boarded out apart from, and 3025 with, 
their mothers. The expenditure for the entire service of the 
department was £69,772. Contributions of parents amounted 
to £2078, leaving the actual cost to the State of each child 
at £15 6». Allowances to widows and deserted wives 
towards the support of their children at home amounted to 
£19,269, so that the State appears to be assuming a large 
undertaking in addition to education. 1201 children are 
apprenticed under the control of the Board. Their wages 
are paid into the Savings Bank and disbursed according to a 
scheme that has worked well, two-tbirds being retained till 
the child is 21 years old. Street-trading licences were issued 
to 735 children. 

British Medical Association. 

The annual meeting of the Victorian branch of the British 
Medical Association was held on Dec. 3rd. The retiring 
president (Professor H. B. Allen) delivered an address in 
which he outlined the scheme by which the branch had 
become amalgamated with the Medical Society of Victoria. 
The following office-bearers were elected for 1908: President, 
Mr. G. A. Syme ; Vice-Presidents, Dr. R. R. Stawell and 
Mr. G. Cuscaden ; Secretaries, Dr. L. J. Balfour and Dr. 
Henry Laurie ; Treasurer, Dr. 0. H. Mollison ; Librarians, Mr. 
A. W. F. Noyes and Dr. H. D. Stephens ; Council, Dr. W. R. 
Boyd, Dr. Felix H. Meyer, Dr. W. Moore, Mr. F. W. Morton, 
Dr. A. Lewers, Mr. W. Beattie-Smith, Dr. A, J. Wood, and 
Dr. G. T. Howard. 

Dec. 28th, 1907. _ 


BUDAPEST. 

(From our own Correspondent.) 


Bradycardia in Appendicitis in Children. 

Dr. Jlinos Bokay, professor of paediatrics at the University 
of Budapest, has drawn attention in a clinical lecture to the 
importance of bradycardia in children suffering from ap¬ 
pendicitis. This symptom has not been dealt with as yet; in 
the literature of the subject there is only one memoir 
referring to bradycardia in appendicitis, and in it only adults 
are considered. Professor Bokay draws the following con¬ 
clusions from an experience of ten cases treated successfully. 
1. Daring the absorption of the periappendicular exudation 
bradycardia sets in almost regularly and persists for many 
days ; it may even last for more than a fortnight. 2. Brady¬ 
cardia may also be observed after an appendicular abscess 
has been evacuated by an operation. 3. In children 
between the ages of seven and 16 years the pulse-rate ranged 
from 52 to 80. 4. There is no parallelism whatever between 
the pulse-rate and the temperature. 5. Bradycardia cannot 
be regarded as an unfavourable sign from the point 
of view of prognosis ; on the contrary, in cases of peri¬ 
appendicular exudation it iB a sign of the commencement of 
the process of absorption. In all the ten cases observed by 
Professor Bokay the bradycardia must have been of extra- 
cardial, i.e., nervous, origin, because organic heart disease 
could be excluded. He was therefore justified in assuming 
that the essential cause was irritation of the vagus, probably 
due to the absorption of toxins from the periappendicular 
exudation. 


Why do not the Living Stomach and Intestine Digest 
Themselves. 

Dr. Nandor Klug, professor of physiology, has ■ been 
investigating in his laboratory the still unsolved question, 
why the living stomach does not digest itself. His investi¬ 
gations were based on Weinland’s experimental results, 
according to which the walls of the stomach and intestines 
defend themselves against the proteolytic enzymes by means 
of anti-enzymes or anti-ferments. Professor Klug has found 
that the inner half of the gastric mucous membrane con¬ 
tained a substance which powerfully resisted the digestive 
action of the trypsin and the gastric juice. The stomach 
(and the small intestines as well) were therefore protected 
against self-digestion by mucin which they themselves 
secreted. Dr. Klug’s experiments did not prove the preset 09 
of so-called anti-ferments, as supposed by Weinland. The 
mucin could not be digested either by the mixture of pepsin 
and hydrochloric acid or by the trypsin solution. Mucin 
was not liable to diffusion ; it retained the trypsin and pepsin, 
and this property sufficed for the protection of the stomach 
and intestines from self-digestion. The ascaris lumbricoides 
was not digested by the intestinal fluids on account of the 
resistant properties of its external covering. 

Cancer of the Lip. 

At a recent meeting of the Budapest Medical Society 
Dr. Heiner Pill read a paper giving statistical details of the 
cases of cancer of the lip which have been under observation 
in Professor Dollinger’s clinic during the last seven years. He 
said that labial cancer was ten times as frequent in men 
as in women and that cancer of the lower lip was twelve 
times as frequent as that of the upper lip. All parts of the 
lower lip were alike liable to be attacked ; in the upper lip, 
on the other hand, the favourite site of the disease was the 
middle part. Cancer of the lip was most frequent in agri¬ 
cultural labourers and men who smoked pipes. It mostly 
occurred between the ages of 55 and 60 years. Preceding 
inflammations, psoriasis, leukoplakia, and scars had an 
important influence in the development of the disease. With 
regard to the period of admission to hospital, 84 per cent, of 
the patients presented themselves within the first year from 
the onset of the cancer and in 76 per cent, of the cases the 
parts were already ulcerated. In 67 per cent, of the cases 
there was a regional glandular infiltration present. Of the 
cases operated on, 69'6 percent, have now remained free from 
recurrence for over five years. In two-thirds of the cases in 
which there has been recurrence death supervened in the 
course of the first year. 

1 he Position of the Assistant Medical Officers of the Budapest 
Hospitals. 

On Jan. 28th the assistant medical officers of the Budapest 
municipal hospitals—namely, St. Rochas, St. Ladislaus, 
St. Stephen, the Workhouse Hospital, St. John and Margareth 
Hospitals—gave notice to the director, Professor Kolomann 
Midler, that they would resign their posts on Feb. 4th. 
The motive for taking this step is the lowness of the salaries 
paid to the assistant medical officers. In 1904 they asked 
the municipal board to raise their remuneration from 1200 
kronen (£50) to 2C00 kronen, considering the great amount 
of work which they have to do and the expensiveness of living 
in Budapest. They pointed out that an assistant medical 
officer has to attend 200 patients daily and that the duties 
as well as the present salaries were fixed many years ago at a 
time when x ray work, advanced bacteriology, and the mani¬ 
fold forms of physical treatment now in U9e did not exist. 
It could therefore be easily understood that they have to 
work hard from early morning till late in the evening. They 
hoped that the municipal board would comply with their re¬ 
quest, but on Jan. 27th the board refused the application. The 
assistant medical officers accordingly gave notice of their 
intention to resign their posts. The medical profession in 
general sympathises with them and is ready to offer help and 
support if the board maintains its present attitude. 

Jan. 28th. 


St. Mary’s Hospital.— A new special depart¬ 
ment for nervous diseases has been instituted in the out¬ 
patient practice of this hospital; it is a development of the 
electro-therapeutic department and will receive new cases as 
such, instead of only dealing with cases referred to it from 
other departments. The x ray department remains separate 
as before. Dr. Wilfred Harris has been appointed physician- 
in-ebarge of the department for nervous diseases in addition 
to his duties as senior physician to out-patients. 





468 The Lancet,] 


OBITUARY. 


[Feb. 8, 1908 



SIR THOMAS McCALL ANDERSON, M.D. Glasg., 
F.E.P.8. Glasg., 

BEGIUS PBOFESSOB OF MEDICINE IN THE UNIVERSITY OF GLASGOW* 

The tragically sudden death of Sir Thomas McCall 
Anderson on the evening of Jan. 25th has removed a 
prominent personality from the rants of the profession 
in Glasgow and the West of Scotland and a popular 
and highly successful teacher from the Glasgow Medical 
School in which he laboured with conspicuous ability for a 
period of nearly 50 years. On that evening be was present 
at the anniversary dinner of the Glasgow Ayrshire Society 
as the guest of his old friend the chairman, Surgeon-Colonel 
Robert Pollok, and appeared to be in his ordinary health 
and spirits. In felicitous terms he proposed the last toast 
on the list, that of the directors and other office-bearers of 
the society. Immediately afterwards he left the dining¬ 
room in company with his friend and colleague Sir 
Hector 0. Cameron, apparently quite well, but on his way 
down the staircase he suddenly fainted and, surrounded by 
a number of medical friends who like himself had been 
guests of the chairman, he expired in a few minutes from 
heart failure. He had promised Dr. Pollok to be present aDd 
to propose a toast. He had felt somewhat tired during the 
day but in spite of the remonstrances of his family he felt 
that he could not disappoint his old friend and pupil who 
had been called to the honourable office of chairman of the 
society. He attended the dinner and kept his promise, with 
the tragical result which has just been stated. During 
the past year or more, probably as the result of a 
sudden but transient illness of an apoplectic nature, he 
had not enjoyed his usual vigorous good health, and last 
summer, on the advice of his medical frieDds, he took a pro¬ 
longed holiday from teaching and professional work. He bad 
benefited by the rest and change so much that he was able to 
resume his professorial duties at the beginning of the present 
winter session. At the meeting of the General Medical Council 
in November last he appeared to be in good health and took 
an active part in all the business of the session. He also 
attended the meeting of the Scottish branch council in 
Edinburgh last month. 

Thomas McCall Anderson was born in Glasgow in 1836 
and came of a family long and honourably connected with 
the city. His father, Dr. Alexander Dunlop Anderson 
(1794-1871), was the son of a merchant in Greenock and 
nephew of Dr. John Anderson, professor of natural 
philosophy in the university and founder in 1796 of the 
“ Andersonian ” university which is still famous as the 
leading extramural medical school in Glasgow. Through 
the Dunlops his family was intimately connected with 
the university, one of the Dunlops having been 
principal at the end of the seventeenth and another 
professor of Greek during the greater part of the 
first half of the eighteenth century. It will thus be 
seen that he came from a family which was able 
to give him a good start on the journey of life, and 
he himself soon proved that he was fitted and willing 
to make the very best use of his hereditary endow¬ 
ments. After a brilliant career as a medical student in 
the university of his native city he graduated “ with honours ” 
in 1858. For the succeeding two years he acted as one of 
the resident assistants in the Glasgow Royal Infirmary, in 
which institution his father had served during a number of 
years on the visiting staff. ' He then spent some time at 
Vienna and other great continental schools, and soon after¬ 
wards he settled in practice in Glasgow. In these early 
years he securely laid the foundations of his future success as 
a teacher and physician by his enthusiasm for his medical 
work and his tireless industry in the prosecution of it. He 
possessed that capacity for taking pains which is said to be 
akin to genius. Two old notebooks given by him to 
a friend many years ago bear abundant evidence of this. 
One of them contains full records of the symptoms and 
treatment of the rarer cases coming under his observa¬ 
tion, and the other full notes of the books he studied. In the 
list of books thus annotated are such classics as Louis on 
Phthisis, Williams on Diseases of the Chest. Brinton on Ulcer 
of the Stomach, Yirchow on the Cellular Pathology, Ricord 
on Syphilis, Gairdner and Garrod on Gout, Brown-S6quard 
on Epilepsy, Adams on Rheumatic Gout, and many others. 


In such a thorough manner did be prepare himself for his 
life’s work. 

Soon after settling in Glasgow he was appointed professor 
of the practice of medicine in the “Andersonian ” College and 
somewhat later one of the visiting physicians to the Glasgow 
Royal Infirmary. From this time his success as a teacher 
and a physician was rapid and was maintained till the end of 
his long career. When the clinical school of the University 
was removed from the Royal to the Western Infirmary in 
1874 he was appointed professor of clinical medicine in the 
University and one of the visiting physicians to the newly 
founded infirmary, where by far the greater part of his 
clinical work was done, and in the wards of which he was 
on full duty at the time of his death. In addition to bis 
great industry another element in his success was the 
methodical manner in which he arranged his work. The 
proof of this is found in the fact that his great work on 
diseases of the skin was written at a time when his con¬ 
sulting practice was at its highest level and his popularity 
as a clinical teacher at its greatest. Regularly every after¬ 
noon in the midst of his numerous academic, professional, 
and social engagements an hour or two was devoted to the 
writing of the book. His custom then was to make pencil 
notes late at night and to dictate them the next afternoon as 
they were to appear in print to his amanuensis. His untiring 
industry and his method of working were an example and an 
inspiration to his students and assistants. 

From what has been said it will readily be understood 
that the reason of McCall Anderson’s great popularity and 
success as a teacher, especially of clinical medicine, is 
not far to seek. In the old Royal Infirmary days, before 
the University migrated to the west, he had already displayed 
his powers as a teacher, and his clinical classes were always 
most numerously attended. His definite aim in these days 
was to raise the standard of clinical teaching. He saw that 
in order to be effective clinical study and practice should be 
something more than a mere “walking the hospital.” He 
set himself definitely so to organise his large classes that so 
far as possible individual students should be brought into 
personal contact with the cases. For this purpose in the 
most thorough manner he adopted the tutorial system, 
dividing the students into groups so that the elements of 
physical diagnosis and urinary analysis might be efficiently 
taught. The same methods were adopted when he went 
in 1874 to the Western Infirmary as Professor of Clinical 
Medicine in the University. Similar popularity attended 
him in his new sphere, and to the end in the Western 
Infirmary his clinical classes were always the largest. His 
great success in clinical teaching was due mainly to three 
characteristics : (1) to his clear and systematic method of 
exposition and demonstration; (2) to his intense concentra¬ 
tion upon the subject in hand, which prevented his being 
led iDto the discussion of irrelevant matters ; and (3) to 
his admirable powers of organisation in arranging for 
the teaching of large classes of students. These are 
qualities which, if combined with enthusiasm and 
industry, are bound to command success in clinical teaching. 
Everyone recognised that under the conditions of medical 
education which have up to now prevailed in this country 
no better method of instruction than that carried out by 
McCall Anderson could be devised for laying a sure founda¬ 
tion in the study and practice of clinical medicine. 

As a physician Sir Thomas McCall Anderson may be 
described as at once practical and sagacious. His powers 
were greater in the direction of therapeutics than in that of 
pathology or the minutim of diagnosis. He did not belong 
to the expectant sohool and was never content to rely merely 
on the vix vudicatrix natura. He believed thoroughly in 
the practical applications of the medical art and nothing 
delighted him more than to demonstrate to his students the 
beneficial effects of the drugs and therapeutic measures which 
he had prei-cribed. Indeed, this was the part of his teaching 
from which many of his students felt that they had profited 
most. And outside the wards of the infirmary his clear and 
common-sense instructions as to the treatment to be carried 
out in a given case were greatly valued by the numerous 
medical men who were in the habit of seeking bis advice as 
a consultant. For many years he enjoyed a very extensive 
consulting practice. He did not, however, confine himself 
to general medicine ; he also had a deservedly high reputa¬ 
tion as a specialist in diseases of the skin. It was, indeed, 
as a dermatologist perhaps that he was best known in 
England and on the continent of Europe. Very early 
[ in bis professional career he was instrumental in 






Sir Thomas McCall Axdkrson, M.D. Glasg., F.F.P.S. Glasg., 

REGIUS PROFESSOR OF MEDICINE IN THE UNIVERSITY' OF GLASGOW. 






The Lancet,] 


OBITUARY. 


[Fee. 8, 1908. 471 


founding the Glasgow Hospital and Dispensary for 
Diseases of the Skin. In this institution he worked hard 
all his life and obtained a wide experience of all varieties of 
cutaneous maladies. His annual clinique on diseases of the 
skin) has done much to promote a thorough knowledge of 
dermatology amongst the practitioners graduating from 
the Glasgow school. During his busy life Sir Thomas 
McCall Anderson found time also to contribute largely to 
the literature of medicine. His largest work, as has 
already been mentioned, was the “ Treatise on Diseases 
of the Skin.” Among the long list the following may 
also be mentioned: “ On the Curability of Attacks of 
Tubercular Peritonitis and Acute Phthisis (Galloping Con¬ 
sumption) ” ; on “Syphilitic Affections of the Nervous 
System : their Diagnosis and Treatment ” ; and 1 ‘ Lectures 
on Clinical Medicine delivered in the Royal and Western 
Infirmaries of Glasgow.” These, and we might mention 
many more, are sufficient to show the wide scope of his 
literary efforts and of his clinical studies. As a writer his 
Btyle was clear and terse; and his views both on diagnosis 
and treatment were always based upon cases actually 
observed and treated. As a man of affairs he had a high 
reputation. He was a good business man ; and his sound 
common-sense was recognised by his being placed on a 
number of public and charitable boards. In politics he waB 
a Conservative and he took an interest in the local affairs of 
the party. For many years he was an elder in the Church of 
Scotland. 

In 1900 Sir Thomas McCall Anderson was transferred by 
Lord Balfour of Burleigh, then Secretary for Scotland, to the 
chair of Practice of Medicine vacated by Sir William T. 
Gairdner. In 1903 he succeeded the same gentleman as 
representative of the University of Glasgow on the General 
Medical Council. He was knighted in 1905 and two years 
later, on the death of Sir William Gairdner, he succeeded 
him as one of the honorary physicians to the King in 
Scotland. He has now ended bis busy life full of honours, 
having discharged his daily duties to the very last. On the 
Monday after his death the headings of his intended lecture 
for that day on cerebral haemorrhage were found written in 
his own band on the blackboard of his class-room. His 
punctuality and diligence in his medical work have long 
been admired by his medical brethren ; and those who were 
his students will not soon forget the clear and succinct 
clinical teaching which in the case of many of them laid the 
foundation of their own success in the profession of medicine. 

He is survived by Lady McCall Anderson, one son, and five 
daughters, with whom much sympathy is felt. 


JAMES BELL PETTIGREW, M.D. Edin., F.R.C.P. Edin., 
F.R.8. Lond., LL.D.Glasg., 

PROFESSOR OF MEDICINE AND ANATOMV Hr THE UNIVERSITY OF 
ST. ANDREWS. 

Professor James Bell Pettigrew died at his residence, 
The Swallowgate, St. Andrews, on Jan. 30th, after a long 
illness. He was born in 1834 at Itoxhill in Lanarkshire, 
and was related on his mother’s side to Henry Bell, the 
founder of steam navigation in Europe. He studied medi¬ 
cine in the University of Edinburgh, where he graduated 
as M.D. in 1861, receiving a gold medal for his thesis; he was 
also a gold medallist in the subjects of anatomy and medical 
jurisprudence. From 1862 to 1868 he held the appointment 
of assistant curator at the Hunterian Museum of the Royal 
College of Surgeons of England. Returning to Edinburgh 
he worked for the Royal Oollege of Surgeons in that city, 
being appointed curator of the mnseum in 1869 and lecturer 
on physiology in 1873. In 1875 he became Chandos professor 
of medicine and anatomy in the University of St. Andrews, 
a position which he held till the time of his death, although 
increasing infirmities compelled him not long ago to relin¬ 
quish the active duties connected with his chair. Professor 
Pettigrew made many valuable contributions to medical 
literature, chiefly in the form of articles published in various 
journals and papers read before societies. At an early part 
of his career he worked at the muscular structure of the 
heart, stomach, and bladder; and some of his results were 
published in the Philoiophieal Tramactiom in 1864 and 1867. 
The latter of these two memoirs gained for him in 1874 
the Godard prize of the French Academy of Sciences 
and he also received the distinction of laureate of the 
Institute of France. He subsequently gave much atten¬ 
tion to problems connected with the flight of birds. 


In 1873 he published a treatise on “ Animal Locomotion,” 
and the article entitled “Flight: Natural and Artificial,” 
in the ninth edition of the “ Encyclopaedia Britannica” 
(1879) was written by him. Various forms of flying 
machines were devised by him for the purpose of illus¬ 
trating his views. On Nov. 23rd and 30tb, 1901, we 
published two valuable papers by him on the making of 
anatomical preparations, and again in January, 1904, an 
article on Spiral Fomrations in Relation to Walking, 
Swimming, and Flying. Marrying in 1890, Professor 
Pettigrew has left a widow who was a daughter, of the 
late Sir W. Gray of Greatham, Durham. 


CHARLES JAMES WRIGHT, M.Sc. Leeds, M.R.C.S. Eng., 

EMERITUS PROFESSOR OF OUSTETRICS, UNIVERSITY OF LEEDS; HONORARY 
CONSULTING SURGEON TO THE HOSPITAL FOR WOMEN AND 
CHILDREN, LEEDS. 

The loss which Leeds has sustained by the death of 
Mr. 0. J. Wright will he felt not only by those with 
whom he has for so many years been associated but by a 
large number of medical men in practice in various parts of 
the county of York and elsewhere. Though Mr. Wright had 
been manifestly failing in health for some years he went 
on bravely with his work until about a week before he 
passed away on Jan. 17th, and the announcement of his death 
came as a surprise even to many of his friends in Leeds. 
Mr. Wright, who was in his sixty-sixth year, was a native 
of Wakefield. He was educated at St. Peter’s School, York, 
and was a student of the old Leeds School of Medicine as 
well as of Guy’s Hospital. It may be said that the whole of 
bis professional life was identified with the Leeds School of 
Medicine, for as a student he worked in the old house in 
East Parade, and in this house he also taught. He was asso¬ 
ciated with the school when it was housed in the new 
premises in Park-street, opened by Sir James Paget, and he 
continued his work until last year in the new buildings opened 
by the present Prince of Wales in the early " nineties.” 
To few men indeed is it given to be a member of the active 
teaching staff of any institution for the long period of 41 years, 
and not only was this the case with Mr. Wright, but everyone 
who was acquainted with his work will cordially agree that 
during the whole of that time his energies were unsparingly 
devoted to the welfare and reputation of the school. Mr. 
Wright’s earlier work was done in the departments of ana¬ 
tomy and physiology but from the year 1884 he was re¬ 
sponsible for the teaching of obstetiics, first as lecturer in 
succession to the late Mr. William Nicholson Price, and 
subsequently to 1888 as professor. The University honoured 
him by conferring upon him the degree of Master of Science 
and on his resignation of the professorship last year it will be 
remembered that he was promoted to the honorary position 
of emeritus professor. 

For many years Mr. Wright was a member of the honorary 
staff of the Hospital for Women and Children. On retiring 
from the active staff last year he was elected honorary con¬ 
sulting surgeon to the institution. In the reconstruction of 
this charity and in the erection of the new buildings, which 
were opened a few years ago, he took a very active part. 
For many years he was connected with the important work 
of the Leeds District Nursing Association and the committee 
will for long look back with gratitude to his genial and un¬ 
sparing solicitude for the welfare of the nurses, at whose 
disposal he always held himself in times of illness. 
Though always in general practice Mr. Wright de¬ 
voted himself more especially to obstetrics and gynaeco¬ 
logy and he was frequently called in consultation by 
his former students in cases of difficulty. A distinguishing 
characteristic of Mr. Wright was his extraordinary grasp of 
details ; he was apparently able at any time to lay his hand 
on some memorandum of an event which everyone else was 
at a loss to give a clear account of. One of his colleagues 
described him as “a bom secretary,” and another in joke 
said “ his house must be full of pigeon holes,” bo unfailing 
was his accuracy in this respect. With this he combined a 
geniality of manner and a true kindness of heart which those 
who came much in contact with him will never forget. He 
probably valued nothing so much as the esteem and gratitude 
of bis students, and this he had in a measure which was alike 
an honour to them and to him on whom it was bestowed. 
The sympathy of all who knew him will be freely extended 
to Mrs. Wright and his family, and his colleagues will always 
keep his memory fresh in their minds as of one who did Ms 
duty manfully. 




472 The Lancet,] 


MEDICAL NEWS. 


[Feb. 8,1908. 


HMfal Setos. 


University of Oxford.— In a Congregation 
held on Jan. 23rd the following degrees in medicine 
and surgery were conferred :— 

Bachelors in Medicine and Surgery.—0. G. Douglas, Fellow o* 

St. John’s College ; G. M. Johnson, Magdalene College ; N. Flower. 

Exeter College; S. Hartill, New College ; and 13. G. Kleiu, Corpus 

Christ! College. 

—The remaining degree days in the present term are:— 
Saturday, Feb. 15th, at 2.30 P.M., and Thursday, March 12th, 
at 10 a.m. 

University of Cambridge.— The council of 

the Senate recommends that the centenary of the birth of 
Charles Darwin shall be celebrated by the University in the 
week beginning June 20th, 1909.—The following degrees 
were conferred on Jan. 30th :— 

M.D.—C. J. Coleman, Trinity. 

Ii.C.—C. E. M. Jones, King's; O. Heath, Trinity; A. F. Jackson, 

Peterhouse; C. H. Treadgold, Clare; and A. W. C. Drake and 

S. G. Luker, Pembroke. 

University of Liverpool— At a meeting of 
the Senate held on Jan. 29th diplomas in Public Health 
were awarded to— 

E. ,S. Jones, M.H.C.S., L.11.C.P. ; It. O. Mather, M.B., L.R.C.P.’, 

L.R.C.S. ; and J. Orr, L.R.C.P., L.R.C.S., L.F.P.S. 

British Medical Benevolent Fund.— The 

annual general meeting of subscribers to the British Medical 
Benevolent Fund will be held at 15, Wimpole-street, London, 
W., on Tuesday, Feb. 18th, for the purpose of receiving the 
treasurer’s financial statement and the report of the com¬ 
mittee and for the election of a president and other officers 
and of a committee. The chair will be taken at 5.30 o’clock. 

Vaccination Fees. — At a meeting of the 
Falmouth board of guardians held on Jan. 29th a letter 
was read from the Local Government Board stating that the 
revised scale of fees submitted by the guardians for payment 
to the public vaccinators was too low. After some discussion 
it was decided to inform the Local Government Board that 
the guardians had arranged the fees with the public 
vaccinators. 

Medical Inspection of School Children.— 
The Thornbury (Gloucestershire) board of guardians at 
its meeting on Jan. 25th passed a resolution advocating 
the desirability of the medical inspection of school children 
being placed in the hands of local medical men instead of 
appointing a medical officer solely for that purpose.—At a 
meeting of the Somerset connty council held on Jan. 31st it 
was stated that 68 candidates bad applied for the post of 
chief medical inspector of schools, the salary offered being 
£500 per annum, with necessary out-of-pocket expenses. 
Eventually Dr. T. H. Craig Stevenson of Walthamstow 
was elected. 

Examinations in Hygiene.— A series of exa¬ 
minations in hygiene has been promoted and organised by 
the Incorporated Institute of Hygiene of London. These 
examinations will be held at the leading centres throughout 
England, Scotland, and Ireland, and will include not only 
the necessary examination showing general proficiency in 
hygiene but the following additional honours subjects—viz., 
the hygiene of the home ; the hygiene of motherhood; the 
feeding and rearing of children ; food and cooking ; home 
nursing and first aid ; school hygiene ; and physical braining. 
The future heads of households are those to whom 
this syllabus more particularly appeals, and there is 
no doubt that the young women of this country have 
still muoh to learn in connexion with personal and 
domestic hygiene. Nursing and the needs of the invalid 
and the feeding and rearing of children are subjects 
which are worthy of being placed in the forefront 
of a girl’s education, as they are likely to be of far more 
practical use in her daily life than many branches of study 
which now receive an attention out of proportion to their 
value. The prevalent ignorance in regard to child-life is 
one of the chief causes of infant mortality. In personal and 
domestic hygiene we lag sadly behind some other countries, 
especially France. It is most important that every school 
teacher should have a general knowledge of the principles 
of hygiene, quite apart from the special knowledge required 


- 

f 


in teaching it. An examining board, composed of some of the 
leading physicians and men of science throughout the country, 
has been formed to further this branch of the educational 
work of the Institute of Hygiene ; and every assistance and 
encouragement will be given to candidates who may carry 
on their studies at school, college, or at home, while they 
will receive the certificate of the institute for proficiency in 
elementary knowledge and the diploma of the institute for 
proficiency in advanced knowledge should they pass the 
examination successfully. Further particulars can be 
obtained from the Secretary, Incorporated Institute of 
Hygiene, 34, Devonshire-street, Harley-street, London, W. 

The Royal Sanitary Institute.— A provincial 
sessional meeting of the institute will be held at the Council 
Chamber, Exchange Bnildings, Nottingham, on Saturday, 
Feb. 15th, when a discussion will take place on “Present- 
day Road Requirements in Town and Country.” The 
discussion will be opened by Mr. E. Parnell Hooley, 
M.In8t.C.E., connty surveyor, Notts, to be followed by, 
amongst others, Mr. A. Brown, M.Inst.C.E., city engineer, 
Nottingham, and Dr. F. R. Mutch, chairman of the health 
committee, and a general discussion is invited. The chair 
will be taken at II A.M. by Mr. H. D. Searles Wood, 

F R.I.B.A., chairman of the council of the institute. 
Tickets for admission of visitors may be had on application 
to Dr. P. Boobbyer, medical officer of health, Guildhall, 
Nottingham, who is acting as the local honorary secre¬ 
tary of the meeting ; and of Mr. E. White Wallis, secretary, 
Parkes Museum, Margaret-street, London, W. 

Literary Intelligence.— Messrs. J. and A. 

Churchill are just about to publish the second and concluding 
volume of “ The Labyrinth of Animals,” by Dr. Albert A. 
Gray, aural surgeon to the Victoria Infirmary, Glasgow ; the 
work will be illustrated by stereoscopic plates. Another 
new book to be published by the same firm is entitled 
“Abdominal Tuberculosis,” by Mr. A. E. Maylard; the 
text will be illustrated. New editions nearly ready are 
the second of “Lectures on Medical Jurisprudence and 
Toxicology,” by Dr. F. J. Smith of the London Hospital; 
additional lectures on “The Examination of the Person 
Alive and Dead,” “Anaesthetics,” and “Death Certifica¬ 
tion” have been included; also the sixth edition of “A 
Simple Method of Water Analysis,” by Dr. J. C. Thresh of 
the London Hospital.—A branch of the London Independent 
Labour Party, viz., the Committee for Promoting the 
Physical Welfare of Children, has issued a pamphlet by 
Mr. M. D. Eder on “ Diseases in the Schoolroom,” in which 
the writer points out how urgent the need is for attention to % 
the many diseases now prevalent in the State schools. The 
pamphlet is published at the nominal price of Id. and 
aims at helping the efficacious carrying out of the Act 
which came into force on Jan. 1st for the medical inspection 
of school children. 

The Eleventh International Congress of 
Ophthalmology. —This congress will meet at Naples at the 
beginning of April, 1909, and its organising committee has 
already issued a circular letter of invitation. Professor Marc 
Dufour will be honorary president and Dr. Landolt will be 
vice-president. The corresponding members of the congress for 
Great Britain are Mr. Walter H. H. Jessop, 73, Harley-street, 
London, W. ; Professor George Mackay, 20, Drumsheugh- 
gardens, Edinburgh ; and Sir Henry R Swanzy, 23, Merrion- 
sqnare, Dublin. Ophthalmologists subscribing to the congress 
and wishing to communicate papers n^ust forward their titles 
during the September of this yeary All papers mast be 
compiled in one of the official languages of the congress— 
viz., Italian, French, English, German, and Spanish. Docu¬ 
ments will be sent before the meeting to those who shall have 
signified their intention to be present and will contain the 
information relating to the work of the commission nominated 
at the preceding congress to consider tfrie themes of discussion : 
First, to fix, with regard to an indemnity, the value of a 
lost or damaged eye ; and, secondly, unification of the 
measure of the visualunification of the notation 
of the meridiaow-eMStigmatrsm. The subscription for the 
congress is 25 francs for members and 10 francs for every 
member of their family. Notification of presence, subscrip¬ 
tions, and communications relating to the congress should be 
addressed directly to Professor Arnaldo Angelucci, R. Clinica 
Oculistica in S. Andrea delle Dame, Naples, or to one of 
the corresponding members of the respective countries. The 
member’s tioket which those taking part at the congress will 


r 


l 

3E 

erd 

tl 

**] 

:b 

u ) 

ri; 

■ft 


•• A 


* 

Hi 

»:] 



i j 


•4i 

'•*1 

•*? 


5 • 


J 




The Lancet,] 


MEDICAL NEWS. 


[Feb. 8,1908. 473 


receive is strictly personal and available for no one else. 
It will also give free entrance to the museums and to 
public bnildings as well and entitle its holder to reductions 
from the railways and to other privileges which will be 
indicated later. 

Donations and Bequests.— Under the will of 

Colonel E I ward Sanderson Tozer, VD., of Sheffield, the 
Sheffield Royal Infirmary, the Sheffield Royal Hospital, and 
the Jessop Hospital for Women will each benefit by a legacy 
of £500 —By the will of Major Christopher Deake Brick- 
macn of Bath £200 have been left to the Eastern Dispensary, 
Bath, and £500 to the Royal United Hospital, Bath, for the 
maintenance of a cot to lie called after the testator. 

The After-Care Association for poor persons 

discharged as recovered from asvlums for the insane held its 
annual meeting on Jan. 29th, at 48. Wimpole-street, London. 
Mr. Anthony Hope Hawkins was in the chair. The report of 
the council read by the secretary, Mr. H. T. R-»xby, stated that 
the proportion of cases successfully treated bad been very en¬ 
couraging. The results showed that the prevention of relapse 
into insanity was possible when an efficient re-start in life 
was given. Many persons discharged from asylums for the 
insane were quite capable of work if suitable occupation were 
found for them, bnt were unable to stand the anxiety and 
strain of procuring it for themselves. The council wished to 
call particular attention to this point as it was often over¬ 
looked when patients were discharged and their slender 
means were spent before they applied for help from the 
association at the Church House, Dean’s yard, Westminster. 
Amongst those present were Dr. G. H. Savage who spoke on 
the difficulties of convalescence from mental disorders, Dr. 
G. F. Blandford, Dr. G. Amsden, and Dr. H. Bond. 

The West African Medical Staff.— The 

winter dinner of the West African Medical Staff took place 
on Jan. 29th, at the New Gaiety Restaurant, Strand, London. 
There was a large attendance of members, including Dr. 
W. T. Prout, C.M.G., of the Liverpool School of Tropical 
Medicine, late principal medical officer, Sierra Leone, who 
presided ; Mr. G. J. Rutherford, senior medical officer. Gold 
Coast; Dr. C. R. Chichester, senior medical officer. Northern 
Nigeria; Dr. M. Cameron. Blair, senior medical officer. 
Southern Nigeria, and others. Among the guests were 
Sir Patrick Manson, K.C.M.G., Mr. J. Robinson of the 
Colonial Office, and Dr. C. W. Daniels of the London 
School of Tropical Medicine. Letters regretting inability 
to be present were received from Mr. R. Antrobus, C.B., 
Assistant Under Secretary of State for the Colonies, Sir 
Alfred Jones, K.C.M.G., Sir Robert Boyce, and others. 
Dr. Prout, in proposing “ Success and Prosperity to the 
West African Medical Staff,” said that he was sure that 
in the midst of these luxurious surroundings those present 
would remember their brother officers who were bearing 
the white man's burden in the unhealthy wilds of West 
Africa. He then briefly reviewed the changes which had 
come about since he first went out to West Africa and drew 
attention to the vast developments which had taken place in 
tropical science of late years, many of which were 
due to the ability, the dogged determination, and the far¬ 
sightedness of that veteran of tropical medicine whom they 
were proud to have as an honoured guest that evening, Sir 
Patrick Manson. But up to the present there had been one 
thing lacking—the feeling of comradeship and enprit de corpt 
which was so essential to the welfare of any body of men, 
scientific or otherwise, who are bound together by a common 
training, common knowledge, and common interests. This 
was possibly due mainly to the geographical conditions of 
West Africa and he believed that these dinners would do 
much to foster that feeling of nnion and cohesion which was 
so necessary. It was his conviction that whatever was 
conducive to the efficiency of the medical staff would 
undoubtedly be for the benefit of the general community 
who lived nnder the unhealthy conditions of West Africa, and 
he was sure that he was speaking for all of them when 
he said that they would welcome any improvement of this 
nature, not for merely selfish and personal considerations, 
but because of the great gain to health and sanitation 
which would result. The health of the guests, coupled 
with the name of Sir Patrick Manson, was briefly pro¬ 
posed by Mr. Rutherford. Sir Patrick Manson, in reply, 
expressed the great pleasure he had at being present and 
considered that such meetings would be of great benefit to 
the West African Medical Staff and would be conducive to 


a feeling of union which would strengthen their hands for 
good. He was aware that there was a feeling that they had 
not always received that support in sanitary matters to 
which they were entitled ; this was not due to any want of 
sympathy on the part of the Colonial Office which was fully 
alive to the value of their services and was anxious 
to assist in forwarding sanitary reforms, but was 
perhaps to be attributed to local conditions. He 
realised that it was desirable that some form of 
organisation should be devised which would enable them 
to bring forward their views in a more direct manner 
but it was difficult to see how this could be done at once and 
it was necessary to proceed slowly and cautiously. He hoped 
that ere long it would be found possible to find some meanB of 
surmounting these difficulties. Efficiency in the West African 
Medical Staff was especially desirable at the present time. 
They were at the beginning of new developments, of a new 
pathological era for West Africa, which the political changes of 
recent years, increasing inter communication, and, above all, 
the new railways, were sure to bring about. Diseases 
formerly limited in their area would become diffused and 
widespread and diseases hitherto unknown there—for ex¬ 
ample, plague and cholera—would be introduced.—Mr. G. T. 
Whyte, medical officer in Northern Nigeria, has resigned his 
appointment with effect from Oct 4th, 1907. Mr. P. 
Phillips, medical officer in Southern Nigeria, has been 
invalided from the service with effect from Nov. 7th, 1907. 
Dr. W. Fletcher, D.S.O., medical officer in Southern Nigeria, 
has retired on pension from Nov. 15th, 1907. Mr. J. D. 
Small, senior medical officer in Southern Nigeria, has retired 
on pension from Dec. 12th, 1907. Dr. T. 0. Caldwell, 
medical officer in Southern Nigeria, has been invalided from 
the service with effect from Dec. 24th, 1907. Dr. D. H. R. 
Waldron, senior medical officer of the Gold Coast, will 
retire on pension from Feb. 18th, 1908. Dr. C. R. 
Chichester, senior medical officer in Northern Nigeria, 
will retire on pension from March 28th, 1908. Dr. 
J. A. Pickels, medical officer in Southern Nigeria, has 
been promoted to senior medical officer, vice Mr. J. D. 
Small. The following gentlemen have been appointed to 
the staff:—Sierra Leone : Mr. J. C. Murphy, dated Nov. 16th, 
1907. Northern Nigeria : Mr. F. E. Bissell, dated Nov. 16th, 
1907. Southern Nigeria: Dr. G. Beatty, dated Dec. 28th, 
1907; and Mr. W. R. Larbalestier, Mr. W. S. Snell, Dr. 
T. L. Craig, and Dr. J. Boyd, dated Jan. 11th, 1908. 

Dr. A. Newsholme and Brighton.— At a special 

meeting of the Brighton town council on Jan. 30th it was 
unanimously decided that the following resolution should be 
engrossed on vellum, sealed with the common seal of the 
borough, and presented to Dr. Newsholme :— 

That the council with great regret accept the resignation of Dr. 
Newsholme. medical officer of health for the borough, and tender him 
their very hearty congratulations upon his appointment as head of the 
medical department of the Local Government Board. They desire to 
assure Dr. Newsholme of their high appreciation of the unstinted 
service rendered by him to the inhabitants of the borough during the 
period of 20 years throughout which he has held his important office, 
by which a continuous and progressive decline in the death-rate has 
been brought about, the housing conditions of the poor have been 
greatly improved, and the standard of public health administration 
has been raised to a very high degree of efficiency. They further 
wish to congratulate Dr. Newsholme upon his early recognition of the 
importance from the public health standpoint of the treatment of con¬ 
sumption and upon the national service which he has rendered in the 
deoartment of medical science. 

At the same meeting Dr. Newsholme was allowed to 
terminate his engagement on Feb. 3rd, thue abrogating the 
usual quarter’s notice, and Dr. Henry Collier Lecky, 
resident medical officer of health at the sanatorium, was 
appointed acting medical officer of health pending the 
appointment of a successor to Dr. Newsholme. 

Second Annual Dinner for Past and Present 
Students of the Royal London Ophthalmic Hos¬ 
pital —The second annual dinner for past and present 
students of the Royal London Ophthalmic Ho8pital was held 
at the TrocadCro Restaurant on Jan. 29cb, under the 
presidency of Sir John Tweedy, consulting surgeon to the 
hospital and late President of the Royal College of Surgeons 
of England. About 60 past and present students and guests 
were present and the success which attended the initiation 
of this celebration last year, under the presidency of Mr. 
Jonathan Hutchinson, was repeated. Sir John Tweedy pro¬ 
posed the toast of “The Moorfields Hospital and Medical 
School ” in felicitous terms, response being made by Mr. 
Stnrgis, chairman of the hospital committee, and Mr. W. T. 
Holmes Spicer, dean of the school. The latter drew attention 




474 Thb Lancet,] PARLIAMENTARY INTELLIGENCE.—APPOINTMENTS.—VACANCIES. 


[Feb. 8,1908. 


si 


to the increase in the number of courses of lectures and the 
flourishing conditions of the teaching department, students 
being attracted from all parts of the world. The health 
of the chairman was proposed by Mr. R. Marcos Gann, 
senior surgeon to the hospital. 


Ijarlianuntarj Jnttlligem. 


NOTB3 OH CURRENT TOPIC8. 

The Opening of Parliament. 

Parliament was opened with the usual State ceremonial by His 
Majesty the King on Wednesday, Jan. 29th. Amongst the measures 
which were promised in the Bpeech from the Throne were Bills to 
amend the Acta relating to the housing of the working classes and to 
regulate the laying out of land needed for the development of growing 
nrban centres; to Improve and extend university education in Ireland, 
and to consolidate and to amend the law relating to the protection of 
children and to the treatment of juvenile offenders. 

The Pharmacy ( Ireland) Acts. 

An order approving of a regulation made under the Pharmacy 
(Ireland) Acta by the Pharmaceutical Society of Ireland has been 
ordered to lie upon the table of both Houses of Parliament. 

New Bills. 

Since the Session began the following Bills have been introduced 
into the House of Commons: The Sweated Industries Bill, by Mr. 
Toulmin; the Housing of the Working Classes (Ireland) Bill, by Mr. 
Hagan; the Education (Provision of Meals) (Scotland) Bill, by 
Mr. T. F. Richards; the Coroners’ Inquests (Railways Fatalities) 
Bill by Sir Francis Channi.no ; the Coroners’ Inquests Bill, by Mr. 
Higkam; and the Infant Life Protection Bill by Mr. Stavelev-Hill. 
Several of these measures have been before the House on previous 
occasions. Mr. Higham’s measure is designed to dispense with the 
compulsory viewing of bodies on the holding of coroners’ inquests. 

Legislation on Milk-Supply. 

It is the intention of the Bari of Northbrook to put a question to 
the Government in the House of Lords next week with respect to 
legislation with regard to milk-supply. Mr. Burns, however, has 
intimated in the House of Commons that it is the intention of the 
Government to promote a Bill on the subject during the session. 

Alcohol and Tuberculosis in Ireland. 

On the motion of Mr. Sloan, the House of Commons has ordered a 
return giving statistics showing the number of deaths in Ireland due 
to alcohol and tuberculosis for the 12 months ending on the 3Lst day of 
December, 1907. _ 

HOUSE OF LORDS. 

Wednesday, Jan. 29th. 

The International Conference on Sleeping Sickness. 

Answering a question put by the Earl of Mayo in the course of the 
debate on the Address, Lord Fitzmaurice. the Under Secretary for 
Foreign Affairs, said that the International Conference upon Sleeping 
Sickness and Tropical Disease which met at London, arrived at certain 
conclusions, but as the delegates who came from various foreign 
States had no power to sign a treaty the Conference adjourned. It 
was hoped that the Conference would reassemble in March and that 
then a convention would be signed. 


HOUSE OF COMMONS. 

Friday, Jan. 31st. 

Medical Appointments in India. 

Dr. V. H. Rutherford in the course of a speech advocating changes 
in the method of governing India, incidentally observed that the natives 
of that country could not get the high appointments in the medical pro¬ 
fession there. All the best appointments in the hospitals and medical 
colleges were kept In the hands of Europeans. 

Monday, Feil 3rd. 

Children in Public-houses. 

' Mr. Wedgwood asked the Secretary of State for the Home Depart¬ 
ment whet her his attention had been drawn to the statement of the 
Chief Coustable of Liverpool that the action of the Liverpool Licensing 
Bench in discountenancing the presence of children in public-houses 
was responsible for the fact that the children observed to be taken into 
ublic-houses in Liverpool amounted to only 1'25 per public house per 
our against 912 in London ; and whether the same method of checking 
this evil could be recommended by the Home Office to other licensing 
benches.—Mr. II. Samuel (who replied) said : The Secretary of State 
does not find that the Chid Constable of Liverp‘X>l committed himself 
to so definite a statement as my honourable friend attributes to him, but 
there can be no doubt that the views of a licensing authority on theques- 
tion of the admission of women and children into public-houses must 
have a strong influence on the licence holders within their district. The 
Secretary of State has no power to advise licensing authorities in this 
roarter, but he is sure that they must all be fully alive to a question 
which is so much in the public mind at the moment and which will be 
dealt with in coming legislation. 

Tuesday, Feb. 4th. 

The Sleeping Sickness. 

Mr. Rees asked the Under Secretary of State for the Colonics what 
measures had been taken to prevent the spread of sleeping sickness 
from Uganda towards Nyassaland.—Mr. Churchill answered: The 


question of the spread of sleeping sickness towards Nyassaland is being 
investigated by a party of scientific exjierts sent out by the Liverpool 
School of Tropical Medicine with the assistance of a grant from Govern¬ 
ment funds. When their report has been received the Secretary of 
State will consider in consultation with the Governor of the Protectorate 
what measures, if any, are required. The w hole matter is being closely 
watched. 

Regulations on Imported Meat. 

Mr. Coubthope asked the President of the Local Government Board 
what steps, if any, were being taken to remove the danger to the public 
health arising from imported meat and to carryout the recommenda¬ 
tions contained in Dr. G. S. Buchanan’s recent report on the subject.— 
Mr. Burns replied: I have caused regulations to be prepared under 
the Public Health (Regulations as to Food) Act of last session dealing 
with the subject* referred to in Dr. Buchanan's report, and I am now 
in communication with the other departments concerned with regard 
to them. 

Milk-supply and Legislation. 

Mr. Victor Cavendish asked the Prime Minister whether, in view 
of the widespread anxiety existing in many parts of the country, he 
would cause a full inquiry to be made into the question of the supply 
of milk in relation to public health before any legislation was intro¬ 
duced.—Mr. Burns (who replied to the question) said: The Govern¬ 
ment Is desirous that there should be legislation with regard to milk- 
supply during the present session, and I could not promise further 
inquiry before introducing a Bill on the subject. 

Irish Poor-law Medical Officers. 

Mr. Fetherstonhaugh asked the Chief Secretary to the Lord 
Lieutenant of Ireland whether It was intended to introduce any legis¬ 
lation during the present session to give effect to the report of the Com¬ 
mission on the Irish Poor-law Administration, and in particular to deal 
with the grievances of the Irish Poor-law medical officers.—Mr. Bibrell 
answered : It is the intention of the Government to introduce legisla¬ 
tion to amend the Irish Poor-laws, but I cannot hold out any hope that 
an opportunity will arise during the current session. 

Wednesday, Feb. 5th. 

A Tuberculosis Prevention Bill for Ireland. 

Mr. Augustine Roche asked the Chief Secretary to the Lord 
Lieutenant of Ireland whether, In view of the unanimous expression 
of public opinion all over Ireland during the past six months on the 
urgent necessity of taking steps to check the ravages of consumption 
in Ireland, any action would be taken this session to amend the law in 
conformity with the views expressed at the meetings. — Mr. Birbell 
replied : It is intended to introduce a Bill on the subject referred to in 
the question. The Bill, which has been drafted, is entitled “The 
Tuberculosis Prevention (Ireland) Bill, 1908." I hope it will pass into 
law during the present Bession. 



Successful applicants for Vacancies, Secretaries of Public Institutions, 
and others possessing information suitable for this column, are 
invited to forward to The Lancet Office, directed to the Sub- 
Editor, not later than 9 o’clock on the Thursday morning of each 
week, such information for gratuitous publication. 


Bailey, T. Ridley, M.D. Edin., has been appointed School Medical 
Officer under the Bilston Education Committee. 

Bird, W. E. F., M R.C.S., L.R.C.P. Lond., has been appointed Medical 
Officer to the York Post Office. 

Charles. Herbert, M.K.C.S., L.R.C.P. Lond., has been appointed 
Anaesthetist to the Paddington Green Children's Hospital. 

Collier, James, M D., F.R C.P. Loud., has been appointed Physician 
in Charge of Wards to St. George’s Hospital. 

Bdington, G. H.. M.D. Edin., F.F.P.S. Cilasg , has been appointed 
Assistant to the Professor of Clinical Surgery, University of 
Glasgow. 

Jardixk. Robert, M.D. Edin., M.R.C.S. Eng., F.F.P.S. Glasg., 
F.R S.K., has been appointed External Examiner in Obstetrics to 
the Victoria University, Manchester. 

Maynard, Edwin, F.R.C S. Eng., L.R.C.P., D.P.IL Lond., has been 
appointed Senior House Surgeon at the Bristol General Hospital. 

Mudge, Zachary Belling, L.R.C.P. Lond., M.R.C.S., has been ap¬ 
pointed Medical Officer of Health for the Hayle (Cornwall) Urban 
District Council. 

Nayl<*r, Rupert George St. John, F.R.C S. Eiin., has been ap¬ 
pointed Public Vaccinator for the South-Eastern District of 
Victoria. Australia. 

Slkfman, James Henry, M.B., Cb.B. Melb., has been appointed 
Public Vaccinator for the South-Western District of Victoria, 
Australia. 

Stevenson, Thomas Henry Craig, M.D., B.S. Lond., L.R C.P. Lond., 
M.R.C.S., D.P.H. Cantab., baa been appointed Chief Medical 
Inspector of Schools by the Somerset County Council. 

Thomas, Frank Leslie, M B., B.S. Lond., M.R.C.S., L.R.C.P. Lond., 
has been appointed pro tem. District Medical Officer by the Barn¬ 
staple Board of Guardians. 


Vacancies. 


For f urther information regarding each vacancy reference should be 
made to the advertisement (see Index). 


Abfrtillf.ry Urban District Council. Education Committee.— 
Doctor (female). Salary at rate of £150. rising to £200 per annum. 
Acton Urban District Education Committee.— Medical Inspector 
of Schools (female). Salary £200 per annum. 

Bangor, Carnarvonshire and Anglesey Infirmary.— House Sur¬ 
geon. Salary £80 per annum, with board, lodging, and washing. 
Bath. Royal Mineral Water Hospital.— Resident Medical Officer. 
Salary £100 per annum, with lodging, board, and laundry. 


r * 

*ri 

p»! 

-kn 


.c 


,£3 



Ills 

'El 


-Hi 





V 


flL $ L'fi'i w \\ 







The Lancet,] 


VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS. 


[Feb. 8, 1908. 475 


Bath. Royal Unitkd Hospital.— House Physician, also House 
Surgeon. Salaries £80 per aunum, with board, lodging, and 
washing. 

Birkenhead Borough Hospital.— Senior Resident House Surgeon. 
Salary £100 and fees. Also Junior Resident House Surgeon. Salary 
£80 and fees. 

Brighton, County Borough of.— Medical Officer of Health. Salary 
£630 per annum. 

Brighton, Sussex County Hospital.—H ouse Physician, unmarried. 
Salary £70 per annum, with board, residence, and laundry. 

Brighton Throat and Ear Hospital, Church-street, Queen's-road. 
—Non-resident House Surgeon for six months, renewable. Salary 
at rate of £75per annum. 

Bristol Royal hospital for Sick Children and Women.—H ouse 
Surgeon. Salary £80 per annum, with board, roomB, and 
attendance. . 

Bristol Royal Infirmary.— Obstetric Officer. Salary £75 per annum. 
Also Junior House Surgeon for six months. Salary at rate of £50 
per annum. Also Casualty Officer for six months. Salary at rate 
of £50 per annum. All with board, lodging, and washing. 

Carmarthen, Joint Counties Lunatic Asylum.— Second Assistant 
Medical Officer. Salary £160, increasing to £180 per Annum, with 
board, lodging, washing, and attendance. 

Colchester, Essex and Colchester General Hospital.— House 
Physician. Salary £80 per annum, with board, residence, and 
washing. 

Dudley*, Guest Hospital. —Assistant House Surgeon. Salary £60 
per annum, with residence, board, and washing, 

Grocers’ Company's Scholarships —Two Scholarships for original 
research in Sanitary Science, vplue £300 a year each, with allow¬ 
ance to meet the cost of apparatus and other expenses. 

Ingham Infirmary and South Shields and Westok Dispf.nsary.— 
Junior House Surgeon. Salary £90 per annum, with residence, 
board, and washing. 

King Edward VII. Sanatorium. Midhurst, Sussex.—Junior 
Assistant Medical Officer, unmarried. Salary £100 per annum, 
with board, lodging, and attendance. 

King's College Hospital.— Assistant Physician. 

Leicester Infirmary.— Assistant House' Physician, for six months. 
Salary at rate of £50 per annum, with board, lodging, and 
washing. 

Lindsey County Council, Lincolnshire.—Medical Officer of Health 
and Medical Inspector of School Children. Salary £400 per annum, 
rising to £500, with expenses. 

London Temperance Hospital.— Medical Registrar and Surgical 
Registrar. Salaries 40 guineas per annum. Also Pathologist and 
Bacteriologist. Salary 50 guineas per annum. Also Anaesthetist. 
Sadary 20 guineas per annum. Also Radiographer. Salary 
10 guineas per annum. 

Maidstone, Kent County Asylum.— Fourth Assistant Medical 
Officer, unmarried. Salary £175 per annum, with quarters, attend¬ 
ance, Ac. 

MANcUf-siKR, Ancoats Hospital.— Resident House Surgeon. Salary 
£100, with board, residence, Ac. 

Metropolitan Hospital, Kingsland-road, N.E.—Resident Anes¬ 
thetist. Salary at rate of £40 per annum. 

Mullingar District Lunatic Asylum.— Resident Junior Assistant 
Medical Officer. Salary £100 a year, all found. 

National Hospital for the Paralysed and Epileptic, Albany 
Memorial, Queen-square, Bloomsbury.—Assistant Pathologist. 
Salary 50 guineas per annum. 

Norfolk County* Council.— Medical Officer of Health. Salary £500 
per annum, rising to £650. 

North-Eastern Hospital for Children, Hackney-road, Bethnal 
Green, E.—Resident Medical Officer. Salary £100 per annum, with 
board, residence, and washing. 

Nottingham City* Asylum.— Second Assistant Medical Officer. Salary 
£150 per annum, with board, apartments, Ac. 

Nottinghamshire Education Committee.— School Medical Officer. 
Salary £300 per annum, and travelling expenses. 

Roy al Navy, Medical Department.—E xamination for not less than 
15 Commissions. 

St. Peter's Hospital for Stone, &c., Henrietta-street, Covent 
Garden, W.C.—Junior House Surgeon for six months. Salary at 
rate of £50 a year, with board, lodging, and washing. 

Sheffield Royal Hospital.— Honorary Assistant Surgeon. 

Warrington Infirmary and Dispensary.— House Surgeon, un¬ 
married. Salary £80 per annum, with residence and board. 


Ktarriap, anfe 


BIRTHS. 

Anderson.—A t Newholme, Pitlochry, on the 2nd inst., the wife of 
John Anderson. M.B., C M. Edin., of a daughter. 

Curtis. -On Jan. 31st, at Alton House, Redhill, the wife of Frederick 
Curtis, F.R.C.S. Eng., Ac., of a son. 


MARRIAGE. 

Tatlor—Hop arts.—O n Jan. 3uth. at St. John the Baptist Church, 
Fladbury, Stuart Hopcraft Stanley Taylor, B A. Cantab., M.B., 
Ch.B K«iin., of Lacock. Wilts, to Hilda Mary Fanny, third surviving 
daughter of the late Arthur Frederick Robarts and Fanny Robarts, 
of Craycombe Pershore, Worr*ps-<»r«hire. 


DEATHS. 

Allisoham.— On Feb. 4th, at Kingsdene, Worthing, William Ailing- 
ham, F.R.C S., aged 78. 

Harris. — On Feb. 3rd. at St. John's Wood-road, N.W., Benjamin 
» Barrie. M.R.C.S. Eng., L.S.A. Lond., aged 70 years. 

Pettigrkw. - On Jan. 30th, at The Swallowgate, St. Andrews, James 
Bell Pettigrew, M.D , LL.D., F.R 8., F.R.C.P., Chandoa Professor 
of Medicine and Anatomy in the University of St. Andrews. 


N.B.—A fee Of Bt. is charged for the insertion of Notices of Births, 
Marriages, and Deaths. 


Stoles, J%rt Cffmmtnts, anb Jnsfotrs 
to Cornspoitknts. 

MEDICAL CERTIFICATES FOR GOVERNMENT SCHOOL 
CHILDREN. 

A correspondent asks us the oft-repeated question as to how a 
medical man giving a medical certificate to an educational authority 
for the absence of a child from school should be paid if the parents 
are too poor to pay. We have not seen the report of the case in 
question but we believe the position of affairs to be this. The 
London County Council has been charged by the Government with 
the duty of providing education for children and of seeing that 
they attend school. If the children do not attend school the 
London County Council has the right to summon the parents of such 
children and of demanding that they Bhould give a reasonable 
excuse for their children not having been to school. A medical 
certificate properly signed by a registered medical man is, we 
believe, accepted as a reasonable excuse but the London County 
Council has no legal power to demand a medical certificate. It 
can only be demanded by the magistrate before whom the parents 
have to appear. The London County Council, we believe, has no 
power to pay medical men fees for certifying that the absence of a 
child is due to illness, and in fact the forms of certificate by the old 
Loudon School Board had a notice distinctly printed upon them that 
the school board was not responsible for the fee. As the State 
requires the County Council to see that the children attend school it 
would seem to be only fair that the State should also reimburse 
medical men for certifying that children are unable to attend, but at 
present this is not the case. 

HOSPITAL REFORM. 

To the Editor of The Lancet. 

Sir,—T he few suggestions I venture to make might be the means of 
drawing out the opinions of other members of the profession as to 
much needed hospital reform. 1. All hospitals to be under State 
supervision excepting cottage hospitals in small towns supported by 
local subscriptions. 2. The staff to be advertised for and selected for 
their worth, ability, and experience alone, not chosen by interest, 
canvassing, or by purchase, the usual proceedings. 3. No member 
of staff to hold more than one hospital appointment—a gross 
injustice to others of equal ability who are thus debarred 
from obtaining office. 4. The staff to be paid by the State, the 
fees from students going to help Buch payment. 5. No out¬ 
patients to be treated without letter from one of their local medical 
men stating they are unable to pay a doctor. 6. Bach member of staff 
to hold office for ten years only and (in any case) to be compulsorily 
retired at the age of 60 yearn. These suggestions may lead to 
far better being proposed, and certainly it appears high time 
something should be done to alter the plan of assessment 
of each hospital's claim on the King’s Fund so as to improve 
on the usual one—viz., bulk of patients attended to—naturally 
making the staff of each hospital anxious for crowded attend¬ 
ance (numbers of whom can afford to pay cost of coming from 
a distance but prefer to save the money—by paying no doctor's fee— 
for admission to football-match, music-hall, or perhaps a drunken 
debauch). I am. Sir, yours faithfully, 

Feb. 4th, 1908. A Former Hospital Physician. 

A WARNING. 

To the Editor of The Lancet. 

Sir,—I am informed that a young man, pretending to be a son of 
mine, is going about asking for pecuniary assistance. This person is 
an impostor and I shall be glad to hear that he is in custody. 

I am, Sir, yours faithfully. 

Upper Brook-street, W., Feb. 4th, 1908. F. H. Champneys. 

THE MUFFIN-MAN. 

So far as the streets of London are concerned which are inhabited by 
the more well-to-do class of citizen, the itinerant muffin-man’s bell 
is less often heard than formerly, and probably we may regard the 
Bale of muffins and crumpets from a tray carried on the vendor's head 
as a “disappearing industry.” Its survival is not likely to be fostered 
by a receut prosecution at the Marylebone police court of a muffin- 
man for ringing his bell, although he was not fined by Mr. Plow den 
but was allowed to go upon payment of the costs, a sum of 2s. only. 
The magist rate informed the defendant that he was prosecuted under 
an Act of Parliament passed 60 or 70 years ago which provides a 
penalty for the use of any noisy instrument for the purpose o 
selling anything. It may also be observed that the man in question 
appears to have been made the subject of legal proceedings by the 
police not on account of their solicitude for the nerves of the 
ordinary citizen but because ho was rousing some police officers 
who were asleep after night duty. Protest has frequently 

been made in The Lancet against the annoyance and even 
injury to health caused by street noiscB in a vast city 

like London where the majority of the Inhabitants are workers, 

and it is a matter for observation that the police should have 




476 The Lancet,] NOTES, SHORT COMMENTS, AND ANSWERS TO CORRESPONDENTS. [Feb. 8,1908. 


allowed the muffin-bell to become a familiar, but unnecessary, 
form of nuisance, only to take steps against it upon its disturbing the 
slumbers of members of "the force.” Nevertheless, if we are to 
witness the total disappearance of the muffin-man as a result of his 
being unable to advertise Ids wares in the accepted manner of doing 
so we may temper our sympathy with the individual by the reflection 
that he distributed articles of diet of doubtful origin in a manner 
which few could regard as desirable. His tray often covered with a 
piece of baize of a hue suggestive of long service in the murky 
atmosphere of the London streets has not been an ideal means of 
conveyance from a sanitary point of view, nor has his personal 
cleanliness been always above criticism. 

A medical correspondent writes under the signature “Phenad”: 
" Can anyone give me information as to any localised poisonous 
possibilities from a leech-bite, as distinct from an infection of the 
wound left by the bite ?’* 


P. A. F.—We have read most of the stories before. These people 
thrive on contradiction, while nothing minimises the mischief of 
their action so much as never to mention them. 

Communications not noticed in our present issue will receive attention 
in our next. 


METEOROLOGICAL READINGS. 

(Taken daily at 8AO a.m, by Steward's Instruments.) 

The Lancet Office, Feb. 6th, 1908. 


Date. 

| Barometer 
| reduced to 
8oa Level 
and 52° F. 

Direc¬ 
tion ; 
of 

Wind. 

1 Rain¬ 
fall. 

Solar 

Radio 

In 

Vacao. 

1 Maxi- 

j mum 
Temp. 

| Shade. 

Min. 

Temp. 

Wet 

Bulb. 

SSL 

Remarks. 

Jan. 31 

29*94 

S.W. 

0-02 

69 

48 

35 

39 

41 

Overcast 

Feb. 1 

29-87 

N.W. 


72 

43 

37 

35 

38 

Fine 

2 

30-22 

W. 


61 

42 

33 

35 

36 

Fine 

M 3 

30-17 

w. 


50 

45 

33 

38 

.38 

Overcast 

.. 4 

30*35 

N. 

0 05 

66 

43 

36 

35 

37 

Fine 

5 

30*62 

N.E. 

... 

53 

45 

3b 

35 

37 1 

Hazy 

.. 6 

30-65 

W. 

... 

52 

48 

36 

43 

43 | 

Foggy 


Utebkal $hinr for % ensuing (&M. 


OPERATIONS. 

METROPOLITAN HOSPITALS. 

MONDAY (10th>.— London (2 p.m.), St. Bartholomew’s (1.30 p.m.), St. 
Thomas’B (3.30 p.m.), St. George’s (2 p.m.), St. Mary's (2.30 p.m.), 
Middlesex (1.30 p.m.), Westminster (2 p.m.), Chelsea (2 p.m.), 
Samaritan (Gynecological, by Physicians, 2 p.m ), Soho-square 
(2 p.m.), City Orthopedic (4 p.m.), Gt. Northern Central (2.30 p.m.). 
West London (2 30 p.m.), London Throat (9.30 a.m.). Royal Free 
(2 p.m.), Guv’s (1.30 p.m.), Children, Gt. Ormond-street ‘(3 p.m.), 
St. Mnrk’s (2.30 P.M.). 

TUESDAY (lltll). —London (2 p.m.), St. Bartholomew's (1.30 p.m.), St. 
Thomas’s (3 30 p.m.), Guy's (1.30 P.M.), Middlesex (1.30 p.m.), West¬ 
minster (2 p.m.), West London (2.30 p.m.), University College 
(2 p.m.), St. George's (1 p.m.), St. Marv's (1 p.m.), St. Mark's 
(2.30 p m.), Cancer (2 p.m.). Metropolitan (2 30 p.m.), Loudon Throat 
(9.30 a.m.), Samaritan (9.30 a.m. and 2.30 p.m.), Throat, Golden- 
Bquare (9.30 a.m.), Soho-square (2 p.m.). Chelsea (2 p.m.), Central 
London Throat and Ear (2 p.m.). Children. Gt. Ormond street 

_(2 p m., Ophthalmic, 2.15 p m.), Tottenham (2.30 p.m.). 

WEDNESDAY (12th).— St. Bartholomew's (1.30 p.m.), University College 
(2 p.m. ), Royal Free (2 p.m. ), Middlesex (1.30 p.m.), Charing Cross 
(5 p.m.), St. Thomas’s (2 p.m.), London (2 p.m.). King's College 

. (2 p.m.), St. George's (Ophthalmic, 1 p.m.), St. Mary’s (2 p.m.). 

National Orthon?roic (10 a.m.), St. Peter’s (2 p.m.), Samaritan 
(9.30 a.m. and 2 30 p.m.), Gt. Northern Central (2.30 p.m.), West¬ 
minster (2 p.m.). Metropolitan (2.30 p.m.), London Throat (9.30 a.m.), 
Cancer (2 p.m.), Throat, Golden square (9 30 a.m.). Guv’s (1.30 p.m.). 
Royal Ear (2 p.m.). Royal Orthopedic (3 p.m.), Children, Gt. 
Ormond-street (9.30 a.m.. Dental, 2 p.m.), Tottenham (Ophthalmic, 
2.30 p.m.). 

THURSDAY (13th).— St. Bartholomew’s (1.30 p.m.), St. Thomas’s 
(3.30 p.m.), University College (2 p.m.), Charing Cross (3 p.m.), St. 
George's (1 p.m.), London (2 p.m.), King’s College (2 p.m.), Middlesex 
(1.30p.m.), St. Mary's (2.30 p.m.). Soho-square (2 p.m.), North-West 
London (2 p.m.), Gt. Northern Central (Gynecological, 2.30 p.m.), 
Metropolitan (2 30 p.m.), London Throat (9.30 a.m.), Samaritan 
(9.30 a.m. and 2.30 p.m.). Throat, Golden square (9.30 a.m.), Guy’s 
(1.30 p.m.), Royal Orthopedic (9 a.m.), Royal Ear (2 p.m.), Children, 
Gt. Ormond-street (2 30 p.m ), Tottenham (Gynecological. 2.30 p.m.) 

FRIDAY (14th).— London (2 p.m.), St. Bartholomew’s (1.30 p.m.), St. 
Thomas’s (3.30 p.m.), Guy's (1.30 p.m.), Middlesex (1.30 p.m.), Charing 
Cross (3 p.m.), St. George's(l p.m.). King’s College (2 p.m.), St. Mary’s 
(2 p.m.), Ophthalmic (10 a.m.). Cancer (2 p.m.), Chelsea (2 p.m.), Gt. 
Northern Central (2.30 p.m.), West London (2.30 P.M.), London 
Throat (9 30 a.m.), Samaritan (9 30 a.m. and 2.30 p.m.), Throat, 
Golden-square (9.30 a.m.), City Orthopedic (2.30 P.M.). Soho-square 
(2 p.m.). Central London Throat and Bar (2 p.m.), Children, Gt. 
Ormond-street (9 a.m., Aural, 2 p.m.), Tottenham (2 30 p.m.), St. 
Peter's (2 p.m.). 

SATURDAY (15th).— Royal Free (9 a.m.), London 72 p.m.), Middlesex 
(1.30 p.m.), St. Thomas’s (2 p.m.), University College (9.15 a.m.), 
Charing Cross (2 p.m.), St. George’s (1 p.m.), St. Maiy’s (10 a.m.), 
Throat, Golden-square (9.30 a.m.), Guy’s (1.30 p.m.), Children, Gt 
Ormond-street (9.3^ A M.). 

At the Royal Bye Hospital (2 p.m.), the Royal London Ophthalmic 

(10 a.m.), the Royal Westminster Ophthalmic (1.30 p.m.), and the 

Central London Ophthalmic Hospitals operations are performed daily. 


SOCIETIES. 

ROYAL SOCIETY OF MEDICINE. 20, Hanover-square, W. 

Tuesday.— (Surgical Section). 5.30 p.m., Mr. A. H. Tubby: Coxa 
Vaiga 

Thuhsday.— (Obstetrical and Gynecological Section). 7.45 p.m., 
The President, Dr. Macnaughto'•-Jones, Dr. E. Holland, and 
Dr. A Routh: Specimens. Dr. R. Andrews and Dr. D. 
Maxwell; A Case of Difficult Labour, with Remarks on the 
Specimen of the Frozen Section of the Uterus. Dr. M Randall: 
An Ovarion Dermoid with Secondary Cysts connected with the 
Omentum, with Pathological Report and Remarks by Mr. 
T. W. P. Lawrence. 

Friday .—(Clinical Section). 8.30 p.m., Dr. L. Guthrie and Mr. 8. 
Mayou Mr. J. P. Houghton, Dr. H. French, Mr. R. J Godlee, 
Dr.'S. Taylor, Dr. A. Latham, and Dr. F. P. Weber: Exhibition 
of Cases. Dr F. G. Batten and Dr. J. G. Forbes: Note on a 
Case of Gaertner Infection in an Infant. The patients will be 
in attendance at 8 p.m. 

MEDICAL SOCIETY OF LONDON, 11, Chandos-street, Cavendish- 
square, W. 

Monday.— 8.30 p.m.. Clinical Bvening. Mr. G. Watson, Dr. E. 
Wynter. Dr. M. Dockrell, Dr. R. Hutchison, Dr. W. H.Willcox, 
Dr. de H. Hall, Dr. A. Morison, Dr. C. Wall, and others: Cases. 

OPHTHALMOLOGICAL SOCIETY OF THE UNITED KINGDOM, 
11. Chandos-street, Cavendish-square, W. 

Thursday.— 8 p.m.. Clinical Evening. Mr. L. Paton. Mr. J. S. 
Hobford, Dr. F. W. Edridge Green, Mr. J. H. Fisher, and 
others: Cases and Demonstrations. 9 p.m.. Discussion of the 
Cases. 

UNITED SERVICES MEDICAL SOCIETY, Royal Army Medical 
College, Millbank, S.W. 

Thursday.— 8.30 p.m., Dr. Pembrey: The Physiological Principles 
of Physical Training. 

MEDICO LEGAL SOCIETY, 22, Albemarle-street, W. 

Tuesday.— 815 p.m.. Narration of Cases and Exhibits of Medico- 
Legal Interest. Dr. L. Freyberger An Analysis of 74 Cases of 
Sudden Death while under the influence of an Anaesthetic. 

HARVEIAN SOCIETY OF LONDON, Stafford Rooms, Tichbome- 
street. Bdgw&re road, W. 

Thursday.— 8 30 p.m., Mr. M. Smith: The Diagnosis and Treat¬ 
ment of Abdominal Injuries. Dr. C. Jones: The Treatment of 
Bronchial Asthma by Inoculation with a Bacterial Vaocine. 


LECTURES, ADDRESSES, DEMONSTRATIONS, &c. 

ROYAL COLLEGE OF SURGEONS OF ENGLAND. 

Monday.—5 p.m., Mr. S. G. Shattock : Ovarian Teratomata. 
Wednesday.— 6 p.m.. Dr. J. W. H. Eyre: The Importance (Sur¬ 
gically) of the Pyogenetic Activities of Diplococcus Pneumoniae. 
Friday.— 5 p.m., Mr. L, S Dudgeon: Infection of the Urinary 
Tract due to Bacillus Coli. 

(Erasmus Wilson Lectures.) 

MEDICAL GRADUATES’ COLLEGE AND POLYCLINIC, 22. 
Chenies-street, W.C. 

Monday.—4 p.m.. Dr. A. Whitfield: Clinique (Skin). 5.15 p.m.. 
Lecture:—Dr. P. Stewart: Thalamic Hemiplegia. 

Tuesday.—4 p.m., Dr. A. Morison: Clinique (Medical). 5.15 P.M., 
Dr. M. Dobbie: Swedish Medical Gymnastics, their Application 
in the Treatment of Diseases of the Circulatory and Respiratory 
Systems. 

Wednesday.— 4 p.m., Mr. H. L. Barnard: Clinique (Surgical). 
5.15 p.m., Lecture:—Mr. R. H. J. Swan : Carcinoma of the 
Breast, Its Early Recognition and Treatment. 

Thursday. —4 p.m., Clinique (Surgical). 6.15 p.m.. Lecture :—Dr. 

J. E. Squire : Pneumothorax. 

Friday. —4 p.m.. Dr. StClair Thomson: Clinique (Throat). 
POST-GRADUATE COLLEGE, West London Hospital, Hammersmith, 
road, W. 

Monday.— 12 noon: Lecture:—Dr. Low: Pathological. 2 p.m., 
Medical and Surgical Clinics. X Rays. Mr. Dunn : Diseases 
of the Eye. 2.30 p.m., Operations. 5 p.m., Lecture:—Dr. 
Davis: Clinical. 

Tuesday.— 10 a.m., Dr. Moullin -. Gynaecological Operations. 
12 noon-. LectureDr. Pritchard: Practical Medicine. 2 p.m., 
Medical and Surgical Clinics. X Rays. Dr. Ball : Diseases of 
the Throat, Nose, and Ear. 2.30 p.m.. Operations. Dr. Abraham: 
Diseases of the Skin. 5 p.m., Lecture .—Dr. Moullin : Gynaeco¬ 
logical Cases. 

Wednesday. - 10 a.m., Dr. Ball: Diseases of the Throat, Nose, and 
Ear. Dr. Saunders: Diseases of Children. 2 p.m., Medical and 
Surgical Clinics. X Rays. Dr. Scott: Diseases of the Eye. 
2.30 p.m., Operations. 5 p.m.. Lecture:—Mr. Pardoe: Cystitis. 
Thursday.— 12 noon, Lecture:—Dr. Pritchard: Practical Medicine. 
2 p.m., Medical and Surgical Clinics. X Rays. Mr. Dunn: 
Diseases of the Eye. 2.30 p.m.. Operations. 6 p.m.. Lecture i— 
Mr. Baldwin -. Practical Surgery. 

Friday.— 10 a.m..’ Dr. M. Moullin: Gynaecological Operations. 
2 p.m.. Medical and Surgical Clinics. X Rays. Dr. Ball: 
Diseases of the Throat, Nose, and Ear. 2.30 p.m.. Operations. 
Dr. Abraham: Diseases of the Skin. 3 p.m.. Lecture:—Dr. 
R. Jones: Types of Insanity (at the London County Asylum, 
Clay bury, Woodford Bridge, Essex). 

Saturday.— 10 a.m., Dr. Ball: Diseases of the Throat. Nose, and 
Ear. Dr. Saunders: Diseases of Children. 2 p.m., Medical and 
Surgical Clinics X Rays. Dr. Scott: Diseases of the Eye. 
2.30 p.m.. Operations. 

NORTH-EAST LONDON POST GRADUATE COLLEGE, Prince of 
Wales’s General Hospital, Tottenham, N. 

Monday.— Cliniques:— 10 a.m., Surgical Out-patient (Mr. H. 
Evans). 2.30 p.m.. Medical Out patient (Dr. T. R. Whipham); 
Throat, Nose, and Ear (Mr. H. W. Carson); X Ray (Dr. A. H. 
Pirie). 4.30 p.m., Medical In-patient (Dr. A. J. Whiting). 











The Lancet,] 


DIARY.—EDITORIAL NOT ICES.—MANAGER’S NOTICES. 


[Feu. 8 , 1908. 477 


Tuesday.— Clinique10.30 a.m.. Medical Out-patient (Dr. A. G. 
Auld). 2.30 P.M., Surgical Operations (Mr. Carson). Cliniques:— 
Surgical Out-patient (Mr. Edmunds); Gynecological (Dr. A. E. 
Giles). 

Wednesday.— Cliniques:— 2.30 p.m., Medical Outpatient (Dr. 
Wbiph&m); Dermatological (Dr. G. N. Meachen); Ophthalmo- 
logical (Mr. H. P. Brooks). 

Thursday.— 2.30 p.m.. Gynecological Operations. (Dr. Giles). 
Cliniques:—Medical Out-patient (Dr. Whiting); Surgical Out- 

K tient (Mr. Carson); X Ray (Dr. Pirie). 3 p.m.. Medical 
-patient (Dr. G. P. Chappel). 4.30 p.m., Throat Operations 
(Mr. Carson). 

Friday. —10 a.m., Clinique:—Surgical Out-patient (Mr. H. Evans). 
2.30 p.m., Surgical Operations (Mr. Edmunds). Cliniques:— 
Medical Out-patient (Dr. Auld); Eye (Mr. Brooks). 3 p.m., 
Medical In-patient (Dr. M. Leslie). 4.30 p.m., Demonstration:— 
Mr. R. P. Brooks: Selected Rye Cases. 

LONDON SCHOOL OF CLINICAL MEDICINE, Dreadnought 
Hospital, Greenwich. 

Monday.— 2.15 p.m., Sir Dyce Duckworth : Medicine. 2.30 p.m.. 
Operations. 3.15 p.m., Mr. W. Turner : Surgery. 4 p.m.. Dr. 
StClair Thomson: Ear and Throat. Out-patient Demonstra¬ 
tions ;—10 a.m., Surgical and Medical. 12 noon, Ear and Throat. 
Tuesday.— 2.15 p.m., Dr. R. T. Hewlett: Medicine. 2.30 p.m.. 
Operations. 3.15 p.m., Mr. Carless: Surgery. 4 p.m., Mr. M. 
Morris: Diseases of the Skin. Out-patient Demonstrations:— 
10 a.m.. Surgical and Medical. 12 noon, Skin. 

Wednesday.— 2.15 p.m., Dr. F. Taylor: Medicine. 2.30 p.m., 
Operations. 3.30 p.m., Mr. Cargill: Ophthalmology. Out¬ 
patient Demonstrations:—10 a.m., Surgical and Medical, 
11 a.m.. Eye. 3.30 p.m., Special Lecture:—Mr. Cargill: The 
Diagnosis of Errors of Refraction. 

Thursday.— 2.15 p.m., Dr. G. Rankin : Medicine. 2.30 p.m., Opera¬ 
tions. 3.15 p.m., Sir W. Bennett: Surgery. 4 p.m., Mr. M. 
Davidson : Radiography. Out-patient Demonstrations :— 
10 a.m., Surgical and 'Medical 12 noon. Ear and Throat. 
2.15 p.m.. Special Lecture:—Dr. Rankin: Neurasthenia, its 
Etiology and Treatment. 

Friday.-2.15 p.m., Dr. R. Bradford: Medicine. 2.30 p.m., 
Operations. 3.15 p.m., Mr. McGavin: Surgery. Out-patient 
Demonstrations:—10 a.m.. Surgical and Medical. 12 noon, 
Skin. 

Saturday. —2.30 p.m.. Operations. Out-patient Demonstrations:— 
10 a.m., Surgical and Medical. 11 a.m., Eye. 

GREAT NORTHERN CENTRAL HOSPITAL, Holloway-road, N. 

Monday.—9 a.m., Operations (Mr. White). 2.30 p.m., In-patients— 
Medical (Dr. Beevor); Out-patients—Medical (Dr. Willcox), 
Surgical (Mr. Low), Eye (Mr. Morton and Mr. Coats). 

Tuesday. -2.30 p.m., In-patients Medical (Dr. Beale), Throat and 
Ear (Mr. Waggett); Out-patients—Surgical (Mr. Edmunds), 
Throat and Ear (Mr. French); Operations (Mr. Beale). 
Wednesday.— 2.30 p.m.. In-patients—Surgical (Mr. Stabb); Out¬ 
patients—Medical (Dr. Horder), Gynaecological (Dr. Lockyor), 
Skin (Dr. Whitfield), Teeth (Mr. Baly); Operations (Mr. Stabb). 
Thursday. -2.30 p.m., In-patients—Medical (Dr. Moriaon). 
Friday.—3.30 p.m.. Lecture:—Mr. G. B. M. White: Urethral 
Stricture. 

NATIONAL HOSPITAL FOR THE PARALYSED AND EPILEPTIC. 
Queen-square, Bloomsbury, W.C. 

Tuesday.— 3.30 p.m.. Lecture :—Sir W. Gowers: Clinical. 
Friday.— 3.30 p.m., Lecture:—Dr. Batten : Hereditary Ataxy. 

ST. JOHN’S HOSPITAL FOR DISEASES OF THE SKIN, 
Leicester-square, W.C. 

Thursday. — 6 p.m.. Lecture:—Dr. M. Dockrell: Treatment (Con¬ 
stitutional and Local in all its Forms). 

CHARING CROSS HOSPITAL. 

Thursday.— 3 p.m., DemonstrationDr. Galloway and Dr. 
MacLeod ; Diseases of the Skin. 4 p.m., Demonstration :— 
Mr. Boyd: 8urgical. (Post-Graduate Course). 

HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST, 
B romp ton. 

Wednesday. —4 p.m. Lecture:—Dr. Habershon: Cases from the 
Wards. 

HOSPITAL FOR SICK CHILDREN, Great Ormond-street. W.C. 

Thursday.— 4 p.m., Lecture: — Mr. Corner: Injuries and Diseases 
of the Epiphyses. 

ROYAL INSTITUTION OF GREAT BRITAIN, Albemarle street, 
Piccadilly. W. 

Tuesday. —3 p.m., Prof. W. Stirling: Membranes—their Structure, 
Uses, and Products. 


EDITORIAL NOTICES. 

It is most important that communications relating to the 
Editorial business of The Lancet should be addressed 
exclusively “To the Editor,” and not in any case to any 
gentleman who may be supposed to be connected with the 
Editorial stafi. It is urgently necessary that attention should 
be given to this notice. _ 

It is especially requested that early intelligence of local events 
having a medical interest, or which it is desirable to bring 
under the notice of the profession , may be sent direct to 
this office. 

Lectures, original articles, and reports should be written on 
one side of the paper only , AND WHEN ACCOMPANIED 
BY BLOCKS IT IS REQUESTED THAT THE NAME OF THE 


AUTHOR, AND IF POSSIRLE OF THE ARTICLE, SHOULD 
BE WRITTEN ON THE BLOCKS TO FACILITATE IDENTI¬ 
FICATION. 

Letters, whether intended for insertion or for private informa¬ 
tion, must be authenticated by the names amd addresses of 
their writers—not necessarily for publication. 

We cannot prescribe or recommend practitioners. 

Local papers containing reports or news paragraphs should be 
marked and addressed “ To the Sub-Editor.” 

Letters relating to the publication, sale and advertising 
departments of The Lancet should be addressed "To the 
Manager.” 

We cannot undertake to return MSS. not used. 

MANAGER’S NOTICES. 

THE INDEX TO THE LANCET. 

The Index and Title-page to Vol. II. of 1907, which was 
completed with the issue of Deo. 28th, were given in 
The Lancet of Jan. 4th, 1908. 

VOLUMES AND CASES. 

Volumes for the second half of the year 1907 are now 
ready. Bound in cloth, gilt lettered, price 18s., carriage 
extra. 

Cases for binding the half year's numbers are also ready. 
Cloth, gilt lettered, price 2s., by post 2s. 3d. 

To be obtained on application to the Manager, accompanied 
by remittance. _ 


TO SUBSCRIBERS. 


Will Subscribers please note that only those subscriptions 
which are sent direct to the Proprietors of The Lancet at 
their Offices, 423, Strand, London, W.C., are dealt with by 
them ? Subscriptions paid to London or to local newsagents 
(with none of whom have the Proprietors any connexion what¬ 
ever) do not reach The Lancet Offices, and consequently 
inquiries concerning missing copies, Sec., should be sent to 
the Agent to whom the subscription is paid, and not to 
The Lancet Offices. 

Subscribers, by sending their subscriptions direct to 
The Lancet Offices, will insure regularity in the despatch 
of their Journals and an earlier delivery than the majority 
of Agents are able to effect. 

The Colonial and Foreign Edition (printed on thin 
paper) is published in time to catch the weekly Friday mails 
to all parts of the world. 

The rates of subscriptions, post free, either from 
The Lancet Offices or from Agents, are :— 


Foe the United Kingdom. 

One Y'ear .£1 12 6 

Six Months. 0 16 3 

Three Months . 0 8 2 


To the Colonies and Abroad. 

One Year .£1 14 8 

8ix Months. 0 17 4 

Three Months . 0 8 8 


Sutacriptions (which may commence at any time) are 
payable in advance. Cheques and Post Office Orders (crossed 
“London and Westminster Bank, Westminster Branch”) 
should be made payable to the Manager, Mr. Charles Good, 
The Lancet Offices, 423, Strand, London, W.C. 


TO COLONIAL AND FOREIGN SUBSCRIBERS. 

Subscribers abroad are particularly requested 

TO NOTE THE RATES OF SUBSCRIPTIONS GIVEN ABOVE. It 

has come to the knowledge of the Manager that in some 
cases higher rates are being charged, on the plea that the 
heavy weight of The Lancet necessitates additional 
postage above the ordinary rate allowed for in the terms of 
subscriptions. Any demand for increased rates, on this or on 
any otner ground, should be resisted. The Proprietors of 
The Lancet have for many years paid, and continue to pay, 
the whole of the heavy cost of postage on overweight foreign 
issues; and Agents are authorised to collect, and generally 
do so collect, from the Proprietors the cost of such extra 
postage. 

The Manager will be pleased to forward copies direct from 
the Offices to places abroad at the above rates, whatever be 
the weight of any of the copies so supplied. Address— 
The Manager, The Lancet Offices, 423, Strand, 
London, England. 


Daring the week marked copies of the following newBpapere 
have been received :—Edinburgh Evening Sews, Morning Post, 
Daily Chronicle, Daily Sews, Manchester Dispatch. Sorthem Whig, 
Bournemouth Echo, Westminster Gazette, Cork Examiner, Lymington 
Chronicle, Poole Herald, Coventry Times. The Tribune. Daily 
Graphic. Liverpool Courier, Manchester Courier, Daily Express, 
Birmingham Post, etc. 









478 The Lancet,] 


ACKNOWLEDGMENTS OK LETTERS, ETC., RECEIVED. 


[Feb. 8 , 1908. 


Oommtmic&tions, Letters, &c., have been 
received from— 


A. —Acton Urban District Council, 
Clerk to the; Anconts Hospital, 
Manchester, Secretary of; Dr. 
F. H. Alderson, Bournemouth; 
Anglo American Pharmaceutical 
Co., Croydon. 

B. —Sir John W. Byers, Belfast; 
Bath Royal United Hospital, 
Secretary of; Messrs. Bale, 
Sons, and Danielsson, Lond.; 
Bristol Royal Infirmary, Secre¬ 
tary of; Mr. F. D. Byrne, Lond.; 
Misa C. S. Bremner, Lond.; 
Mr. J. C. H. Beaumont, Ply¬ 
mouth; Mr. Frank Birch, Lond.; 
Dr. Alexander Brown, Lond.; 
Dr. G. P. Blacker, Lond.; 
Mr. J. L. Baskin, Salisbury; 
Messrs. S. W. Bush and Son, 
Bath: Mr. J. Bell, Hong-Kong; 
Dr. W. Bulloch, Lond.: Bayer 
Co., Lond.: Messrs S. W. Bush 
and Son, Bath; Mr. P. Burgle, 
Buenos Aires; British Medical 
Benevolent Fund, Lond., Hon. 
Secretary of. 

O. —Dr. Harry Campbell, Lond.; 
Mr. J. T. Ciapham, Felixstowe; 
Messrs. Cassell and Co., Lond.; 
Messrs. E. Cook and Co., Lond.; 
Messrs. A. H. Cox and Co., 
Brighton ; Dr. James Corns, 
Oldham; Clerical, Medical, and 
General Life Assurance Society, 
Lond.; Mr. A. Clarke, Tempo; 
Dr. J. Collins, New York; Mr. 
J. M. Car veil, Lond.; Dr. George 
Carpenter, Lond.; Dr. Edmund 
Cautley, Lond. 

D. —Dr. W. G. Dickinson, Lond.; 
Mr. A. J. Davy, Lond.; Dr. 
Andrew Duncan, Lond.; Mr. H. 
Dawson, Peterborough. 

B.— East Sussex County Asylum, 
Hellinglv, Clerk to the ; Edin¬ 
burgh Life Assurance Co., Edin¬ 
burgh. 

P. —Fairplay, Lurgan; Messrs. 
Flood and Sons, Lond. 

0.—Mr. H. H. Gottstein, Lond.; 
Mr. W. H. Godden, Folkestone; 
Dr. H. M. W. Gray, Aberdeen; 
Dr. Harold Goodman, Hems- 
worth; Sir W. R. Gowers, Lond.; 
Mr. W. M Griffiths, Carmarthen; 
Messrs. W. Grant and Son, Duff¬ 
town ; Guest Hospital, Dudley, 
Secretary of; Miss A. Green- 
halgh. Exmouth. 

H. —Mr. F. H. Humphris, Lond.; 
Dr. H. Handford, Nottingham; 
Mr. J. Holmes. Turvey; Messrs. 
Ha&sonsteinand Vogler, Cologne; 
Dr. E. C. Hort, Lond.; Dr. 
W. E. A. Heilborn, Bradford; 
Mr. T. Hamer, Llandrindod 
Wells; Dr. F. W. Hewitt, Lond.; 
Hospital for 8ick Children, 
Lond., Secretary of. 

I. —Messrs. Ingram and Royle, 
Lond.; Ingham Infirmary, South 
Shields. Secretary of; Income- 
Tax Adjustment Agency, Lond., 
Secretary of. 

J. —Mr. G. M. Jones, Alton; Mr. 
W. Jones, Liverpool; J. K. F. 

K. —Dr. James Kirkland, Lond.; 
Dr. C. F. Knight, Edinburgh; 
Kent County Asylum, Maid¬ 
stone, Clerk to the; Messrs. 
Keidzumi and Co., Kyoto, 
Japan; Messrs. R. A. Knight 
and Co., Lond.; Dr. W. E. de 
Korte, Lond. 

L. —Mr. H. K. Lewis, Lond.; 


Leeds Corporation, Clerk to the ; 
Dr, W. Lane, Weymouth; 
Lindsey County Council, Lin 
coin. Clerk of; Leeds and West 
Riding Medico - Cbirurgical 
Society, Senior Secretary of; 
Dr. fl. G. Lawrence. Lond.; 
Leicester Infirmary, Secretary 
of; Mr. A. K. Lamport, Lond. 

M. —Dr. J. S. Manson, Oldham; 
Miss Lesbia Mordaunt, Brith; 
Mr. R. Mosse, Zurich; Maltine 
Manufacturing Co., Lond.; 
Mullingar District Asylum, 
Clerk to the; M., Brighton; 
Mr. L. Mackay, Pitlochry; 
McGill University, Montreal, 
Bursar of; Dr. A. Morison, 
Lond.; Mr. David Mason, Lond.; 
Dr. G. W. F. Mscnaughton, 
Lond.; Dr. J. Miller, Glasgow; 
Mr. C. Mansell Moullin, Lond.; 
Messrs. C. Mitchell and Oo., 
Lond. 

N. —Dr. G. W. Nicholson, Lond.; 
Nottingham County Asylum, 
Medical Superintendent of; 
Messrs J. Nisbet and Co., Lond.; 
Norfolk News Co., Lond.; New 
South Wales, Agent General for, 
Lond.; Mr. J. C. Needes, Lond.; 
Mr. H. Needes, Lond. 

P. —Dr. W. T. Prout, Liverpool; 
Professor P. Purpura, Pavia; 
Mr P. C. Pearce, Leicester; 
Messrs. Peacock and Hadley, 
Lond.; Mr. J. Potter, Oldham. 

Q. —Queensland, Agent - General 
for. Lond. 

R. —Dr. Nathan Raw, Liverpool; 
Dr. H. D. Rolleston, Lond.; 
Royal College of Surgeons of 
England, Lond., Secretary of; 
Mr. R. P. Rowlands, Loud.; Pro¬ 
fessor R. W. Reid, Aberdeen; 
Royal Society of Arts, Lond., 
Secretary of; “Rossi, 1 ' Ltd., 
Lond.; Royal Society of London, 
Librarian of; Royal Society of 
Medicine. Lond., Secretary of; 
Messrs. Reynolds and Branson, 

8 .— Mr. S. G. 8battock, Lond.; 
Dr. Julius Springer, Berlin; Mr. 
B. Atkinson Stoney, Dublin; 
Dr. G. H. Simmonds, Chicago; 
Society for the Propagation of 
the Gospel in Foreign Parts, 
Lond.; Mr. N. Usher Somers, 
West Bromwich; Messrs. Siebe, 
Gorman and Sons, Lond.; 
Dr. C. G. Seligmann, Colombo; 
Messrs. John Swain and Son, 
Lond.; Dr. Walter Smith, Lond.; 
St. John’s Hospital for piseases 
of the Skin, Lond., Secretary - 
Superintendent of; Society of 
Engineers, Lond., Secretary of; 
Messrs. Spottiswoode, Dixon, 
and Hunting. Lond.; Sheffield 
Royal Hospital, Secretary of; 
Messrs. Southall, Birmingham; 
Messrs. Smith and Hardy, Lond.; 
South Wales Argus, Newport, 
Manager of; Seltzogene Patent 
Charges Co., St. Helen’s; Dr. S. 
Sunderland, Lond.; Scholastic, 
Clerical, Ac., Association. Lond ; 
Dr. John Lindsay Steven, Glas¬ 
gow; Star Engineering Co., 
Wolverhampton; Messrs. Smith, 
Eider, and Go. Lond. 

T.—Mr. J. C. Thomson, Edin¬ 
burgh ; Messrs. Tozer, Kemsley, 
and FiBher, Lond. 


V. —Mrs. Verini, Billericay; Vic¬ 
toria, Agent-General for, Lond. 

W. —Dr. F. G. Wallace. Lond.; 
Mr. John Wise, Liverpool: 
Westminster, Medical Officer of 
Health of; W. S. H.; Messrs. 
Wright, Dyer, and Daykin, 
Redditcb; Warrington Infirmary, 


Secretary of; Mr. Chisholm 
Williams, Lond.; Mr. E. C. 
Wilson. Paignton; Mr. W. H. 
Willcox, Lond.; Mr. F. Faulder 
White, Coventry. 

Y. —Mr. Walter A. Yearsley, 
Accrington; Dr. Ernest Young, 
Lond. 


Letters, each with enclosure, are also 
acknowledged from— 


A. —Dr. J. Adam, West Mailing; 
Messrs. Aked and Aked, Lond.; 
Mr. C. Adams, Elgin; Dr. T M. 
Allison, Newcastle - on - Tyne; 
Dr. W. S. Anderson, Chapel- 
en le Frith; Mr. A. Anderson, 
Rosewood, Queensland; Messrs. 
Allen and Hanburys, Lond.; 
Apollinaris Co., Lond. 

B. —Dr. M. C. Ballabcne, Berlin; 
Mr. D. W. Bishop, Zeernst; 
Mr. H. J. van Broekhuizen, 
Hulls River; Captain J. H. 
Burgess, I M S., Malnkand ; 
Blaeoavon Workmen’s Doctor’s 
Fund, Blaenavon, Secretary of; 
Mr. N. Basak, Drug, India; 
Dr. D. H. Baria, Dhrangadhra, 
India; Dr. D. Bower, Bedford; 
Dr. H. J. D. Birkett, Southsea; 
Mr. K. H. Bcazley, Wallington ; 
Messrs. Bates, Hendv, and Co., 
Lond.; Birmingham City Asylum, 
Clerk to the; Mr. S H. Benson, 
Lond.; Dr. W. W. Baldwin, 
Rome; Mr. F. B. Bennett, 
Margate; Birkenhead Borough 
Hospital, Hon. Treasurer or; 
Dr. H. H. Borland, Glasgow; 
Dr. J. C. Bowie, Clousta; 
Dr. J. S. Byrne, Goodmayes. 

0.—Mr. L. E. Creasy, Lond.; 
Mr. A. F. Comyn, St. Albans; 
Messrs. Cornish'Bros., Birming¬ 
ham ; Messrs. S B. Clark and 
Son, Lond.; Chelsea Guardians, 
Clerk to the; C. M.; Messrs. 
Cleaver and Co., Lond. 

D.—Dadson Nursing Homes, Lond., 
Secretary of; David Lewis Epi¬ 
leptic Colony, Manchester, Secre¬ 
tary of; Devon port Corporation, 
Treasurer of; Dorset County 
Asylum, Dorchester, Secre¬ 
tary of. 

B.-Mr. M. K. Evans, Sidcup; 

E. A. B. P.; Mr. W. Edmunds, 
Lond.; Dr. A. Edington, Edin¬ 
burgh; Epsom College, Epsom, 
Bursar of. 

F. —Dr. J. G. French, Lond.; 
Mr. H. McG. Forbes, Turriff; 
Mr. P. J. Flanagan, Castlegarren ; 

P. C. H. H.; Mrs. Forster, 
Christon Bank. 

G. — Dr. E. Gardner, Weybridge; 
Messrs. C. Griffin and Co., Lond.; 
Messrs. Guyot, Guenin, and Son. 
Lond.; G. G. E.; General Life 
Assurance Co., Lond., Secretary 
of; Messrs. Gale and Co., Lond.; 
Mr. A. H. Griffith, Manchester; 
Dr. G. R. Griffith, Carnarvon; 
Messrs. R. W. Greeff and Co., 
Lond.; Messra. Gallon and Son, 
Leeds ; Mr. J. W. Griffin, Rowley 
Regis. 

H. Mr. R. J. Howard, Lond.; 
Mr. E. Hemsted, Kintbury; Mr. 
J. H. Hodge, Bromley, Kent; 
Messrs. Hastings Bros., Lond.; 
Messrs. Hooper and Co., Lond.; 
Messrs. Haar and Steinert, Paris; 
H. A.; H. F. W.; H. P. S.; 
H. W. 

I. -Lieutenant - Colonel D. L. 
Irvine, R.A.M.C., Fambam; 


Mr. R. E. Ingram Johnson, South 
Moor. 

J.—Mr. J. Joule, Sampford 
Peverell; J. H. R.; Dr. W. 
Jamison, Abercynon; J. H. 

IL—Dr. B. Kuhn, Frankfort; 
Kidderminster Friendly Societies' 
Medical Aid Association, Secre¬ 
tary of; Kuala Lumpur State, 
Surgeon of; Messrs. Kirkby and 
ThomaB, Maesteg; Mr. G. W. 
Kidd, Newcastle-on-Tyne. 

L. - Mr. G. S. Landon, Lond.; 
Mr. W. W. Linney, Croydon; 

L. S. A., St. Johns; Leeds Public 
Dispensary, Secretary of; Mr. 

R. M. Leith, Port Elizabeth; 
Mr. C. Lean, Lond.; Dr. G. M. 
Lowe, Hyde; Mr. R. T. Lang, 
Lond.; Dr. R. J. Lytle. Southsea; 
Dr. M. E. Leicester, Penryn; L. 

M. —Mr. O. C. Mitra, Calcutta; 
Mr. E. Merck, Lond.; Manches¬ 
ter Corporation, Clerk to the; 
Dr. K. Manson, Hordle; Dr. 
MacGregor, Morvern; Medical 
Graduates’ College, Lond., Secre¬ 
tary of; Dr. H. MacBry&n, Box. 

N. —Messrs. Noakesaud Co., Lond.; 
N. O 

O. —Professor W. Osier, Oxford. 

P. —Dr. B. Pickering, Bolton; 
Dr. H. Porter, Sutton-in-Ash- 
field; Mr. H. Powell-Rees. Load.; 
Peck ham House, Lond., Medical 
Superintendent of; Paddington 
Guardians, Clerk to the; Mias 
C. E. Pring, Lond.; Dr. F. W. 
Pavy, Lond. 

R.-Dr. H. Rayner, Lond.; Dr. B.; 
Royal Ear Hospital, Lond., Hon. 
Secretary of; Messrs. Robinson 
and Sons, Chesterfield. 

8.— Dr. R. S. Srivaatuna, Almora, 
India; Sangli State, India, Chief 
Medical Officer of; Messrs. 
J. Smith and Co., Lond.; Messrs. 
Southall Bros, and Barclay, Bir¬ 
mingham ; Mr. W. B. Silas, Lond.; 
St. Andrew's Hospital, North¬ 
ampton, Clerk to the; W. B. 
SaundersandCo., Lond., Manager 
of; Dr. S. D.; Surgeon, Benwell; 
Sanitary Wood Wool Co., Lond.; 
Somerset County Council, Wes¬ 
ton-super-Mare, Treasurer of. 
T.-Mr. W. B. Tubbs, Lond.; 

Mr. M. J. Thompson, Louchtoo; 
i T. W. M. 

W.— Mr. T. F. Wyse, Dal key; 
Mr. L. Williams, Lond.; Mr. 
W. T. Williamson, Bredwardine; 
Dr. S. West, Lond.; Captain P. 
Winslow, R.A.M.C., Bodmin; 
Dr. F. J. Woollacott, Lond.; 
Messrs. F. Williams and Co., 
Lond.; Wameford Hospital, 
i Oxford, Superintendent of; 
Mrs. Wiseman, Lond.: W. G.; 
Dr. W. B. Warrington, Liverpool; 
W. R. C.; W., North Curry; 
Mr. J. H. White, Workington; 
Messrs. Winkworth. Brighton; 
j Wrexham Infirmary, Secretary 
of; Messra. H. Wilson and Son, 
Lond. 

i Y.—York County Hospital, Secre- 
i tary of. 


EVERY FRIDAY. 


THE LANCET. 


PRICE SEVENPENCE. 


POST FREE. i ADVERTISING. 

To the Colonies and Abroad. 

One Year .£1 14 8 

Six Months. 0 17 4 

Three Months ... ... 0 8 8 

Subscriptions (which may commence at any time) are payable in 
advance. 

The Lancet can be obtained at all Messrs. W. H. Smith and Son’s and other Railway Bookstalls throughout the United Kingdom, 
tisement* are also received by them and all other Advertising Agents. 


SUBSCRIPTION, 

For the United Kingdom. 

One Year .£1 12 6 

Six Months. ... 0 16 3 

Three Months . 0 8 2 


Books and Publications ... Seven Lines and under £0 5^0 
Official and General Announcements Ditto 0 5 0 

Trade and Miscellaneous Advertisements) ~ „ 

and Situations Vacant . f 1J1 ™ 0 4 6 

Every additional Line 0 0 6 

Situations wanted : First 30 words, 2 s. 6 d. ; per additional 8 words 6<7, 
Quarter Page, £1 10«. Half a Page, £2 15a. An Entire Page, £5 6*. 

Adver- 


Agent for the Advertisement Department in Trance—J. ASTIER, 31, Rue Bapst, Asnieres, Paris. 





THE LANCET, February 15, 1908 


Erasmus Milson future 

ox 

OVARIAN TERATOMATA. 

Delivered before the Royal College of Surgeons of England on 
Feb. 10th, 190S, 

By SAMUEL GEORGE SHATTOCK, F.R.C.S., 

PATHOLOGICAL CURATOR OP THE COLLEGE MUSEUM. 


[Mb. Shattock commenced by describing an embryoma 
projecting into an ovarian cyst in which the indications of 
a second fcetus were unusually evident. The embryoma con¬ 
sisted of a trunk furnished with two lower limbs and a 
peritoneal cavity containing a blind coil of intestine. The 
skeleton comprised a short rudimentary spinal column with 
a pelvic girdle, and in each of the lower limbs there was a 
long osseous element filled with fatty marrow. Between the 
limbs were two distinct labia bounding a blind depression, 
and behind these a perineal raph6. The embryoma, except 
on the soles of the feet, was covered with short fine hair, but 
over the pubes there was a well-pronounced tuft of long 
pubic hair. The wall of the cyst into which the embryoma 
projected was smooth and devoid of hair or epidermal lining. 
He continued :—] 

The growth of pubic hair is a subject of no little interest in 
this remarkable specimen. It must be taken as marking the 
advent of puberty. As the presence of sexual glands in 
the embryoma itself may be excluded (for there is nothing 
but a coil of intestine in the peritoneal cavity), the 
explanation of its puberty must be sought in a maternal 
influence, or more definitely in the action of an internal 
secretion produced by the sexual glands of the autosite ; the 
autosite and the embryoma will have acquired the cutaneous 
marks of puberty simultaneously. It is, in fact, a natural 
experiment which successfully carries out one devised and 
attempted by Dr. C. G. Seligmann and myself. Our experi¬ 
ment consisted in grafting together by the legs a castrated 
cockerel (after its recovery) and an intact cockerel of the 
same age and kind. Although the operation was itself 
successful, one of the grafted birds, in each of the four cases 
in which it was carried out, died within a few days without 
obvious cause. The object of the experiment was to see 
whether the castrated bird would, as it matured, put on the 
plumage and comb of the cock from the access of blood to it 
from the intact bird. In the ovarian embryoma the experi¬ 
ment has been accomplished. The trunk of the embryoma 
being without heart and independent circulation has been 
supplied with blood from the side of the autosite and with, 
the result that the overgrowth of hair which marks the 
advent of puberty has actually been brought about. 

[Mr. Shattock next demonstrated a series of ovarian 
teratomata, showing the progressive disappearance of limbs 
from an amorphous trunk, the true nature of which latter 
appeared from the presence of a rudimentary intestine, or (as 
he had demonstrated in three oases) from the presence of a 
central nervous system. He continued :—] 

The presence of teeth necessarily shows the tera¬ 
tomatous character of the cyst in which they occur ; but 
in the case of other ovarian teratomata, even those of a well- 
pronounced kind, teeth are wanting. These differences we 
must attribute to differences in the developmental arrest 
which involves now one part and now another of the em¬ 
bryoma. There are acormous (or trunkless) and acephalous (or 
headless) embryomata, as there are trunkless and headless 
acardiac homologous twins. In regard to the displacement 
or lateral dislocation of dentigerous and other bone, and the 
utter absence in most cases of any structure morphologically 
like a cranium, one must not overlook the mechanical action 
of the enlarging cyst and the pressure of its contents in 
exaggerating what are, probably, also original defects of 
formation. The striking length of the hair in certain 
ovarian cysts, again, can hardly be explained, except by 
regarding such hair as growing from a cutaneous area 
answering to the scalp, and this view is strengthened when 
the hair arises in the neighbourhood of a dentigerous 
process of bone. The hair in one College specimen (Mr. J. 
Bland-Sutton’s) is 20 inches in length. Here, as in 
other cases, the mass of hair is confined to an elevation 
covered with true skin—i.e., to the proper teratoma. But 
the view that such dentigerous bones represent the cephalic 

No. 4407. 


end of an embryo is definitely proved by the presence of 
central nervous tissue in connexion with them. So long ago 
as 1853 Henry Gray described an ovarian cyst containing a 
tooth and hair, and projecting into this cyst was an 
eminence about the size of a walnut, situated near the den¬ 
tigerous bone referred to ; the wall of this eminence was 
delicate, its inner surface was highly vascular, and the 
contents consisted of a soft white substance, the surface of 
which was perfectly smooth and presented all the characters 
of brain. On microscopical examination it was found to 
consist entirely of the ordinary elements of nervous matter, 
being composed of a very large number of varicose nerve 
tubules of varying size intermixed with the “elementary 
components of grey matter—viz, nuclei and nucleated 
vesicles containing granules.” 

[Mr. Shattock also demonstrated the presence of a 
stomodieum with two lips and an appendage containing 
elastic cartilage and representing a rudimentary pinna at 
the same end of an elongated ovarian teratoma. He con¬ 
tinued :—] 

The astonishing excess of teeth, in rare cases met with in a 
teratomatous cyst, is perhaps explained by the occurrence of 
twin or triple teratomata in a single cyst. Or, it may be 
that the excess is brought about by an abnormal extension 
of the epithelial surface corresponding with that of the gum 
during the early enlargement of the cyst, so that the dental 
germs are increased in number and give rise to as many 
teeth or ill-deformed denticles. For even if we allow 
that two complete sets of teeth, a first and second, have 
been produced, the total (20 4- 32) would not equal the 
numbers which have been encountered, which may be over 
100. One must not, of course, fall into the error of reckon¬ 
ing multiple dentigerous cysts in the same ovary as a single 
“ dermoid,” and must also recognise the possibility of such 
coming to communicate through their partitions so as to 
produce a single multiiocular cavity. 

Not one of the least strange things in connexion with 
ovarian teratomata is that though themselves so abnormal 
they may nevertheless be the seats of disease. Setting aside 
the different degrees of aplasia and hypoplasia which, ipso 
facto, they illustrate, or the misdevelopment of particular 
teeth, or the presence of odontomata upon their fangs, we 
must look upon the relative amount of fat as in some cases 
quite reaching the proportion of disease. It is not simply 
subcutaneous fat duly proportionate to the skin over it, but 
it may constitute the bulk of the embryoma, the amount of 
bone and other structures being relatively insignificant as in 
the case described in the present communication, or in 
others already referred to from the College Museum (Nos. 
4511, 4511a, 4526e). The morbid condition, in short, is that 
of lipomatosis, or a generalised abnormal formation of fat, as 
distinguished from a local tumour or lipoma. For it must 
be borne in mind that the presence of any fat in the ovary 
itself is something altogether as abnormal as it is in the 
testicle and that the fat of the embryoma appertains entirely 
to the latter. I am not aware of a fatty tumour ever having 
been observed in the ovary. In the testicle I have examined 
one only, and this in the horse ; and so far as my knowledge 
goes it is unique. 

But that hydromyelus should occur is still more strange. 
Yet it is shown in three of the teratomata already described, 
from Specimen No. 2371 in St. Thomas’s Hospital Museum. 
In one of these the tubular hydromyelic sac is lined with 
columnar epithelium and the halves of the spinal cord lie one 
on either side of it, the whole being invested with a 
separable membrano-cutaneous covering or body-wall. Aa 
there is no spinal column we cannot speak, of course, of a 
spina bifida. The largest example of this morbid condition 
of the embryoma is contained within an ovarian cyst in the 
opposite ovary of the same patient. It consists of a double 
sac, the portions of which, each about three and a half 
inches in length, lie side by side, and communicate by a 
small aperture half surrounded by a process of bone. From 
the inner aspect of the sac a delicate continuous membrane 
can be raised ; there is no trace of further structure. Yet 
that this bilocular sac is an embryoma dilated into a great 
cyst by hydromyelic and hydrocephalic distension is clear 
if it be compared with that first referred to in which the 
halves of a spinal cord lie on the sides of the sac ; and by 
the circumstance that the sac itself is furnished with a 
delicate, separable lining representing the meninges of the 
dilated central nervous system, and an outer membranous 
body-wall. 

We may, indeed, classify the last as a new form of cyst and 

« 




480 The Lancet,] 


MR. S. G. SHATTOCK ; OVARIAN TERATOMATA. 


[Feu. 15, 1908. 


add it to the heterogeneous category of such without violence, 
for it is as simple in structure, though not in its origin, as a 
cyst, say, of the urachus. It is a cyst produced from an 
embryo and 1 venture to name it an embryonal cyst. And 
such teratoma may become the seats of malignant disease. 
We may be sure that the localised epithelioma or squamous- 
celled carcinoma encountered at times in an ovarian 
cyst has arisen in the cutaneous covering of a teratoma. 
But more frequently the tumour arising from the teratoma 
is of a mixed kind ; all the histological elements of the 
teratoma, seeing that they are all embryonic residua, may 
partake in the abnormal overgrowth and the resulting 
tumour may be simple, or malignant producing metastasis. 
Mr. H. T. Hicks and Mr. J. H. Targett have published 
two cases of malignant embryoma of the ovary, one of 
the patients being but six years of age. And a case of 
yet younger age is recounted by Mr. L. S. Dudgeon, where a 
huge tumour of this kind filled the abdomen of a child under 
four years of age. In some of the similar cases reported 
cerebral tissue has been found in the tumour. 

To return now to the theories which have at different 
times been advanced in explanation of the so-called ovarian 
dermoid. One, which has been long held, is that such 
cysts result from an impregnation which haB been relatively 
abortive and incomplete in result. As a sufficient refutation of 
this view it can be pointed out that these cysts may be met 
with in the unmarried and in children, and this objection 
has not yet been met. We often find it recorded that a 
patient from whom such a teratomatous cyst was taken was 
unmarried. Yet such a history of itself is scientifically 
inconclusive in this regard. And then we come across one of 
those decisive but simple observations of Hunter, which 
forces us to believe that he saw its importance for the 
Bimple reason that he made it. In the case of the Hunterian 
specimen (No. 4508 in the College Museum) we find it 
recorded that the hymen was intact. The cyst was taken 
from a woman, aged 18 years, and from its otherwise smooth 
interior there projects an embryoma covered with piliferous 
skin and bearing a tooth. And as regards the presence of 
such cysts in children, No. 4514 is a thin-walled ovarian cyst 
bearing a small piliferous teratoma, which contains cartilage, 
the parts being removed from a girl, aged eight years. It is 
clear, moreover, that in the case of the teratomatous or 
so-called dermoid cyst of the testicle the theory of a post¬ 
natal impregnation is reduced to an absurdity. The view 
usually adopted in regard to the ovarian teratoma is that the 
latter is due to the impaction of a second individual which 
has started on its development synchronously with its host 
but which has subsequently failed in its progress. 

The chief argument against the theory of a twin impac¬ 
tion in explanation of the ovarian embryoma is the sheer 
commonness of the latter; partly this and partly the 
difficulty of understanding why such an impaction should 
so regularly take place into the substance of the 
ovary and why, being so common in the ovary, it should 
be of such excessive rarity in the testicle, seeing that 
these organs occupy the same primitive position and are, in 
fact, at first indistinguishable from one another. The occur¬ 
rence, again, of a teratomatous cyst in each ovary adds to 
the difficulty of accepting this explanation. This bilateralism 
is, indeed, very far from rare. The presence of two or even 
three teratomatous cysts in the same ovary accentuates the 
difficulty, for it would involve the impaction of as many 
embryoes. 

A further difficulty in regard to the theory of impaction 
arises from the discrepancies referable to the colour of the 
hair in such cysts. In multiple teratomatous cysts of the 
same ovary the hair may be of different colour. In bilateral 
dermoids, too, the hair may be of different colours; it has 
been found dark in one cyst and light in the other. The 
colour of the hair in the dermoid again may be markedly 
different from that of the patient. In the case described in 
the present communication the hair of the teratoma, which 
consists of a tuft growing from the pubes, the parasite being 
acephalous and devoid of teeth, is of the palest flaxen, whilst 
that of the patient is of a well-pronounced or medium brown, 
although, as is so regularly the case, it had darkened since 
infancy ; it is fair, however, to contrast the two, for the 
growth of the pubic hair in the parasite must be regarded as 
synchronous with the puberty, and not with the infancy, of 
the patient, A more striking instance of this dill'- rence is 
afforded by a specimen in which the cyst is filled with a mass 
of shed hair, the colour of which is flaxen or light yellow; 
hair of similar colour grows from the teratoma : the hair of 
the patient and that of her husband are of a full black. 


Such facts go towards showing, in the first place, that the 
piliferous skin of the “ ovarian dermoid ” has not the same 
histological origin as the skin of the patient, i.e., that its 
pertaining epidermis is not a portion of the general and 
primitive epiblast. In the second place, they go towards 
showing that the embryoma is not an impacted homologous 
twin. For such twins (which arise irom a single ovum, are 
formed on a single blastodermic vesicle, and inclosed within a 
single amniotic sac) are not only of the same sex, but so alike 
in detail as to be with difficulty or not at all distinguishable. 
This, too, is true of double monsters, which have the same 
kind of origin as homologous twins, from the misdevelopment 
of which they arise. For the colour of the hair is, I find, 
invariably the same upon the two heads. Were the ovarian 
embryoma due to the impaction of a homologous twin its 
hair should be of the same colour as that of the patient; and 
in the case of multiple embryomata it should, moreover, be 
of the same colour in all. 

The foregoing considerations lead me to propose a theory 
which may explain both the frequency of the ovarian 
embryomatous cyst and its particular location, a theory, 
moreover, with which the occurrence of embryomatous cysts in 
the testicle is not incompatible and which at the same time 
iB in harmony with their rarity. This theory is, that the 
ovarian teratoma results from the fertilisation of one of the 
primordial ova in the ovary of the embryo, 60 that the 
embryo gives rise to a second imperfect individual whose 
origin is, therefore, not synchronous with but of later date 
than itself. It is the formation of one embryo within another, 
and the name I venture to suggest for the theory is that of 
epi-embryogenesis. 

With respect to the access of spermatozoa to the primitive 
ova, it is not necessary to suppose that a second penetration 
of the developing ovum takes place. It is well known that 
more than a single spermatozoon may perforate the investing 
membrane of the ovum. It becomes thus quite conceivable 
that surplus spermatozoa may remain about the segmenting 
mass or morula, may become engaged between its com¬ 
ponent cells, and in this way be actually ready in the 
blastoderm to fertilise the primordial ova which are 
developed so soon after its lamination and the cleavage of 
the mesoblast which results in the formation of the 
body-cavity. The longevity of spermatozoa when under 
conditions not adverse to their life is a subject upon which 
little is known. Somewhat to the point, however, is the 
fact, well known to poultry breeders, that after a siDgle 
impregnation the hen of the turkey will lay her whole brood 
—that is, will lay the entire succession of fertile eggs, about 
12 in number, which makes the brood, one egg being laid 
about every other day and the whole process extending over 
a period of about four weeks. Mr. W. B. Tegetmeier has 
told me that he knew of one instance in the common fowl 
in which fertile eggs were laid and hatched six weeks after 
the access of the male bird. 

Not only does this theory of an epifecundation of 
primordial ova in the ovary of the embryo explain the frequency 
and particular location of embryomatous cysts of the ovary, 
but it explains the multiplicity of such cysts in the same 
ovary and their occurrence in both the ovaries of the same 
patient. The theory, again, will account for the difference 
in colour of the hair in multiple teratomatous cysts, or of the 
teratomata in cysts of opposite ovaries. For such differences 
become examples only of the differences in colour so fre¬ 
quently seen in children born of the same parents, or still 
more closely in heterologous twins whose hair may be of 
different colour. Nor does the difference in colour between 
the hair of the embryoma and that* of the patient offer any 
difficulty. The patient is, whilst yet an embryo, the 
mother of the teratoma ; the father of the teratoma is 
the father of the patient. The colour of the hair of the 
embryoma need not therefore resemble that of the patient, 
the mother; it might resemble that of the father, or it might 
not resemble either, but that of a more remote ancestor. 

Amongst zoologists three methods of embryogenesis are 
recognised in addition to the common one in which the 
ovum, previously and independently matured by the ex¬ 
trusion of its polar globules, is fertilised by a spermatozoon. 
1. Shock-fertilisation : this involves the preliminary inde¬ 
pendent maturation of the ovum, but the incentive to the 
subsequent division of the latter and the development of the 
embryo is mechanical. The ova of the star-fish, as is now 
universally known, can be fertilised by means of “soda- 
water” added to the sea-water of the aquarium, or by mere 
shaking. 2. Parthenogenesis, which takes place in many of 
the insecta (particularly the bee), involves a maturation of 


The Lancet,] DR RAW: TUBERCULOSIS TREATED BY DIFFERENT KINDS OF TUBERCULIN. [Feb. 15,1908. 481 


the ovum, but not a proper fertilisation, the embryogenesis 
being started by the return, or want of extrusion, of the 
second polar globule which acts in place of the male element. 
3. Sporogeny: here the embryo develops from the ovum 
without any preliminary maturation of the latter and apart 
from fertilisation. This phenomenon has been observed in 
the jelly-fish. 

The theory of epi-embryogenesis in connexion with ovarian 
embryomata involves (as would also that of parthenogenesis) 
a premature preliminary “ maturation ” of the ovum, seeing 
that the process of fertilisation would take place in the 
embryo itself. The phenomenon of parthenogenesis, however, 
is limited to forms so far below mammals that it is difficult 
to think it obtains with such great frequency in the human 
subject as the common occurrence of ovarian teratomata 
would necessitate. Still more inapplicable is the pheno¬ 
menon of sporogeny, the only one which does not involve a 
histological maturation of the ovum, when the extreme 
lowness of the forms in which it occurs is considered. 

Let me, in conclusion, take up the difficulty presented by 
the occurrence of similar embryomatous cysts in the testicle. 
How is the extremely rare occurrence of such cysts to be 
accounted for on the theory advanced ? In the embryonic 
sexual gland the proper reproductive cells are at first 
undiiferexidated from one another. These cells become in 
the female the ova and in the male the spermatogenic 
elements of the testicle. The occurrence of embryomatous 
cysts of the testicle, then, would involve on the theory of 
epi-embryogenesis a hermaphrodite condition of the gland 
in which the cyst is formed, and the intra-embryonic fertilisa¬ 
tion of one of the ova. True it is that in the human subject 
the condition of glandular hermaphroditism is but rarely 
observed, but still more rare is the teratomatous cyst of the 
testicle. The rarity of the one accords with the rarity of the 
other. Yet on any of the other theories advanced such cysts 
should be as frequent in the testicle as they are in the ovary. 


% Jttte 


THE TREATMENT OF TUBERCULOSIS BY 
DIFFERENT KINDS OF TUBERCULIN. 


Delivered, at the Medical Graduates' College and Polyclinic , 
London, on jVov. 12th, 1907, 

B? NATHAN HAW, M.D., M.R.C.P. Lond., 
F.R.S. Edin., 


PHYSICIAN TO THE MILL ROAD INFIRMARY, LIVERPOOL ; MEMBER OF 
THE INTERNATIONAL COMMITTEE FOR THE PREVENTION 
OF CONSUMPTION, EIC. 


Gentlemen,- —The treatment of phthisis pulmonalis and 
other forms of tuberculosis is of such intense urgency and 
importance that any method based on scientific investigation 
ought to be thoroughly tested with a view to diminish the 
awful mortality in this country from tuberculosis. I have 
been greatly disappointed in the treatment of phthisis by 
Koch’s tuberculin B., but in the treatment of surgical tuber¬ 
culosis, such as tuberculous peritonitis, meningitis, bone and 
joint disease, enlarged glands and lupus, the results with 
tuberculin R. (Koch) have been most excellent, and I have 
at present a great many cases under treatment in hospital 
by this tuberculin as supplied by the Clinical Research 
Association. 

I have recently had prepared from my own cultures of 
bovine tubercle a tuberculin for use in phthisis pulmonalis 
with, so far, encouraging results. A perusal of my paper in 
the April, 1907, number of Tuberculosis (Berlin) will explain 
the reason why tuberculin from bovine sources should be 
used for phthisis, whilst Koch’s tuberculin R., which is pre¬ 
pared from human tubercle bacilli, should be used for the 
other forms of tuberculosis. The general results and im¬ 
pressions of that work are given here, but in the limited space 
at my disposal it is impossible to do more than touch 
generally on a few of the more important points investigated 
during this research. 

Following the lines of my original paper of 1903, I have no 
reason to modify the view then set forth—namely : “That 
human and bovine bacilli are divisible into two distinct 


types of a common species: (1) typus humanus ; and 
(2) typus bovinus.” Another fact of the most profound 
importance in studying this problem is that for centuries 
man has been accustomed to feed upon cattle and their 
products—milk, butter, cheese, &c.— and in this way the 
human body has become tolerant to bovine tubercle bacilli. 
Whilst I firmly believe that human and bovine bacilli are 
different types of parasites, yet I am convinced that bovine 
bacilli are freely communicable to humans and are the cause 
of a large amount of tuberculosis in children. I believe that 
man is attacked by two distinct varieties of tubercle, one 
conveyed by infection from one person to another, the other 
by receiving into the body bovine bacilli from infected food. 
In other words, the human body is susceptible to both forms 
of tubercle. The difficult problem to determine now is what 
particular lesions in the human body are produced by each 
variety of tubercle. 

To sum up my own views on the distribution of tubercle in 
the human body, I would say, speaking provisionally and 
without any final evidence of proof, that (1) tubercle bacilli 
of the typus humanus produce phthisis pulmonalis, ulceration 
of the intestines, and tuberculous laryngitis ; and (2) tubercle 
bacilli of the typus bovinus produce tuberculous peritonitis, 
tuberculosis of the lymphatic glands, tuberculous joints, 
meningitis (probably), and lupus. I am of opinion, also, 
that acute miliary tuberculosis is of bovine origin. 

Working on the hypothesis that the human body is 
attacked by two varieties of tubercle which may be present 
in the body at the same time and which, generally speaking, 
are antagonistic to each other, I have devoted my attention 
within the last few months to the preparation of tuberculins 
for the treatment of these different lesions. After a fairly 
complete experience I have come to the conclusion that 
Koch’s tuberculin R. has little or no healing effect in 
phthisis pulmonalis, and when we remember that it is 
manufactured from human tubercle, if my theory is correct 
it is exactly what we would expect. Consequently I 
have had prepared from one of my own pure cultures 
from bovine sources a special tuberculin for the treatment 
of phthisis pulmonalis. The tuberculin was made from a 
typical culture of ‘ 1 perlsucht ” and was very carefully 
sterilised and standardised. Several guinea-pigs were in¬ 
oculated but without any bad effect. Working on these lines 
I am at present treating over 70 cases of surgical or bovine 
tuberculosis in the wards of Mill Road infirmary with Koch’s 
tubercnlin R., commencing with very small doses and slowly 
increasing up to a maximum dose of one-hundredth of a milli¬ 
gramme. The results, without any accessory treatment, have 
been beyond all my anticipation. Enlarged glands, joints, 
and lupus have been immensely improved, whilst discharging 
sinuses have cleared up and in two cases the symptoms of 
tuberculous meningitis associated with tuberculous peri¬ 
tonitis entirely disappeared. The full results of this large 
number of cases treated by tuberculin will be published in 
due course. On the other hand, I have treated 16 cases 
of early phthisis, four of which were associated with 
haemoptysis and all of which showed tubercle bacilli in 
the sputum, with distinctive physical signs at one apex, 
with the tuberculin prepared from a pure culture of bovine 
tubercle (kindly supplied to me by Professor Calmette 
of Lille). These cases are still under treatment, but up 
to the present many of them have shown marked improve¬ 
ment, with total disappearance of physical signs. It is 
too soon yet to speak of the final results of treatment, but I 
hope to publish them after one year. My tuberculin should 
only be used in early cases and, if possible, in conjunction 
with open-air or sanatorium treatment. The directions and 
dosage issued by the Clinical Research Association should 
be strictly adhered to if good results are to be obtained. 

With a view to produce immunity against human tubercle 
in children, especially in those who have been exposed to 
infection from a consumptive father or mother, I have lately 
been working with the serum of tuberculous cattle. I have 
purchased several dairy cows suffering from tuberculosis of 
the udder and have obtained, with the kind cooperation of 
Professor H. E. Annelt, a large amount of the serum of these 
cows. This serum has been very carefully sterilised and 
injected into guinea-pigs without any ill-effects. I believe 
that the serum of a cow which has suffered from bovine 
tuberculosis will confer such immunity when injected into a 
child as will suffice to protect him against an attack of human 
tuberculosis. Considering the large number of children who 
are attacked by phthisis pulmonalis as the direct result of 
contact with a consumptive parent a protective serum would 




482 Tiie Lancet,] DR. RAW : TUBERCULOSIS TREATED BY DIFFERENT KINDS OF TUBERCULIN. [Feb. 15,1908. 


be an immense step in the direction of stamping out con¬ 
sumption. In any case, the serum is quite harmless and will 
only be used with the full consent of those parents whose 
children have been exposed to infection. 

Method of Treatment. 

It is preferable (though not necessary) that the patient 
should stay in bed a few days before and after the first 
injection. The temperature and pulse should be noted every 
four hours before treatment and if not above 100° F. at any 
time the first injection of 0 • 0001 milligramme may be 
given under the skin with, of course, the strictest aseptic 
precautions. The temperature and pulse should be taken 
every two hours afterwards for 24 hours and then every four 
hours for 48 hours more. If any reaction is going to 
take place the temperature will rise up to 100° or 101° 
within the first 12 hours or even later; but expe¬ 
rience has shown that if the injections are commenced 
with such a small dose and slowly and gradually in¬ 
creased no reactions follow and beyond an occasional 
slight headache or feeling of sickness no disagreeable 
symptoms are observed. In fact, many patients visit the 
consulting-room for their injections every week and continue 
their ordinary duties in the interval without any personal 
Inconvenience. The second injection of 0 ■ 0002 milligramme 
is given after an interval of one week, provided no reaction 
has followed the first injection, in which case the first 
injection is repeated and then doses (in milligrammes) in the 
following order: 0 C004, 0 0005, 0 001, 0 002, O'0025, 
O'003, O'004. O'005, 0 0076, and O'01 (maximum dose), 
making in all 12 injections. If the patient requires further 
injections the last injection of 0 01 milligramme is repeated 
for a few more doses but that dose is never exceeded. After 
the first two or three injections the patients feel better, the 
temperature drops to normal, the appetite is improved, and 
there is a feeling of general improvement. Not even the 
slightest bad effect has been observed from the injections, 
but of course great care must be exercised in the technique 
and a careful watch must be kept on the doings of the patient 
during the course. 

Many of us had experience of the tuberculin introduced 
to the profession by Professor Koch 16 years ago. It was 
used in a great many cases of phthisis and other forms of 
tuberculosis without discrimination, but it was soon found 
that the most marked effects of the tuberculin were produced 
by injecting it in cases of lupus. I well remember, after 
obtaining it with great difficulty, injecting several cases of 
lupus. The reaction was terrific, and from notes of one of 
my cases 1 find that the temperature ran up to 105°, the 
pulse 140, whilst the inflammatory reaction on the lupus 
itself was most intense. The patient complained of a hot, 
parched, burning sensation all over his body—in fact, felt he 
was going to die. In the course of five days he developed 
acute tuberculous meningitis and died within a week. 
Although I bad no other fatal cases yet in most of them the 
reaction was acute and in some alarming. In four cases of 
phthisis in which I used it the patients were made rapidly 
worse ; in fact, the effects were so serious that the remedy 
was very quickly dropped by the profession. We now 
know that the only fault of the tuberculin was its 
dosage. It was a powerful remedy and too large a dose 
was administered without the slightest scientific knowledge 
as to its action. At the present time the effects of tuberculin 
are produced by the administration of minute doses with 
careful observation as to the effects of each dose. The 
tuberculin is slowly increased in strength, thus gradually 
immunising the patient to it until by degrees a maximum 
dose of T j 0 th part of a milligramme is administered. 

In the year 1897 on the introduction of Koch’s new tuber¬ 
culin, or tuberculin R., I made a series of observations on 18 
cases of phthisis and recorded the results in The Lancet at 
that time. The dosage commenced with To'joth milligramme 
and was slowly raised to 1 milligramme as a maximum 
dose. Even that dosage was found to be too high and I 
think the present method is si ientifically correct. The 
results of that series of cases wi re not encouraging. In only 
one case of phthisis could we see any definite improvement. 
The remaining 17 cases were not in any way improved but 
they were certainly not in the slightest degree damaged by its 
use. Since then I have need Koch's tuberculin R. in a large 
number of cases of phthisis, and I came to the conclusion a 
year ago, after a very careful examination of its effects, that 
it was not beneficial in phthisis But the same cannot 
be said when we inject Koch’s tuberculin into other forms 
of tuberculosis. In fact, aa I have mentioned before, the 


injection of this tuberculin has a most marked and lasting 
curative effect, so much so that now it is my routine 
practice to give every suitable case of surgical tuberculosis 
injections of Koch's tuberculin and also every case of early 
phthisis injections of tuberculin prepared from bovine 
sources. The results are most encouraging and in some 
cases wonderful, and I am convinced that the treatment of 
the future of tuberculosis in all its forms will be by the 
physician rather than by the surgeon. 

I now proceed to relate the particular cases in which 
tuberculin has been used, and although it is impossible to 
enter into details in this short paper yet I will endeavour as 
far as possible to classify the different groups of cases with 
their results. 

Phthisis Pulmonalis. 

At the present time there are 16 cases of phthisis 
pulmonalis under treatment by injections of bovine tuber¬ 
culin. They are all adults, nine women and seven men, and 
in each case the disease is in the first stage according to the 
classification of Turban—that is, involving one lobe of one 
lung, or both apices limited to above the clavicle and spine 
of the scapula. In ten of the cases tubercle bacilli were 
found ; in the other six cases no expectoration could be 
obtained. 

The following is a brief account of the 16 cases :— 

Case 1. -Male, agcil 23 years. History of hwmoptvsis six months 
ago; constant cough ami slight expectoration. Tubercle bacilli 
found. lie had been steadily losing weight and has even now a typical 
cachexia. Temperature 100° P. at night. He has had ten injections of 
tuberculin, commencing with 00001 milligramme and rising to 0 01 
milligramme. He left the hospital after three months’ treatment, 
having gained 10£ pounds and with total disappearance of all physical 
signs, cough, and exj>eetoration, and with a normal temperature. ‘ He¬ 
lms since been seen on several occasions and remains well and at work. 
He had only early infection of the left apex. 

Case 2.—Male, aged 31 years. Early phthisis with consolidation of 
right apex. Tubercle bacilli found in tputum ; profuse night 
sweats and loss of flesh for five months. The usual injections were 
commenced four months ago with the result that steady improvement 
has followed. Physical signs have practically disappeared and the 
man is feeling very much better. 

Ifc is, of course, too early yet to give ,a final verdict, but in 
this particular case the tuberculin has had a marked effect.. 

Case 3.—Female, aged 31 years, with marked physical signs of 
tuberculosis at both apices. She is of rather frail and delicate consti¬ 
tution but there is no family history of tubercle. She had tried sana¬ 
torium treatment for two months but had to give it up on account of 
it not agreeing with her—in fact, she lost weight whilst in the sana¬ 
torium. In jections were started in July last and she has altogether 
had 14 injections at intervals of one week. Her cough has entirely 
disappeared, expectoration is almost nil, temperature is normal, and 
she has gained 20 pounds. 

Case 4.-Male, aged 17 years, with active tubercle of the left upper 
lobe. He was losing weight steadily and had a troublesome and con¬ 
tinued cough with expectoration which contained tubercle bacilli. He 
has had nine injections and is steadily progressing towards recovery. 

Case 5.—Male, aged 23 years, with active phthisis of the right apex, 
temperature ranging to 101° F. with persistent cough, especially at 
night. He had hiemoptysiB six weeks before treatment. He has had 
ten injections of tuberculin, has gained 17 pounds, and is steadily 
improving. 

Case 6.—Female, aged 29 years, with fairly extensive pulmonary 
tuberculosis and laryngitis. Th© cough and dyspna-a were very 
urgent There was considerable ulceration of the larynx and she had 
great distress aud pain in swallowing, especially hot liquids. Although 
it was not a case that one would select for treatment yet it was thought 
that something ought to be done to relieve the distressing laryngeal 
symptoms. She had altogether seven injections of tuberculin but I 
regret to say without any good effect whatever, so that they were dis¬ 
continued. She died two months afterwards and at the necropsy there 
was considerable destruction of both lungs, with serious Involvement of 
the larynx and extensive secondary ulceration of the intestines, a con¬ 
dition that I invariably find where the larynx is much involved. This 
case strongly supports the view which I hold—namely, that tuberculin 
can only be useful in a localised infection of tuberculosis. In other 
cases it has no immunising effects w hatever, and I am rather inclined 
to believe, although I am not certain, that it may intensify the 

tuberculous process. 

Case 7.—Female, aged 19 years, with early phthisis at the left apex. 
She was very thin on admission and had been steadily going down-hill 
for the last 12 months. Cough troublesome ; expectoration profuse in 
the morning Under tuberculin she improved rapidly, and in 13 
weeks she gained 24 pounds and left the hospital apparently quite 
well. Tubercle bacilli were never found In her expectoration, although 
the physical signs of phthisis were quite pronounced. 

Case 8.—Female, aged 26 years, a nurse, contracted phthisis 
probably from her husband who died from it. She had well-marked 
signs of tubercle over the whole of the left lobe In front and behind, 
constant cough and expectoration, progressive loss of weight and pro¬ 
fuse night sweats. Tubercle bacilli were found in her expectoration 
and she readily consented to inoculation. After 13 Injections she 
made a complete recovery. Physical signs were greatly diminished, 
although there was still some diminished resonance over the affected 
lung; tubercle bacilli disappeared from her sputum, her cough and 
night sweats entirely disappeared, and she gained 28 pounds in weight 

This I consider one of the most successful cases of the 
series. 

Case 9.—Female, aged 26 years, with marked phthisis at the left 
apex. She had been losing ground for the last 12 monthB, with cough, 




Thb Lancet,] DR. RAW: TUBERCULOSIS TREATED BY DIFFERENT KINDS OF TUBERCULIN. [Feb. 15,1908. 483 


•expectoration, and night sweats. She made application for admission 
to a sanatorium but was declined on the ground that her case was not 
sufficiently early. She has up to the present time had six injections of 
tuberculin. Her cough has practically gone, physical signs much less 
active, and she has gained nearly a stone in weight. 

The case is still tinder treatment and I feel no doubt that 
she will eventually make a complete recovery. 

Case 10.—Man, aged 40 years, in Stage 1 of the disease. Tubercle 
bacilli found. Has had 11 injections and is steadily gaining weight. 

Case 11. —Male, aged 50 years. Phthisis involving both apices, 
physical signs most marked behind. Ho has a very distressing cough ; 
has had two attacks of hiemoptysis. Under tuberculin he has made a 
little improvement but he does not seem to possess much natural 
resisting power so that it is rather difficult to produce immunity. 

Although the patient is a little better I am not satisfied 
that he is making any great headway and I rather think of 
discontinuing the treatment. 

Case 12.—Male, aged 31 years, with active tubercle at the right 
apex. Had a severe haemoptysis two months ago when he lost a large 
quantity of blood. Tubercle bacilli are present and it looked as if he 
was going to develop acute tuberculosis of both lungs. Things, 
however, settled down after two weeks' rest and tuberculin was com¬ 
menced. From the very first injection he commenced to improve, his 
appetite returned, the cough became less, expectoration not tinged 
with blood and diminished, night sweats disappeared, and he gained 
over 18 pounds in weight. A.t the end of 12 injections he was trans¬ 
ferred to our sanatorium where his recovery was completed and he left 
that institution two months ago with his disease completely arrested. 

I examined this patient a few days ago and found him con¬ 
tinuing his work with no symptoms at all to cause him any 
inconvenience. He has still retained all his weight and 
there are no tubercle bacilli found in the sputum. 

Case 13.— Male, aged 37 years, with tuberculosis of both apices with 
old pleurisy at the right bise. He had been losing weight for two 
years and h»B not been able to follow his employment for that time. 
He came into hospital for the purpose of having injections and has 
progressed extremely well after ten injections of tuberculin. lie has 
greatly improved, has gained weight, and cough has disappeared. 

The case is still under treatment and although I do not 
hope for cure yet there is certainly great improvement. 

Case 14.—Male, aged 35 years. Tuberculosis at right apex, erratic 
temperature, quick pulse, night sweats, and emaciation. He was 
treated for one month on ordinary hygienic principles, with complete 
rest in the opeu air-such as we have in Mill Hoad Infirmary—which 
had a good effect. Injections were commenced four mouths ago and 
although he has only had 10 yet he appears to be greatly benefited and 
-expresses himself as being quite a different man. 

I think in this case the disease will be arrested. 

Cask 15. —Female, aged 21 years, two sisters having died from 
phthisis within the last three months. She had only complained for 
six weeks of cough and expectoration. Temperature was high at 
night; pulse 120, with progressive emaciation. Under treatment she 
has made wonderful recovery, although no marked improvement was 
observed until after the seventh Injection. She has now had 13 
injections. Her temperature is normal at ail times ; pulse 90. She 
has gained 18 pounds in weight and Bays she is better than she ever 
was in her life. 

The physical signs in this case were limited to the left 
apex but were evidently of an acute and progressing 
character. The girl herself had practically no resisting 
power, consequently she would have very soon been destroyed 
by the tubercle bacilli. This is an example of the excellent 
effects of tuberculin. 

Case 16.—Femalo, age.l 19 years, strong, sturdy physique. 
Ha-moptysiB three months ago, temperature raised one" degree each 
night, and the physical signs limited to the right apex above the 
clavicle ; in fact, a typical example of Class I. in Turban s classirtcation. 
There were no tubercle bacilli found. After 12 Injections of tuberclin 
no signs or symptoms could he detected. She has gained 8 pounds, 
cough has disappeared, and she lias left the hospital apparently cured. 

From this series of cases of phthisis pulmonalis, the 
results of which I will publish in the course of another 
12 months, I am convinced beyond any shadow of doubt 
that a tuberculin prepared from bovine sources has a most 
marked and curative effect in tuberculous affections of the 
lung, but my experience teaches me that, first, the patient must 
have a certain amount of natural resistance to the organism. 
If this is not present at the time of observation endeavours 
must be made by feeding and general tonics to raise the 
resistance somewhat before the tuoerculin treatment is com¬ 
menced. If it is fonnd impossible with the aid of pure air, 
nutritious food, blood tonics, &c.,ti improve the resisting 
power I have come to the conclusion that tuberculin itself wilt 
not be of mach avail. Secondly, the tuberculou-infection must 
be limited either to one lobeof a lung or to twosmall aress of 
two lungs. If the d’sease has progressed to the formation of 
cavities and general constitutional in ection, tuberculin has 
little or no lasting effects, although it i nproves the patient 
for a time. Thirdly, the age of the (adent is of great 
importance; the younger the patients tha more readily do 
they respond to tuberculin, and I have found that afttr 


the age of 50 it is very difficult to produce good effects 
with it, although it is quite common, of course, to see 
patients of that age recover from an early infection of 
tubercle of the lungs. Fourthly, if there is any concurrent 
disease, such as kidney trouble, tuberculin seems to have 
little or no effect. 

I intend to continue the treatment for another 100 case3 
and I will hope to have the pleasure of reporting to you on a 
future occasion on the total results. At present I am quite 
certain that every early case of phthisis under suitable con¬ 
ditions should be inoculated with bovine tuberculin. 

Tuberculous Glands. 

Twenty-three cases of tuberculous glands of the neck and 
other parts of the body have been treated with tuberculin, 
with, in many instances, the most extraordinary results. 
Several cases of extensive disease, especially when localised 
in the neck, have completely reoovered. The glands are 
noticed first of all to become softer, the peri-adenoid tissue 
seems to become more flaccid and less infiammatory, and the 
glands themselves rapidly diminish in size to vanishing point. 
I have noticed, however, that where there is a tendency to 
suppuration the tuberculin has no good effect and there is 
nothing for it but either to incise the glands or remove them 
altogether. In two instances of inflammatory glands where 
suppuration was threatening tuberculin seemed rather to 
increase the swelling than diminish it, so that from my 
experience of treating glands I would say that tuberculin is 
only indicated where the glands are enlarged and not 
caseating or suppurating. 

Lupus. 

Twenty-four cases of lupus have been treated in the 
hospital, and it is here that the very best results of tuber¬ 
culin are ob'ained. All stages of the disease seemed to 
respond rapidly to injections, and in ail the cases in which I 
have used tuberculin, without any other treatment such as 
scraping or medication, the ulcerated surface has healed with 
a firm cicatrix and in only two instances so far has the 
disease recurred. 

Tuberculous Joints. 

Twenty-seven cases of tuberculous joints, mostly of a 
chronic or subacute variety, have been inoculated; 15 
diseases of the knee, 8 of the hip, and 4 of other joints. The 
cases where the best results were obtained were those in 
which there was some suppuration or sinns directly leading 
down to tubercnlons disease. In the great majority of cases 
the suppuration ceased first and then the sinns closed. In 
cases of pulpy disease of the joints there was in many 
instances marked diminution of the size of the joints with 
absence of inflammation and more movement. I have not 
yet seen any case where fixed or ankylosed joints have been 
benefited. 

Tuberculous Peritonitis. 

Eight cases of tuberculous peritonitis have been treated ; 
4 of the plastic or dry variety and 4 associated with (laid in 
the abdomen. Every one of the cases has recovered and ail 
have been discharged well after 12 injections each of tuber¬ 
culin. I consider that tuberculin is an absolute specific in 
cases of tuberculous peritonitis where the disease is confined 
to the abdomen. 

Tuberculous Meningitis. 

This, the most terrible of all diseases that we are called 
upon to treat, may possibly be deprived of its terrors by 
timely inoculation of tuberculin. Unfortunately, as a rale, 
ia hospital practice the cases do not come until the disease 
is well advanced or where there is some intercurrent 
tuberculous lesion. In two cases of apparent tnbercnlous 
meningitis with all the classical signs the symptoms 
entirely disappeared after four injections of tuberculin and 
both children made rapid recovery. In other two instances 
tuberculin had no effect and the children died. Of course, it 
is impossible to be sure that the first two cases were of a 
tuberculous nature, as tubercle bacilli could not be recovered 
by lumbar puncture, but I have no doubt myself that they 
were. 

Tuberculous Abscesses and Sinuses. 

Eighteen ca-es were treated. In 13 of them no definite 
good results were obtained as they were of a chronic nature, 
but. in five cases the sinuses closed and the patients soon got 
fat and apparently well. 

The whole of these 104 cases of surgical tuberculosis have 
been, of course, treated by Koch's tuberculin R., which, as 
you know, is manufactured from tubercle bacilli obtained 




484 The Lancet,] ACUTE POLIOMYELITIS WITH DIPLOOOCCAL INFECTION OF SPINAL SAC. [Feb. 15,1908. 


from human sources and exactly in contra-distinction to the 
cases of phthisis which were treated by a bovine tuberculin. 
In summing up the treatment of surgical tuberculosis I have 
found that if there is any waxy disease present the tuberculin 
has no effect, so that it is important to find out before treat¬ 
ment is commenced, especially in chronic cases, the con¬ 
dition of the liver, spleen, and kidneys. A large number of 
similar cases will be placed under treatment during the next 
few months and I hope to be able to record similar satisfac¬ 
tory results. 

I would strongly advocate the treatment to be carried out 
by practitioners on their patients in their own homes. If 
careful precautions are observed there is no risk or danger 
whatever, and, from my experience, the tuberculin is care¬ 
fully prepared and standardised by the Clinical Research 
Association at a moderate cost. 

The following is a summary of the cases treated by Koch's 
tuberculin : glands in the neck, 23 ; lupus of the face, 24 ; 
joints, 27 ; peritonitis, 8 ; meningitis, 4 ; tuberculous sinuses, 
18; total 104. Number of cases treated by tuberculin pre¬ 
pared from bovine sources : phthisis pulmonalis, 18. 


ON A CASE OF ACUTE POLIOMYELITIS 
ASSOCIATED WITH A DIPLOCOCCAL 
INFECTION OF THE SPINAL SAC. 

By WILLIAM PASTEUR, M.D. Lond., F.R.C.P. Lond., 

PHYSICIAN TO THE MIDDLESEX HOSPITAL; 

ALEXANDER G. R. FOULERTON, F.R.C.S. Eng., 
D.P.H. Cantab., 

LEFTITBKR ON BACTERIOLOGY AND ON PITSI.IC HEALTH TO THE 
MIDDLESEX HOSPITAL; 

AND 

HENRY MACCORMAC, M.B., Ch.B. Edin., 

DEMONSTRATOR IN THE BACTERIOLOGICAL DEPARTMENT OF THE 
MIDDLESEX HOSPITAL. 


Whilst it has been recognised for many years that an 
infective origin is probable for certain nervous affections 
which have a paralysis of acnte onset as their chief clinical 
manifestation, such as acute poliomyelitis, acute disseminated 
myelitis, and Landry’s paralysis, the evidence indicating the 
mode of causation has been hitherto of a circumstantial 
rather than a direct nature. In the coarse of an investiga¬ 
tion into the case which we shall now describe we have 
obtained, however, further evidence of an important kind, 
inasmuch as having identified a micrococcus in the spinal 
fluid withdrawn during life from a boy with symptoms of 
acnte poliomyelitis we have succeeded in producing an 
ascending motor paralysis in the rabbit, after a prolonged 
period of incubation, by inoculating this fluid into the sub¬ 
dural space. On the death of the experimental animal we 
have been able to demonstrate in the cerebro spinal fluid a 
micrococcus similar to that seen in the fluid from the human 
case ; and further, by similarly inoculating another rabbit 
with an emulsion of cerebro-spinal substance and fluid from 
the first experimental animal we have succeeded in repro¬ 
ducing a motor paralysis, again after a somewhat prolonged 
period of incubation, and again associated with the presence 
of the micrococcus in the spinal fluid. But whilst we have 
succeeded thus in obtaining direct evidence of the infective 
nature of the illness and of its association with a certain 
micro-organism, our evidence is incomplete bacteriologically, 
since we failed to obtain the micrococcus in culture on 
artificial media, and so are nnable to give a complete 
description of it. 

The Clinical History op the Case. 

The patient was a slightly built schoolboy, aged 13£ years, 
and of rather delicate appearance. The history of the onset 
of his illness was as follows. He was apparently in his 
usual health on Nov. 11th, 1906. On the evening of the 
next day he complained of shooting pains in the thighs and 
across the abdomen at about the level of the anterior 
superior iliac spines. He was Beriously ill during the night 
and the following day with severe abdominal pain and 
quiet delirium. On the 13th he was free from delirium and 
felt better generally, but during the night he suffered 
again from sharp pains in the legs, which were increased by 
movement. On the morning of the 14th the patient was 
unable to leave his bed because of an almost complete loss of 


power in both legs. By the 16th he had become quite helpless 
and, although he could use his arms to some extent, was 
unable to move himself in his bed. About this time his 
friends noticed that he was unable to cough. He was 
admitted into the Middlesex Hospital on the 19th. There 
was nothing in either the family history or the previous 
personal history of the patient which appeared to have any 
direct bearing on his present illness. He was one of a family 
of five children ; the other four were in good health. The 
patient himself was described as having been always rather 
delicate and nervous ; when younger he had suffered from 
scarlet fever, measles, chicken-pox, and whooping-cough, 
and when five years old had been treated at the hospital for 
rickets and bronchitis He had had “a fit "on two occa¬ 
sions, once at the age of two years and again two years ago ; 
latterly his general health had been fairly good and there 
was no history of any special indisposition immediately 
preceding the present illness. 

On his admission into hospital the patient lay helpless in 
his bed. His complexion was somewhat dusky, his voice was 
feeble, and there were frequent toneless, non explosive 
efforts at coughing. The respiration-rate was 40 and the 
pulse-rate was 100 and regular. The temperature on 
admission was 99° F., but during the first ten days after 
admission it ranged between 100° and 103° in consequence 
of a broncho-pneumonia which was probably secondaiy to 
collapse of the left lung. The head was drawn somewhat 
towards the left side and was moved with difficulty because 
of muscular weakness, the patient being unable to lift it 
from the pillow. There was no evidence of any paralysis of 
the facial, lingual, or pharyngeal muscles ; the movements 
of the eyes were not impaired, the pupils were normal in size 
and as to movement, and the conjunctival reflex was natural. 
Both lower limbs were in a condition of complete flaccid 
paralysis except for some flickering muscular contractions 
which could be seen on attempts to flex or extend 
the toes of the right foot. And, except the right peroneal 
muscles, which responded feebly to strong galvanic stimula¬ 
tion, the paralysed muscles did not react to either faradic or 
galvanic currents. The plantar, patellar, and cremasteric 
reflexes were not obtainable. Respiration was entirely 
thoracic in character ; there was no movement of the abdo¬ 
minal muscles in respiration, nor was there any visible con¬ 
traction of them when the patient attempted to cough or to 
lift his head from the pillow. The diaphragm was apparently 
paralysed completely. The patient was unable to turn to 
either side, but could arch bis back slightly. The abdominal 
and epigastric reflexes were not obtainable. The sphincters 
were not apparently impaired. The thoracic movements 
were equal on either side but were distinctly deficient. On 
auscultation of the front of the chest a fair amount of air 
could be heard entering the lungs, but a complete examina¬ 
tion of the chest was not made at the time because of the 
severe respiratory distress which accompanied the least dis¬ 
turbance of the patient. On subsequent examination, how¬ 
ever, it was evident that there had been some considerable 
collapse of the lungs, and especially on the left side, as a 
result of paralysis of the diaphragm and intercostals. The 
range of movement of the arms was as normal, but the 
muscular power was notably weak. The extensor muscles 
reacted to strong faradic currents, the flexors reacted 
normally. Tactile sensibility and sense of temperature were 
normal everywhere. There were no abnormal sensations nor 
was there any exaggerated surface tenderness. The organs 
of special sense were apparently healthy. 

During the first ten days when the patient was under 
observation his condition was one of much danger because of 
a broncho-pnenmonia which was apparently related to the 
collapse of the lungs which had followed the paralysis of 
some of the respiratory muscles. But on Nov. 30th the tem¬ 
perature fell suddenly to normal and the patient’s general 
condition improved quickly thereafter. Some recovery of 
power in the muscles of the arms, the shoulders, and the 
neck was evident early in December, and by the end of the 
year the patient had apparently free use of his arms, 
could turn readily from side to side in bed, and could raise 
himself to a sitting posture. Borne further improvement 
followed, but when the patient was shown at a meeting of 
the Clinical Section of the Royal Society of Medicine on 
Dec. 13th, 1907, he was still completely crippled so far as 
any use of bis lower limbs was concerned. 

The evolution and progress of the symptoms in the case 
were in complete accordance with the recognised clinical 
features of acute poliomyelitis, and there was little difficulty 


j 





The Lancet ] ACUTE POLIOMYELITIS WITH DIPLOCOCCAL INFECTION OF SPINAL SAC. [Feb. 15, 1908. 485 


in arriving at the conclusion that the patient was suffering 
from one of the less common types of this affection, the 
motor nerve-supply of almost the whole muscular system of 
the trunk as well as that of the limbs being affected in 
greater or less degree. 

The Bacteriological Investigation. 

Four specimens of the patient’s cerebro-spinal fluid were 
obtained by lumbar puncture on the following dates: 
Specimen 1. on Nov. 22nd, 1906; Specimen II. on Dec. 14th, 
1906 ; Specimen III. on March 25th, 1907 ; and Specimen IV. 
on April 17th, 1907. The fluid was clear when withdrawn, 
but on standing threw down a small greyish sediment which 
microscopically consisted of lymphocytes. 

Cgtologioal examination of the cerebrospinal fluid .—The 
deposit obtained on centrifugation of the fluid apparently 
consisted entirely of mononuclear cells (lymphocytes); no 
polymorphonuclear leucocytes were seen. In this respect, 
it may be noted, the fluid resembled that obtained by 
Geirsvold 1 from 12 cases occurring during an epidemic of 
acute poliomyelitis which happened in Norway in 1905 
Geirsvold found that the deposit from the spinal fluid in his 
cases consisted chiefly of mononuclear cells and very rarely 
contained any polymorphonuclear leucocytes. 

Bacteriological examination of the cerebrospinal fluid —A 
micrococcus with an obvious arrangement in pairs was reco¬ 
gnised in stained preparations of the fluid drawn off by lumbar 
puncture on Nov. 22nd and on Dec. 14'h, but could not be 
found in the specimens of the fluid which were drawn off 
on the two later dates. In most of the cover-glass prepara¬ 
tions made from the two earlier specimens of fluid a few 
widely scattered diplococci could be distinguished un- 
mistakeably ; in one or two observed instances two pairs 
were grouped as tetrads. The cocci were of comparatively 
large size and in this respect were equally comparable with 
micrococcus pneumoniae ; there was some indication of a 
capsule, but this was not so distinct as it was with the diplo¬ 
cocci which were found in the cerebro spinal fluid of the 
experimental rabbits. The diplococci were always found 
free in the fluid, no intracellular forms occurred. We were 
unable to obtain a culture of this diplococcns on artificial 
media ; media of every description were inoculated with the 
fluid and incubated both aerobically and anaerobically, but 
in no instance was growth of any kind obtained. 

Animal experiments .—Altogether nine rabbits were inocu¬ 
lated with cerebro-spinal fluid obtained from the case, seven 
being inoculated intracranially, one intraperitoneally, and 
one subcutaneously. Sundry other rabbits were inoculated 
intracranially with an emulsion of cerebro-spinal substance 
and fluid from certain of the first series of experimental 
animals. The intracranial inoculations were carried out by 
means of a fine hypodermic syringe through a small trephine 
opening in the frontal region ; in the case of the first series 
of animals a cubic centimetre of cerebro-spinal fluid from the 
patient was injected into the subdural space. One animal 
(Rabbit 4) died as the direct result of the operation ; all the 
others apparently recovered quickly and completely from the 
immediate effects of the operation. The results of our 
experiments were as follows. 

Rabbit 1, inoculated from the specimen of spinal fluid 
drawn oil on Nov. 22nd, was found dead on the twenty second 
day afterwards and diplococci similar to those identified in 
the patient's fluid were found in its spinal sac. This animal 
had not been under close observation during the week which 
preceded its death and consequently we are unable to say 
whether there had been any paralyses. 

Two rabbits (Nos. 2 and 3) were inoculated with an emul¬ 
sion of the cerebro-spinal substance and fluid of Rabbit 1. 
Rabbit 2 died on the eleventh day after the inoculation and 
Rabbit 3 was killed under chloroform on the following day. 
Both animals were apparently quite well up to the time of 
death ; no cause for the death of the foimer could be found, 
and the appearances in each after death were quite normal, 
nor were any micro-organisms found in the cerebro-spinal sac 
of either. 

Two rabbits (Nos. 4 and 5) were inoculated with the 
specimen of fluid drawn off on Dec. 14th. Rabbit 4 died 
within 24 hours from an intracranial haemorrhage the result 
of the operation. Rabbit 5 remained apparently well for 
more than six weeks, but on the fiftieth day after inocula¬ 
tion it was noticed that the bind limbs were partially 
paralysed. Two days later the hind limbs were completely 
paralysed and the fore limbs partially paralysed ; the animal 


meanwhile had been eating well and, except for the paralysis, 
was not obviously ill. Death occurred on the fifty-third day 
after the inoculation, and a fair number of diplococci were 
found in the animal's cerebro-spinal fluid. 

Two rabbits (Nos. 6 and 7) were inoculated with an 
emulsion of the cerebro-spinal substance and fluid from 
Rabbit 5. Of these, Rabbit 6 was killed under chloroform 
on the forty-first day after the inoculation, the animal being 
then apparently healthy, and no diplococci could be found in 
the cerebro-spinal sac. Rabbit 7 was found to have com¬ 
plete paralysis of the hind limbs on the forty seventh day 
after the inoculation, followed rapidly by a paralysis of the 
fore limbs which was very plainly obvious on the forty-ninth 
day. The animal was killed on the fiftieth day after the 
inoculation and diplococci were found in the cerebro-spinal 
sac. 

Rabbits 10 and 11 were inoculated with an emulsion of the 
cerebro-spinal fluid and substance from Rabbit 7. One died 
on the fourth day after inoculation, but the cause of death 
could not be ascertained ; the other did not suffer from any 
apparent ill-effects and was alive and well four months 
afterwards. 

Diplococci had been seen in the specimens of spinal fluid 
from the patient from which these rabbits had been 
inoculated, but none were seen in the specimens withdrawn 
on March 25th and April 17th, 1907, with which the remaining 
animals (Rabbits 8, 9, 12, 13. 14, and 15) were inoculated, 
and none of these animals suffered apparently from the 
inoculation. 

In the case of each animal that either died naturally or 
was killed under chloroform a careful examination was made 
of stained specimens of the cerebro-spinal fluid, the heart 
blood and the juice from the spinal cord, the spleen, and 
other organs, but in no case were any diplococci found 
except in those instances in which we have noted its presence 
in the cerebro-spinal fluid. Culture media of the most varied 
description were inoculated also from the cerebro-spinal 
fluid, the heart blood, and various tissue juices in every case. 
But except for occasional growth, which was obviously due 
to accidental causes, all the media used remained sterile on 
incubation ; and, in particular, no growth of any kind was 
obtained on any of the media inoculated with the cerebro¬ 
spinal fluid from Rabbits 1, 5, and 7, in which we had been 
able on microscopical examination to demonstrate clearly the 
presence of the diplococci. 

Except in the case of the rabbit which died from an 
accident of the inoculation operation, and Rabbits 14 and 15, 
which died from coccidiosis, no macroscopic morbid change 
was found after death—in every case the meningeal mem¬ 
branes appeared perfectly natural and healthy, nor was any 
excess or other abnormality of the cerebro-spinal fluid 
noticed. 



Microphotograph showing cocci in cerebro-spinal fluid of Rabbit 
No. 1 dying on twenty-second day alter inoculation. 


Unfortunately, no adequate histological examination of the 
spinal cords of the rabbits was made. Small portions of the 
cervical, dorsal, and lumbar cord from Rabbit 7 only were 


1 Geirsvold : Tldaskrilt for den Norake Laegeforening, No. 20, 190 




486 The Lancet,] ACUTE POLIOMYELITIS WITH DIPLOCOCCAL INFECTION OF SPINAL SAC. [Feb. 15,1908. 


examined, but neither any change in the ganglion cells when 
stained by Nissl’s method nor any perivascular change could 
be detected. 

The diplococci, alike in the patient’s cerebro-spinal fluid 
and in that from the rabbits, stained well and deeply with 
Loefller’s blue, bub we were not able to detect any specimens 
of the micro-organisms in films of the fluid which had been 
stained by Gram's method, with a counterstain, and so we 
are unable to state the reaction of the diplococci in this 
respect. In the rabbits’ spinal fluid the diplococci were 
very sparsely scattered, they were grouped in pairs, 
occasionally in tetrads, and in one instance (see Figure) a 
chain of four cocci was noticed. 

The results of our inoculation experiments may be con¬ 
veniently recapitulated in tabular form. 


the years 1903, 1904, 1905, and 1906, and have been recorded 
by Geirsvold 5 and by Harbitz and Sclieile.” Geirsvold, 
writing in 1905, states that 437 cases of the disease, with 
69 deaths, had occurred in Norway during the year. The 
disease was of an epidemic character, spreading from farm 
to farm over the whole country. Frequently preceding, some¬ 
times coinciaently with, a local outbreak of cases of acute 
poliomyelitis there were cases of illness of a milder or 
abortive character. In these milder cases, in which obvious 
illness lasted for from one to four days, the principal 
symptoms were those of fever, with rigors, sore throat, 
sweating, and sometimes evidence of some meningeal irrita¬ 
tion. In this type of case paralyses did not occur as a rule 
but Geirsvold notes that in some of them a progressive 
paralysis, sometimes terminating fatally, developed after 


Table of Animal Experimf.nts. 


Specimens of spinal 
fluid. 

Scries I .—Animals inoculated with 
cerebro-spinal fluid from 
patient. 

Series II .—Animals inoculated with 
an emulsion of the cerebro¬ 
spinal substance and fluid 
from rabbits of Series I. 

Series III .—Animals inoculated 
with an emulsion of cerebro¬ 
spinal substance and fluid 
from rabbit of Series II. 

Specimen I., drawn off 
on Nov. 22nd, 1906. 
Contained diplococci. 

Rabbit 1.—Intracranial inoculation : 
died on twenty-second day after¬ 
wards. I>iplococci present in cerebro¬ 
spinal Jluid. 

Rabbit 2. — Inoculated on Dec. 14t,h 
from Rabbit 1; died on Dec. 25ih; 
cause oi’ death not ascertainable; 
result of experiment negative. 

Rabbit 3. — Inoculated on Dec. 14th 
from Rabbit 1; killed on twenty- 
sixth day, apparently healthy. 


Specimen II.. drawn i 
off on Doc. 14th. 1906. 
Contained diplococci. | 

Rabbit 4. —Intracranial inocula’lon ; 
died from accident within 24 hours 
of operation. 

Rabbit 5. — Intracranial Inoculation ; 
marked paralysis of hind limbs on 

1 fiftieth day after inoculation ; partial 
paralysis of forelimbs on fifty-second 
day; death on fifty-1idrd day. Diplo¬ 
cocci present in spinal jluid. 

Rabbit 6—Inoculated on Feb. 6t,h, 
1907, from Rabbit 5; killed under | 
chloroform on forty-first day. Re- 1 
ault of experiment negative. 

Rabbit 7.—Inoculated on Feb. 6th, 
1907, from Rabbit 5; complete para¬ 
lysis of hind limbs and partial of fore- 
limbs on forty-ninth day; killed on 
fiftieth (lay. Diplococci present in 
cerebrospinal Jluid. 

Rabbit 10.—Inoculated on 
March 27th from Rabbit 7; died 
on fourth day after inoculation * 
cause of death not ascertainable. 

Rabbit 11.—I noc u 1 ate d on 
March 27th from Rabbit 7; alive 
and well four months afterwards* 

Specimen III., drawn 
off on March 25th, 
1907. No diplococci 
seen in cover-glass 
preparations. 

Rabbit 8. —Intracranial inoculation ; 
killed on twenty-first day; result of 
experiment negative. 

Rabbit 9.—Intracranial inoculation ; 
alive and well four months after- 
1 wards. 



Specimen IV.. drawn 
off on April 17th, 1907. 
No diplococci Been in 
cover - glass prepara¬ 
tions. 

Rabbit 12.—Intracranial inoculation ; 
died on July 2nd from coccidiosis. 

1 Rabbit 13.—Intracranial inoculation ; 
alive and well three months after- 

1 wards. 

; Rabbit 14.—Intraperitoneal inocula 

tlon; died on May 9th from cocci¬ 
diosis. 

i Rabbit 15-—Subcutaneous inoculation ; 
died on July 12th from coccidiosis. 




As to the Infective Origin of Some Cases of Acute 
Poliomyelitis. 

Whilst there is, as we said at the commencement, a con¬ 
siderable volume of indirect or circumstantial evidence 
which indicates a probable infective origin for, at any rate, 
some cases of acute poliomyelitis, the only reliable direct 
evidence as to causation which has been obtained hitherto is 
that derived from the work of Geirsvold, 2 to which we will 
refer a little later. The indirect evidence as to the causation 
of this affection is comprised in records of outbreaks of 
illness, either limited to a single family or of widely epidemic 
character, in which an acute paralysis, apparently due to 
acute poliomyelitis, has been either a prominent primary 
feature or a frequent consequence. 

As a typical example of what may be termed the family 
outbreak we may refer to the instance recorded by one of 
us (W. P.) 3 in which an entire family of seven children were 
attacked by a mild febrile disorder which was followed in 
between five and seven days by marked motor paralysis in 
three cases, by muscular tremors and temporary strabismus 
in another case, and by general muscular tremors in a fifth 
case. Other outbreaks of similar character have been re¬ 
corded and most of them are referred to in Dr. Farquhar 
Buzzard’s Goulstonian lectures for 1907 on Certain Acute 
Infective or Toxic Conditions of the Nervous System. 1 

Epidemic outbreaks of an illness of which acute polio¬ 
myelitis was a prominent feature occurred in Norway during 


apparent convalescence and after the patient had returned to 
work, and comments on the likelihood of the mild antecedent 
illness being overlooked in such cases of late paralysis. In 
the course of the epidemic children and adults were attacked 
and whilst some types of the disease resembled in their 
broad features cases of epidemic cerebro-spinal meningitis 
caused by diplococcus intracellularis of Weichselbaum a 
consideration of the epidemic as a whole leaves no doubt as 
to the different specific nature of the infection. 

Dealing next with the direct evidence as to the infective 
nature of these cases of acute poliomyelitis, one has only to 
refer to a recent review by Carl Looft 7 of the Bacteriology 
of Acute Anterior Poliomyelitis to show how contradictory 
and generally unsatisfactory most of the evidence which has 
hitherto been brought forward has been, Thus, Harbitz 
and liulow-Hansen have recorded the finding of a diplo¬ 
coccus in the spinal fluid of a case of anterior poliomyelitis 
examined after death. Schultze 7 recorded the finding of 
the meningococcus in a single case, and in a second com¬ 
munication 13 recorded the finding of diplococci in two other 
cases one of which, however, appears to have been of a 
tuberculous nature. Concetti 11 has published the results of 


* Geirsvold : loo. cit. 

o Harbitz and Scheile: The Journal of the American Medical Asso- 
ation, vol. xlix., 1907 ; also Pathologlsch-Anatomische UntorsuchunKen 
oer Aknte Poliomyelitis nnd vorwandte Krankhciten von den fcpl- 
smien in Norwogeh, 1903-19C6. , . , 0 -. 

i Carl Looft: Review of Neurology and Psychiatry, lSOI. 


2 Geirevold : Ibid. ] 1898. 

3 W. Pasteur: Transactions of the Clinical Society of London, 

vol. XXX. 

* F. Buzzard : The Lancet, March 16th (p. 705), 23rd (p. 785), and 30th ] Supplement,! 907. , „ . ,. Aa iqoo 

(p 863), 1907. I n Concetti: Revue Mensuelle des Maladies de 1 Enfance, law. 


s- Schultze: Jahrbuch fiir Kinderheilkunde, Band iv., 1899. 
Schult/.e : Ziegler's Beitriige zur Pathologischen Anatomie, SeventU 



The Lancet,] 


MR. E. C. HORT : THE THERAPEUTIC USES OF NORMAL SERUM. [Feb. 15, 1908. 487 


the examination of the fluid removed by lumbar puncture in 
10 cases of anterior poliomyelitis ; nine of the cases were 
examined by bacteriological methods, and the pneumococcus 
was found in two cases and the meningococcus in a third. 
Looft and Dethloft 12 isolated from the Bpinal fluid of two 
cases an organism which is described as resembling Heubner’s 
type of meningococcus. And, finally, Engel ls obtained 
staphylococcus albus on media inoculated with the spinal 
fluid of a boy with acute anterior poliomyelitis, disease of 
the middle ear, and osteo-myelitis of the clavicle. To these 
bacteriological observations mentioned by Looft may be 
added the experience of Barnes and Miller 11 who found 
staphylococcus pyogenes citreus and staphylococcus albus in 
a case examined after death. 

The results of bacteriological work 60 far are not of any 
particnlar value for the elucidation of the causation of cases 
of acute poliomyelitis ; in some cases it is highly probable 
that the organism obtained on culture media came from 
accidental contamination during the bacteriological pro¬ 
cedure. In other cases question arises as to clinical diagnosis, 
and in no case is any evidence brought forward that the 
organism obtained in culture had any causative relationship 
to the disease. 

The results obtained by Geirsvold, on the other hand, were 
consistent and afford the strongest presumptive evidence 
that he was successful in isolating a diplococcus which stood 
in causative relationship to the disease which was under 
investigation. Geirsvold examined the cerebro-spinal fluid 
obtained either by lumbar puncture during life or after death 
from cases of the epidemic disease which has recently pre¬ 
vailed in Norway. It does not appear how many cases were 
examined, but in 12 cases Geirsvold obtained in pure culture 
a diplo- or tetro-coccus which readily produced chains of four 
or six elements when growing in nutrient broth. 

On solid media the growth of the organism was slow at 
first and scanty, resulting in sparsely scattered, small, 
greyish colonies having the appearance of dewdrops, but in 
subsequent subcultures a more vigorous growth was obtained. 
After growing for some time on agar the colonies acquired a 
toughish consistence; in nutrient broth the growth formed a 
coherent sediment; in peptone water growth was scanty, 
and in this medium “ degenerate ” forms of the micrococcus 
were seen. Some growth was obtained on potato and in 
milk, the latter medium being coagulated after some days. 
Growth was obtained occasionally on gelatin and then the 
medium became liquefied. The organism stained by Gram's 
method. The organism was pathogenic for mice ; some of 
the animals inoculated died within 24 hours and in some 
cases showed signs of muscular paralysis before death ; other 
mice appeared to recover from the inoculation but developed 
paralysis later. Rabbits also were susceptible, sudden 
paresis of the hind limbs developing after a prolonged 
incubation period. Geirsvold notes that in order to obtain 
cultures of the micrococcus large quantities of the spinal 
fluid must be incubated. He very rarely obtained cultures 
after the tenth or twelfth day of the disease, although 
diplococci could be seen in the fluid withdrawn from the 
spinal sac, an experience which has a bearing on our own 
failure to obtain any growth of the organism which could be 
seen in spinal fluid withdrawn on about the twelfth day 
after the onset of illness and again later. 

Conclusions. 

It appears to us that Geirsvold's investigations have estab¬ 
lished beyond question the existence of a specific infective 
disease of which acute poliomyelitis is a frequent and promi¬ 
nent, but not essential, feature. And we believe that the case 
which we now record represents a sporadic case of the 
disease which Geirsvold investigated under epidemic circum¬ 
stances. From the somewhat scanty information at our 
disposal it would appear that this specific disease has no 
clearly distinguishing primary features to enable one to 
differentiate it by its clinical symptoms from many other 
febrile conditions of probably infective origin which are 
frequently met with in practice but which may not have 
sufficiently distinctive symptoms to enable a definite 
diagnosis to be arrived at. And so whilst the Berious 
complication of acute poliomyelitis when it has occurred 
has been at once recognised, the primary disease has 
cot been differentiated hitherto but has in fact usually 
been altogether overlooked. That the disease is not con¬ 
fined to man is suggested by an epidemic of some 160 


cases of what appears to have been acute anterior polio¬ 
myelitis which has been recorded by Dana, 15 and in which 
cases of paralysis were observed amongst lower animals in 
the locality in which the human cases occurred. 

It would be unprofitable, again because of the insufficient 
information at our disposal, to attempt to discuss the exact 
pathology of the acute poliomyelitis which is one of the 
results of this infection. Neither our own experience nor 
Geirsvold's much more extensive investigation throws any 
light upon the question as to whether the affection of the 
nervous system is merely a casual incident of what may be 
termed broadly a general infection or whether, having gained 
an entrance into the tissues, the infecting parasite has, as 
diplococcu s intracellularis of IVeichselbaum apparently has, 
a special tendency to locate itself in the cerebro spinal sac. 
Nor are we at present in a position to consider whether the 
poliomyelitis is due to a direct and localised action of the 
diplococci which are seen in the spinal fluid or whether it 
results from the action of toxins circulating in solution in 
the lymph or blood, which may have an affinity, such as that 
of the toxins of the tetanus bacillus, for nerve-cell substances. 
It must not be forgotten that although the diplococcus has 
hitherto been recognised only in the cerebro-spinal fluid there 
is no reason for assuming that it is specially localised in the 
sac of the central nervous system. We failed in the case of 
our experimental rabbits to obtain cultures of the organism 
from either the cerebro-spinal fluid or from the blood and 
other tissue juices, and the fact that the organism was 
identified in very small numbers only in the almost clear 
cerebro-spinal fluid in which its recognition would be com¬ 
paratively easy did not preclude its existence in the blood, 
where its presence would be much more difficult of demon¬ 
stration by merely microscopic methods without corrobora¬ 
tive cultivation experiments. 

In conclusion, we would suggest that there is not sufficient 
reason for assuming that acute poliomyelitis is always a 
result of this particular diplococcal infection. The sym¬ 
ptoms by which acute poliomyelitis is recognised in clinical 
practice are the consequences of a constitutional alteration 
of certain cells of the central nervous system which causeB 
an impairment of their functional efficiency. That this 
constitutional alteration is necessarily produced by only one 
specific cause appears to us to be highly improbable. We 
think rather that it is probable that the cell changes which 
result in the symptoms of acute poliomyelitis may be caused 
also by the toxins produced in other infective processes, and 
we may refer to the experience of so good an observer as 
Trevelyan 10 who found that out of 50 cases of infantile 
paralysis which he had treated the symptoms had followed 
immediately on measles in two cases, in one case had come 
on after typhoid fever, and in another case after acute 
rheumatic fever. 

Middlesex Hospital, W. 


THE THERAPEUTIC USES OF NORMAL 
SERUM. 

By E. C. HORT, B.A., B.Sc. Univ. Paris, M.R.C.P. Edin. 

In The Lancet of Dec. 21st, 1907, p. 1744, I mentioned 
that daring the last 12 months I had been treating with most 
enconraging results a number of morbid conditions by the 
administration of normal serum. Amongst the diseases that 
I have treated, and am proposing to treat, in this way are 
the following conditions: gastric and duodenal ulcer, with and 
without hsemorrhage; chlorosis and other forms of anaemia ; 
hsemophilia; purpura bscmorrhagica ; tuberoulous peri¬ 
tonitis ; hmmoptysis; ulcerations of all kinds; pulmonary 
cclema; pneumonias, Ac. In addition to these Dr. Arthur 
Latham has, at my suggestion, employed normal serum in 
a number of similar and other cases and has most kindly 
allowed me access to his notes. 

My attention was first drawn to the subject by the work of 
Dr. Emil Weil of Paris on the treatment, by fresh animal 
serums, of hsemophilia and allied conditions, and by Dr. 
Perthes’s observations on hsemophilia. It appears that these 
observers, believing that a deficiency in coagulation power 
was an important factor in the blood in such diseases as 
haemophilia, sought to remedy this by giving an artificial 
supply of fibrin ferment. With this object Weil gave intra¬ 
venously or subcutaneously injections of various animal 


18 Looft and Dethloft: Medicinsk Revue, 1901. 

I: F. Eugel: Prager Medicinieche Wochensehrfft, No. 12, 1900. 
n Barnes and Miller i Brain, 1907. 


15 C. L. Dana: Boston Medical and Surgical Journal, voL cxxxii., 
Jan. 3rd, 1905. 

is E. F. Trevelyan : British Journal of Children’s Diseases, April, 1906. 






[Feb. 15, 1908. 


488 The LANCET,} MR. E. C. HORT: THE THERAPEUTIC USES OF NORMAL SERUM. 


serums in doses strictly limited in quantity to avoid “inverted 
action ” such as obtains in the analogous case of calcium 
salts. I found, however, that the clinical results of giving 
serum in this way in severe cases of haemorrhage were, apart 
from haemophilia, most disappointing. Haemorrhage was 
little afEected and coagulation time was not accelerated. I 
therefore gave much larger doses by the mouth and gave it 
repeatedly, and found it possible to control severe haemorrhage 
in cases of purpura, acute hmmatemesis, and in cases of 
tuberculous haemoptysis otherwise uncontrollable. Further, 
by extending the range of application I found that a most 
remarkable improvement in the clinical symptoms and in the 
condition of the blood followed in cases of many affections 
in no sense haemorrhagic, such as chlorosis and ulcer without 
haemorrhage. Hence, whatever value normal serum therapy 
may prove to have, it does not seem obviously connected with 
supplying fibrin ferment. 

What the true explanation is must at present be a matter of 
speculation. It is conceivable that the administration of normal 
serum may affect the production of auto-anticomplement, or 
in some unknown way correct a disturbance of the regulating 
mechanism that Ritchie and others have postulated in order 
to explain Ehrlich's “horror autolyticns.” For instance, in 
the paper referred to I have suggested that gastric ulcer is 
not a disease sui generit but is merely the local expression of 
a general blood dyscrasia at present unrecognised and that 
the essence of such disease may be the presence in the blood 
of cytolysins for gastric epithelium. The success that I have 
so far been able to obtain by the repeated oral administration 
of serum in many of these cases supports the view that it in 
some way affects the autolysis here supposed to cause the 
disease. Whatever the explanation, the exhibition of a 
large number of cases of different diseases treated in this 
way cannot fail to be of value in determining the utility of 
the treatment. 

It will be seen that many interesting questions will arise 
in connexion with normal serum therapy. For instance, 
what share have the normal constituents of serum in the 
results obtained by the use of Berums such as the anti- 
diphtheritic and the polyvalents which we now attribute 
entirely to the action of abnormally produced bodies 7 
Although I am optimistic as to the effects of normal serum- 
therapy in various conditions, our knowledge of its action 
is so slight that caution must be exercised in its UBe, and it 
is desirable that methods of testing and standardising the 
serum with regard to its anti-autolytic, anti-hsemorrhagic, 
and other properties should be employed in the future. It is 
also important that serum should be used from a horse that 
has been repeatedly bled, as its activity seems to be thereby 
enhanced. 

The results in some of my own cases have been so striking 
that an anonymous donor has placed at my disposal a fund 
for the further investigation of the action of fresh serums. 
I am by this means able to avail myself of the aid of two 
other investigators on the staff of St. George’s Hospital— 
viz.. Dr. F. L. Golla and Dr. A. J. Jex-Blake, and collateral 
researches are now being actively pursued in the laboratory 
and in the clinical wards of several public institutions. I 
hope shortly, therefore, to present a large series of cases of 
various diseases treated in this way and to indicate thereby 
the limit of application. Appended are notes of four cases to 
indicate the possibilities apparently involved. 

Cask 1. Marked, anrrnia .—'The patient, an unmarried woman, aged 
30 years, looked very ill and au^mio. She had had poor health for 
three years and had twice been treated in a nursing home without 
benefit. She complained of obstinate dyspepsia and distaste for food, 
troublesome constipation and amenorrhora, slight gastrectasis and 
heavily loaded tongue, and dyspncea on the slightest exertion. There 
was (rdems in both legs up to the hips which pitted deeply on 
pressure. A loud hmmie bruit could he hoard and the apex beat was 
in the nipple line. The urine was normal and there was no enlarge¬ 
ment of the spleen. The blood count, showed 60 per cent, of hemo¬ 
globin and a fall in red corpuscles to 2,800,000. The blood had never 
previously been examined. The treatment adopted was rest, simple 
salines, ordinary diet and serum given in milk by the mouth on the 
following days—Nov. 24th, 26th. 28th, and 30th, and Dec 1st. 3rd. 5th. 
7th, 9th, and 11th. In three days the (edema had nearly disappeared 
and in a week it was entirely gone, as also were the dyspnoea and 
dyspepsia. The patient was driving in ten davs and walking in 14 days. 
The blood counts were na follows :—Nov. 20th, haemoglobin 60 por 
cent, and red corpuscles 2.800.000: Nov. 26th, hemoglobin 65 per 
cent, and red corpuscles 3.500.000; Dec. 6th, haemoglobin 75 per cent, 
and red corpuscles 4.000,000; and Dec. 19th, hiemoglobn, 85 per cent, 
and red corpuscles 4,560,000. 

This case, then, was one in which there had been obstinate 
dyspepsia for three years, which had proved refractory to 
treatment, and which had been associated with progressive 
anaemia and latterly marked cedema. Ooincidently with the 


giving of serum there was immediate improvement in all 
the symptoms and the patient made a rapid recovery. 

Case 2. Tuberculous hemoptysis.—T his was an exceptionally good 
test case. The patient was a man, aged 26 years, with early but rapid 
tuberculosis of both lungs. When I first saw him in consultation he 
was bleeding profusely. “ Stereotyped ” treatment, including calcium 
chloride, had been tried for three davs without avail. Amyl nitrite was 
the first suggestion that I made. This was as unsuccessful as I have 
always found it to be. Serum was then given by the mouth and bowel 
and two doses were sufficient to arrest bleeding. There was no more 
bleeding of any importance for some weeks when a fresh, though much 
less alarming, attack occurred. On auscultation a fresh focus of infection 
was clearly made out. The hemorrhage was again immediately arrested 
by giving serum. In the next few months, at intervals of a few. weeks, 
fresh hremorrhages occurred from fresh foci of infection and in each 
case were immediately arrested as before by serum. It is fair to add 
that in two of these attacks the medical man in charge had previously 
employed again the ordinary methods of treatment without avail. An 
interesting point in this case was the fact that in Bpite of the rapid 
invasion of the lungs at the beginning of treatment by serum the 
tendency to great improvement, apart from arrest of haemorrhage, w as 
in the later months manifest. This may or may not have been due to 
the influence of the serum given, the total amount of which was 
considerable. . , 

Case 3. Probable gastric ulcer without obvious haemorrhage in a 
chlorotic .—The patient, a young woman, aged 20 years, had for seven 
years suffered from almost constant gastric pain which always becAme 
aggravated by taking food and was al ways referred to one spot, which 
was also extremely tender. There had been occasional attacks of 
vomiting but no hfcmatemeais and no melana. Occult haemorrhage 
was never searched for. The patient had often for many months at a 
time been dieted and put on iron with some improvement, but 6he had 
often relapsed. There had been no amenorrhma and the urine was 
normal. Constipation had been a constant trouble and headache had 
persisted. No ocular defects had been discovered. The present attack 
of acute gast ric pain with frequent vomiting had lasted for three days. 
There was extreme tenderness to the left of the epigastrium. Aloud 
hrrmic bruit, audible over the left chest was loudest in the pulmonary 
area. There was slight dyspnrea on movement with slight dilatation 
of the stomach and some Btasis of the gastric contents. The patient 
looked anaemic. The pulse was 110 and the temperature was subnormal. 
The following treatment was adopted. Complete rest in bed was 
enjoined and the administration of one drachm of compound liquorice 
powder every night. Every four hours small meals, in rotation, of 
stale bread and butter, chicken jelly, and four ounces of milk to which 
eight grains of Bodium citrate were added were taken, and once a day 
for two days 10 cubic centimetres of normal horse serum were given by 
the mouth in milk. No other treatment whatever was undertaken. 
In 48 hours all pain, tenderness, vomiting, and even nausea had entirely 
disappeared and have not returned. On the third day of treatment 
pounded fish and chicken and the velks of lightly-cooked eggB were 
given. On the fifth day 10 cubic centimetres of serum were given and 
pounded meat was added to the dietary. On the tenth day tne patient 
was allowed to get up and was given ordinary household diet. On the 
thirteenth day she was in full work and she declared herself to be in 
perfect health. On Oct. 21st, the hemoglobin was 65 per cent, and the 
red corpuscles numbered 5,300,000. On the 27th, after the administra¬ 
tion of 30 cubic centimetres of serum, the luemoglobin was 75 per cent, 
and the red corpuscles numbered 5,500,000. 

This, then, was a case in which there had been a condition 
of gastric pain for seven years and in which the subacute and 
acute attacks responded little, if at all, to ordinary treatment. 
When serum was given an immediate improvement set in and 
was followed by complete recovery. 

Case 4. Duodenal ulcer with hemorrhage.—In this case, seen by me 
in consultation, the medical man in charge kindly allowed me every 
facility and to his courtesy I am indebted for the notes of the case. 
The patient was an ansEmic-lonkhig woman, aged 32 years. For many 
years Bhe had had constant dyspepsia and Bevere pain referred always 
to one spot in the epigast rium, which she fouud alBo frequently very 
tender. The pain had the following characteristics: it sometimes 
occurred during the swallowing of food and was frequently accom¬ 
panied by a sense of soreness in the neighbourhood of the cardiac 
orifice: it disappeared after meale to reappear very constantly after 
one and a half hours; and it was at times very severe before meals. 
Constipation had never been troublesome and menstruation had always 
been normal. Until 12 months ago no evidence had been available as 
to the presence or the absence of occult haemorrhage and the pat ient 
had never vomited blood or had melfena, but within the last three 
months both had occurred three times. On the last occasion 
she went about for three days with duodeno stasis, still con¬ 
tinuing until faintness and impending collapse compelled her 
to lie up. On examination slight gastrectasis and Btasis were present 
and epigastric pain and tenderness, strictly localised, were elicited. 
The following treatment was adopted : rest in bed; small frequent meals 
of pounded chicken fish, brain, eggs, and stale bread, with strictly 
limited intake of milk, and serum in doses of 10 cubic centimetres 
given in milk on the fourth, sixth, eighth, tenth, twelfth, fourteenth, 
sixteenth, seventeenth, eighteenth, nineteenth, and twenty-first days. 
A control was, so to speak kept in this way. For ten days the patient 
was given no Berum, though complete rest and the above diet were 
given. No improvement took place until the serum was given. From 
the first day of its exhibition improvement was marked and progressive. 
The pain and the vomiting rapidly liiaappeared, there was no trace of 
recurrence of hemorrhage, and the dyspepsia of years had gone. On 
Oct. 30th the hemoglobin content was 60 per cent. Serum was first 
given on Nov. 4th. On the 11th the hemoglobin was 75 per cent, and 
on the 26th it was 92 per cent. 

The blood counts have been taken for me in the above 
cases by Mr. E. Quant, F.O.S., of the South Devon 
Laboratory. 

It may at first sight seem unreasonable to expect good 
results from the application of normal serum-therapy to such 



The Lancet,] 


DR. S. WEST: PLASTIC BRONCHITIS. 


[Feb. 15, 1908 . 489 


widely different conditions as, for example, haemophilia and 
tnbercnlons caseation of lung or other tissue. But it is not 
impossible that there is a common basis of autocytolysis in 
these and in a vast number of other conditions characterised 
by destruction of epithelial, endothelial, hiemic, or other 
cell, and that such autolysis can be inhibited by normal 
serum. It appears from the results that I have obtained by 
the oral administration of serum that subcutaneous or intra¬ 
venous injections are not at all necessary. I found at the 
same time that T.R. tuberculin and antistaphylococcal 
vaccines and other vaccines may be given in the same way, 
and apparently the clinical results are in no way impaired. 
This will of course require confirmation. Since writing this 
paper I learn that in Australia a number of diseases have 
been treated by Dr. Montgomerie Paton with antidiphtheritic 
and other serums administered by the mouth. The cases he 
has published seem to confirm amply the value of normal 
serum-therapy that I have independently arrived at. 

Hurley-street, IV. _ 


PLASTIC BRONCHITIS 

IN A GIRL. AGED 11 YEARS, THE SEVENTH ATTACK 
IN FOUR YEARS, THE FIRST OCCURRING AT 
THE AGE OF SEVEN YEARS : 

EXTREME DISPLACEMENT OF THE HEART AND 
MEDIASTINUM, PRODUCED BY COLLAPSE 
OF THE LUNG, DISAPPEARING WITH 
EXPECTORATION OF THE CAST, BUT 
RECURRING AS EACH FRESH 
CAST FORMED. 

By SAMUEL WEST, M.D. OxoN., F.R.C.P. Lond., 

PHYSICIAN’ TO, AND LECTURER ON MEDICINE AT, ST. JIABTHOLOMEW’S 
HOSPITAL. 


A GIRL, aged II years, was admitted into St. Bartholo¬ 
mew's Hospital with plastic bronchitis. The first attack was 
at the age of seven years ; since then she had had six attacks, 
this beiDg the seventh. She bad been in this hospital for 
the previous three attacks. The present attack began on 
Jan. 14th, 1907, with headache and cough. On the 15th she 
was at school, but on the 16th she was too unwell to leave 
bed. She had slept badly, had much headache, vomited 
several times, complained of a “lump in the throat,” and 
brought up some blood-stained sputum. The patient was a 
well-developed child, but she looked ill, was somewhat 
dusky, had a tight cough, and expectorated a little blood- 
streaked sputum. The temperature was 99° F., the pulse 


of the heart to the opposite side ; on the contrary, the apex 
beat was an inch to the left of the left nipple line in the 
fifth space and the resonance of the right lung extended 
across the sternum and reached an inch to the left of the 
edge of the sternum along the third rib. Corresponding 
with this the respiratory sounds changed from the somewhat 
exaggerated sounds of the right lung to the defective sounds 
of the left. It was evident that the left lung was contracted 
and the right expanded. This was thought to be due to 
collapse of the left lung consequent on the occlusion of the 
left main bronchus by a cast. On Jan. 18th the condition 
was much the same but the breath was shorter and the 
duskiness more marked. On the 19th, at 4 A.M., a large 



Diagrsm showing the displacement of organs before.the 
expulsion of the cast. 

cast was coughed np two and a half inches long and the stem 
was nearly one-third of an inch in diameter, it was brought 
up after much coughing and great distress. The temperature 
the evening before reached 103° but on the morning after 
the cast had been expectorated it fell to 99 ■ 8°. On the 20th 
several more pieces of casts of smaller size were brought up 
along with some muco purulent sputum. The apex of the 
heart returned to the left nipple line—i.e., moved two inches 
towards its proper place. The upper part of the left lung 
be lame resonant and the breath sounds there distinct and 



Chart of temperature between Jan. 17th and Feb. 8th. On the dates indicated below by the letter c casts were expectorated. 


was 140, and the respirations were 36. She complained of 
feeling a “lump in the chest ” in the upper part of the leftside 
in front. The percussion note was greatly impaired over the 
whole left side, back and front, and at the base behind was 
almost dull. The vocal resonance and breath-sounds were 
absent everywhere except in the left interscapular space, 
where they were somewhat exaggerated. The stony dulness 
here almost suggested fluid, but there was no displacement 


accompanied with a little crepitation. The base behind, 
however, continued in statu quo with dulness to percussion 
and absent breath sounds. The patient was now placed 
upon ten grains of iodide of potassium three times a day. 
Gradually the physical signs became much as they were on 
admission, and the heart’s apex returned to its former place 
outside the left nipple line. The patient became more dusky 
and drowsy, and on the evening of the 22nd she brought up 







490 The Lancet,] DR. HEWITT : ARTIFICIAL “AIR-WAYUSED DURING ANACSTHETISATION. [Feb. 15,1908. 


another cast as large as the first and a good deal of muco- 
pnraleat expectoration. The apex immediately returned 
nearly to its former position and was felt half an inch 
inside the left nipple line. As beEore, the whole leftside 
became resonant, vocal resonance returned, the breath sounds 
became audible, and were accompanied with some rhonchus 
and crepitation. At the base behind, as before, there was still 
some dulness and the voice and breath sounds remained 
absent. The child was greatly relieved and slept peacefully 
afterwards for some time. In the course of the next few 
days the samo series of events recurred, the heart gradually 
passed out again, dyspnoea and duskiness recurred, until 
on the 28 ;h another cast of the same size and character 
as the others was coughed up with similar relief to the 
patient and with the return of the heart to its normal position. 
However, a few hours later it was evident that another cast 
was forming with considerable rapidity, for the heart was 
moving outwards again and the other physical signs were 
returning, and at midday on Feb. 1st another large cast 
appeared. On the 3rd several small casts were coughed up 
and on the 7th a large one, each event being accompanied by 
the same changes in physical signs as have been described. 
Up to this time the temperature had been very unstable, 
rising frequently to 103° and being generally at its highest 
just before the cast was expectorated. From the 7th con¬ 
valescence proceeded without interruption. The temperature 
remained normal or subnormal. The heart continued in its 
normal place and the patient looked well. She was kept in 
the hospital for some time largely as a matter of charity and 
was discharged on May 7tb perfectly well, with the heart 
and lungs in their normal position and without any physical 
signs in the chest. The casts were examined microscopically 
and bacteriologically but without any positive result. 

The case is an ordinary one of plastic bronchitis and 
except for the size of the casts does not present any remark¬ 
able features. The point of interest is the displacement of 
the heart and complementary dilatation of the opposite lung 
which followed on the collapse of the affected lung, changes 
which could hardly have been greater with pneumothorax of 
the right side. I have once before observed this in a case 
of extensive broncho-pneumonia of the left lung in a small 
child, the apex beating half an inch outside the left nipple 
line and returning to its normal place as the collapse passed 
off. I have not met with any account of a similar case to the 
present, which therefore seems worth recording. Some con¬ 
siderations of physiological interest arise out of it. The 
processes by which the air is absorbed from the air vesicles 
on collapse or from the pleura in pneumothorax are not fully 
understood. So far as the 0 and CO_, are concerned, these 
gases exist in the blood partly in solution and partly in loose 
chemical combination. So that we may fairly suppose that 
they are removed in these ways. The N presents greater 
difficulties, being so inert a chemical body. Yet it, too, is 
removed and often with considerable rapidity. 

The forces under which the gases are removed are greater 
than the elasticity of the lung—i.e., 6-8 millimetres of Hg— 
otherwise there would be a tendency for air to collect 
spontaneously in the pleura, and this does not occur. But 
this case shows that the forces must be much greater than 
this, for they were sufficient to cause the opposite lung to 
expand to the maximum. No doubt the violent coughing 
increased the forces of expiration very considerably and thus 
favoured absorption during the time of coughing, but in the 
intervals between the attack of coughing the forces at work 
would have to be equal to the elastic tension of the lung in 
its condition of exaggerated stretching, which can hardly be 
less than 10 millimetres of Hg or 5 inches of water and is 
probably more, and it must be against this resistance at least 
that absorption of the air took place. 

Wimpole Btreet, W. 


Royal College of Physicians of Edinburgh.— 

A quarterly meeting of the Royal College of Physicians of 
Edinburgh was held on Feb. 4th, Dr. C. E. Underhill, the 
President, being in the chair. Theodore Charles Maclvenzie, 
M.B.Edin., F.R.C.P. Edin., was introduced and took bis 
seat as a Fellow of the College. Patrick Hehir, M. D. Brux., 
M.R O.P. Edin., Lansdowne, India; and Harold Sherman 
Ballantyne, M.B., C.M. Eiin., M.R C.P. Edin., Dalkeith, 
were admitted by ballot to the Fellowship of the College. 
Lindsay Stephen Milne, M.B., Oh.B. Edin., Montrose, was 
admitted by ballot to the Membership of the College after 
examination. The Registrar reported that since the last 
quarterly meeting 27 persons had obtained the Licence of the 
College by examination. 


AN ARTIFICIAL “ AIR-WAY ” FOR USE 
DURING AN/ESTHETISATION. 

By FREDERIC W. HEWITT, M.V.O., M.A., M.D. 
Cantab., 

AN-ESTHETIST TO HIS MAJESTY THE KING; I'HYSICIAN-AN.ESTHETIST 
TO ST. GEORGE'S HOSPITAL; CORSIT-TIRO AN.ESTHETIST AH1> 
EMERITUS LECTURES OX AN.ESTHETICS AT THE 
LONDON HOSPITAL. 


Ox several previous occasions, not only in the columns of 
The Lancet but elsewhere, 1 have endeavoured to establish 
the proposition that in most of the cases in which difficulties 
arise during general anaesthesia these difficulties are directly 
dependent upon mechanically obstructed breathing and that 
this condition, occurring as an incident, introduces into 
administrations an auto asphyxial element the true nature of 
which is frequently misunderstood. It has been pointed out 
that whilst there are many different varieties of mechanically 
obstructed breathing—i.e., many different ways in which the 
respiratory pump may be thrown out of gear independently 
of any defect in the nerve energy at its disposal—these 
varieties are capable of being arranged in two main groups. 
In Group 1 we have obstructive states dependent upon the 
operation of causes within the upper air-passages, and in 
Group 2 we have obstructive states dejindent upon the 
operation of causes external to those passages. As an 
example of obstructed breathing of the former kind may be 
mentioned that arising from altered position, spasm, or 
swelling of the tongue. As an illustration of mechanically 
impeded breathing of the latter kind, that dependent upon 
spasm of the external respiratory muscles may be cited. 
On the present occasion I propose to deal only with 
the treatment of certain of the obstructive conditions 
of the first of these two groups and to confine my remarks 
to cases in which the respiration of semi-ansesthetised 
or amsithetised patients becomes partially or completely 
obstructed owing to occlusion of the air-tract alove the 
larynx. 

Were it customary, as in physiological experiments, to intro 
duce anaesthetic gases and vapours into the pulmonary pas¬ 
sages through a tracheal cannula the text book descriptions 
of the clinical phenomena of incipient and complete general 
surgical anaesthesia would markedly differ from those with 
which we are now familiar. Under such circumstances we 
should obtain far more equable results in our administrations 
and there would be much less intercurrent respiratory dis¬ 
turbance. But as it is necessary in surgical practice to 
introduce amesthetics through the ever-varying nasal and 
oral passages this smoothness in amesthetisation cannot be 
depended upon. The upper air-passages of all subjects are 
liable to alterations in their conformation and calibre during 
general amesthesia. This is specially noticeable in certain 
subjects, e.g., the thick-set and plethoric, whose upper air- 
passages are naturally narrow ; in certain postures, e.g., the 
Trendelenburg, in which the tongue gravitates towards the 
palate ; and in certain operations, e.g., rectal, which have 
a tendency reflexly to produce spasmodic tongue retraction. 
Everyone who has paid much attention to the clinical 
aspects of general amesthesia knows how frequently he has 
to adopt some means for preserving a free air-way. In some 
cases the jaw must be pressed forwards or the chin pulled 
up continuously ; in others, a mouth-prop adjusted to meet 
the special peculiarities of the case is required ; whilst in 
others again it is necessary to apply tongue forceps in order 
to insure free breathing. 

The question here presents itself Should aniesthetic gases 
and vapours be administered through the oral or through the 
nasal passages l It is interesting that the natural tendency 
towards nasal as opposed to oral respiration persists in a marked 
and often in an inconvenient degree during general amesthesia. 
Even though a patient, obeying instructions, commence to 
breathe orally he will tend, as anaesthesia deepens, towards 
purely nasal respiration, and this nasal respiration frequently 
proves Inadequate. Whilst nasal breathing is undoubtedly 
of paramount importance in everyday life it is, as a rule, 
inferior to oral breathing during the induction and main¬ 
tenance of general amesthesia. Suffocative sensations 
during induction are generally due to nasal respiration, the 
nasal passages being of insufficient calibre to allow of that 
quantity of oxygen reaching the lungs per minute which is 
essential to full blood oxygenation, and hence to the patient’s 
comfort during incipient amesthesia. It is true that when 
amestbesia has become established nasal respiration may 







The Lancet.] MR. SOUTHA.M : THE “ EARLY ” OPERATION IN ACOTE APPENDICITia, ETC. [Fkb. 15, 1908. 49 B 


under certain conditions, be qaite satisfactory, these con¬ 
ditions being (1) the existence of spacious nasal channels, 
and (2) a sufficiently high oxygen percentage in the 
atmosphere presented to the patient. But it often 
happens in practice that the nasal passages, either 
from pre-existing conditions within them, or from causes 
which hare arisen during the administration, do not 
permit that free intake of oxygen by the lungs which is 
necessary in order that all asphyxial phenomena may be 
prevented. With such a restricted inlet to the respiratory 
pump the abdominal and thoracic muscles necessarily 
become thrown into exaggerated action; and muscular 
rigidity, cyanosis, dilatation of the pupils, separation of the 
lids, and even pallor may result. Auto-asphyxia thus 
insidiously arising is not infrequently mistaken for chloro¬ 
form overdosage, surgical shock, or other conditions. 

In order to secure free and exclusively oral respiration when 
administering anaesthetics it is necessary (1) to keep the 
teeth or gums apart ; (2) to keep the tongue away from the 
palate and pharynx ; and (3) to block the nasal channels. 
The little appliance here figured effects this in most cases 
—not, perhaps, in all, because of the great variations which 
exist in the conformation of the upper air passages of 
different subjects. It consists of a circular metal ring, 



with an internal diameter of half an inch, and with a deep 
groove in its outer circumference to allow of the ring being 
held firmly by the teeth. The two flanges which result from 
the presence of this circular groove or trough are of unequal 
size, the smaller projecting within the mouth and the larger 
outside the teeth or gums. From the inner circumference 
of the ring there also projects into the mouth a short metal 
collar carrying a portion of indiarubber tubing the free end 
of which is cut obliquely or whistle-shaped, as shown in the 
figure. The tubing should have a maximum length of about 
three and a quarter inches, a clear internal bore of half an 
inch, and its wall should be sufficiently thick to prevent 
kinking. By a simple screw adjustment in the collar the 
rubber tube may, if desired, be removed from the metal ring 
which will then act as a mouth prop. 

The artificial “air-way” is not intended for use in 
every case. It is principally serviceable in those cases 
in which respiration is performed with some embarrassment 
or difficulty owing to the upper air-tract being more or 
less obstructed. If at the conclusion of the induction 
period, when the patient should be settling down into smooth 
and deep anesthesia, the breathing be laboured and noisy, 
with sniffing or snorting sounds—if, in other words, the 
patient be “taking the anesthetic badly” or “ breathirg 
badly’’—the jaws should be separated and the whistle-shaped 
end of the “airway” passed backwards into the pharynx, 
so that the oblique opening of the rubber tube faces the 
laryngeal orifice, and the metal ring adjusted so that it is 
grasped by the teeth or gums. The substitution of free 
oral for imperfect nasal or oral respiration will, in the 
great majority of cases, immediately be followed by 
slower and quieter breathing, an improvement in colour, 
and greater muscular relaxation; in fact, by an alto¬ 
gether better type of anmsthesia. Should there be much 
jaw spasm at the moment when it is desired to introduce 
the “air-way ’’ it may be necessary to separate the teeth by 
means of a Mason's gag. It is advisable to secure a fairly 
deep ansesthesia before the instrument is placed in situ , 
otherwise inconvenient reflex retching and coughing may be 
excited. The appliance is, in fact, only suitable for cases in 
which it is desired to maintain a fairly deep anresthesia. As 
regards the administration after the introduction of the 
“ air way, ” it must be remembered that with the more free 
intake of atmospheric air less ansesthetic will be required, 
in cases in which partial occlusion of the upper air-tract 
exists much of the vapour which is presented to the patient 
never actually gains access to the pulmonary passages. If, 
therefore, a certain rate of administration has been in force 
during the period of hampered breathing this rate must be 
reduced when the insertion of the “ air- way ” has secured free 


respiration, otherwise an unnecessarily deep anaesthesia will 
result. As the air way does not project beyond the lips it 
may be used either during the administration of ether, 
chloroform, or chloroform mixtures. The writer finds it of 
great value when amcsthetising patients in the Trendelenburg 
posture, for in this posture the swollen tongue frequently 
obstructs breathing. 

Messrs. Barth and Co. of 54, Poland-street, Oxford-street, 
London, W., are the makers of this artificial “air-wav.” I 
am indebted to them for having made other experimental 
appliances for me whilst working at this subject. 

Queen Anne street, W. 


THE “EARLY” OPERATION IN ACUTE 
APPENDICITIS: THE INDICATIONS 
FOR ITS PERFORMANCE AND 
ITS ADVANTAGES . 1 

By F. A. SOUTHAM, M.B.Oxon., F.R.C.S. Eng., 

SURGEON TO THE MANCHESTER KOVAL INFIKMABV; PROFESSOR OF 
CLINICAL SIBGEBY, MANCHESTER UNIVERSITY. 


Thk advisability of early surgical interference in cases of 
acute appendicitis is becoming more and more recognised 
every day and instead of waiting for indications of suppura¬ 
tion, as was formerly the practice, we now attempt to fore¬ 
stall this complication by operating at a much earlier stage 
in the course of an attack. 

For clinical purposes we may divide cases of acnte 
appendicitis into two classes—viz., simple and destructive. 
In the first variety there is a simple or catarrhal inflamma¬ 
tion of the mucous membrane which does not run on to 
suppuration or perforation but terminates in resolution, 
though often leaving the appendix in a somewhat altered or 
damaged condition with a tendency to recurrent attacks. 
In the destructive form serious changes result, either a 
localised perforation or more or less extensive gangrene of 
the walls of the appendix, both conditions being usually 
accompanied by suppuration. This may take the form of an 
encysted abscess or there may be a formation of pus either 
localised, i.e., at first confined to the region of the 
appendix, though not encysted or surrounded by a barrier 
of lymph, but soon spreading and becoming more or less 
general, i.e., diffused throughout the peritoneal cavity 
(“diffuse suppurative peritonitis”), if the case is allowed 
to run its course. 

It has recently become the custom to divide the course of 
an attack into three stages—viz., (1) the “early'' stage, 
which includes the first 48 hours; (2) the “intermediate”' 
stage, which extends from the third to the fifth day ; and 
(3) the “late” stage, which extends from the fifth day 
until the termination of the case. Operations are now 
classified as “early," “ intermediate ,” and “ late ,” Recording 
to the corresponding stage in which they are performed. 

During the past year it has been my practice, when possible, 
to operate at a much earlier period than formerly, i.e., in the 
"early ” stage, in all cases where the initial symptoms were 
of a grave nature and indicating that destructive changes 
were taking place, or were likely to do so, in the walla of the 
appendix. So far the results have been most satisfactory, 
and I append a brief record (Table I.) of ten cases, all 
operated upon in the “ early ” stage, viz., within 48 hours, 
the onset of abdominal pain or sickness being taken as the 
initial symptom. In each instance the appendix was removed 
at the same time and all the patients made a good recovery. 
These cases all occurred in private practice, it being unusual 
to obtain the opportunity of such early operation in hospital 
patients. That this is so is proved by a reference to Tables 
IV. and V., which include all the acute cases, 26 in number, 
admitted into my wards at the Manchester Royal Infirmary 
during the same period. Some of these were operated upon- 
by myself, the others by the honorary assistant surgeons (Mr. 
J. W. Smith, Mr. A. II. Burgess, and Mr. J. H. Ray), or by 
the resident surgical officer (Mr. P. R. Wrigley). None of 
the 26 cases were admitted in the “early ” stage and there¬ 
fore operative interference was not possible within the first 
48 hours. The contrast in the result is striking, for of the 
26 hospital patients operated upon in the “ intermediate ” 

1 A paper read before the Manchester Medical Society on 
March 27th, 1907, in a discussion on the Diagnosia and Treatment ot 
Acute Appendicitis. 





492 The Lancet,] MR. SOUTHAM : THE “EARLY” OPERATION IN ACUTE APPENDICITIS, ETC. [Feb. 15,1908. 


CASES OF OPERATION FOR ACUTE APPENDICITIS. 


Table I.— Early Operations (ie., within 4S hours). Private Cases. 


No. 

Under the care of— 

Date of 
operation. 

Sex. 

! Years 

I 

1 

1 Approxi¬ 
mate dura¬ 
tion of 
symptoms 

Pulse and 
temperature 
nt time of 
operation. 

I 

Suppura¬ 

tion. 

I 

Removal 

1 of 
appendix 

Condition of appendix. 

Result. 

1 

Dr. F. It. Mallott 

1906. 

Feb. 1st. 

M. 

29 

48 hours. 

P. 

88 

T. 

100° 

Localised. 

Yes. 

Small perforation; inflamed 

Recovered. 

2 ! 

(Bolton;. 

Dr. Helene Goldberg- 

June 18 th. 

M. 

1 19 

1 19 

no 

103° 

Absent. 


and very friable; three 
| concretions. 

Lumen completely oc- 


| 

3 

Saul (Withlngton). 

Mr. J. T. Finlay 

July 14th. 

M. 

1 7 

42 „ 

124 

105° 



eluded, distal portion dis- 
1 tended with pus; three 
' concretions. 

Mu cou b membrane in- 


4 

(ilawtenatall). 

Dr. D. Macmillan 

„ 21st. 

F. 

30 

48 „ 

108 

104° 



I flamed ; two patches of 
superficial ulceration. 
Intensely injected, coated 


5 

(Prestwicb). 

Mr. R. A. Shelton Daly 

Nov. 3rd. 

M. 

38 

42 „ 

120-130 


Localised 


with flaky lymph ; mucous 
membrane ulcerated. 
Gangrenous and perforated. 


6 

(Manchester). 

Mr. J. T. Finlay 

,, 19th. 

F. 

24 

18 ,, 

118 1 

99 c 

Absent. 


Intensely congested. 


7 

(Itawtenstall). 

Dr. D. Macmillan 

„ 21st. 

F. 1 

25 

24 „ 

96 

100° 



Acutely inflamed, and 


8 

(Presiwich). 

Mr. G. M. Drury 

1907. 

Jan.13th. j 

F. 

20 

42 „ 

120 

101° 

Localised. 


roughened from deposit of 
ivmph. 

Gangrenous and perforated; 


9 

(Cheadle Heath). 

Dr. A. A. Mumford 

,, 15th. 

M. 

24 ' 

12 „ 

108 

100° 

Absent. 


concretion. 

Intensely congested and of 


10 

(Chorlton-cum-IIardy). 

Mr. A. P. Walker 

i 

Feb. 9th. 

M. 

54 1 

43 „ 

88 

99 6° 

Localised. 


purplish colour, becoming 
gangrenous; distended 
with dark li uid and on point 
of rupture; concretion. 

Small perforation, with ex 



(Had field). 




- 





tensive patch of gan¬ 
grenous raucous mem¬ 
brane; concretion. 



Number of cases 10. Died, 0. Mortality, nil. 


Table II.— Intermediate Operations (i.e., third to fifth day). Private Cases. 


1 

Dr. J. Mason 
(Windermere). 

1906. 

Feb.19th. I 

M. 

8 , 

5 days. 1 

116 

101° 

Encysted. 

No. 

Not seen. 

Recovered. 

2 

Mr. J. T. Finlay 
(Rawteri8tall). 

April 16th. i 

F. 

20 

3 ., 

140 

99-6° 

General. 



Died. 

3 

Dr. D. J. Mackenzie 
(Glossop'. 

Oct. 3rd. I 

F. 

25 

3 „ 

120 

104° 

Localised. 

Yes. i 

Gangrenous and perforated ; 
concretion. 

Recovered. 




Number of cases, 3. 

Died, 1. Mortality, 33 per cent. 





Table III. Late Operations ({.<■., 

after fifth day). Private Cases. 


1 1 

Mr. Edmund Lee 
(Manchester). 

1906. 

iMarch 28th.| 

F. 

8 

12 days. ! 

_ 

| 

Encysted. 

No. 

Not seen. 

Recovered. 

2 j 

Dr. G. F. Waterston 
(Bolton). 

May 1st. 

1 

F. 

23 

14 „ 

| 110 

1 1 

101*2° ; 

«• 

" 

| 

, 

•• 


Number of cases. 2. Died, 0. Mortality, nil. 


and “late” stages no fewer than eight died, giving a 
mortality of 30 per cent. Five private patients were 
operated upon during the “intermediate” and “late” 
stages with one death, giving a mortality of 20 per cent. 
(Tables II. and III ). If all the cases are considered 
together the result is as follows :— 



Cases. 

Died. 

Mortality. 

* Early ” operation . 

... 10 ., 

.. 0 ... 

Nil. 

* Intermediate ” operation 

... 17 . 

.. 8 ... 

. 47 per cent. 

* Late M operation.. 

... 14 . 

.. 1 .. 

7 

Total . 

... 41 .. 

,. 9 

. 22 


It is worthy of note that in eight out of the nine fatal 
cases there was general suppuration throughout the peri¬ 
toneal cavity at the time of operation. Judging by the con¬ 
dition found in four of the cases recorded in Table I 
(Oases 1, 5, 8, and 10), where there was localised suppura¬ 
tion and where success attended the “ early ” operation, it 
is probable that a similar result would also have followed 
earlier surgical intervention in the fatal cases—that is to 
say, if the peritoneal cavity had been opened and drained 
before the suppuration had spread and become general. In 


the remaining fatal case (Table IV., Case 14), though 
suppuration had not taken place, the appendix was becoming 
gangrenous at the time of operation ; in this instance death 
was due to infective endocarditis with pericardial effusion. 

As regards the indications for early operative interference 
in acute appendicitis, the difficulty that we often meet with 
at the onset is that it is impossible to foretell the course 
which the inflammatory process will take—viz., whether the 
attack will be of the simple or of the destructive variety. 
For it is a recognised fact that the early symptoms may be of 
a very mild character, even when grave lesions are taking 
place in the appendix. 

The temperature and pulse-rate bear no constant relation 
to the severity of the attack. They may both be increased in 
the simple form, while in the destructive variety—even when 
perforation and gangrene are impending or have taken place— 
there may be very little rise in either (as in Table I., Case 10), 
or they may remain normal or even become subnormal. A 
rapid pulse, however—e g., over 100, and especially if above 
120 , in the early stage—is always suggestive of serious 
mischief and points to a probable termination in suppuration. 
The same applies to a high temperature—e.g., 103° or 







The Lancet,] MB. SOUTHAM : THE “ EARLY ” OPERATION IN ACUTE APPENDICITIS, ETC. [Feb. 15,1908. 493 


Table IV.— Intermediate Operations (i.e., third to fifth day). Hospital Oases. 


No. 

Date of opera¬ 
tion. 

Sex. 

Years 
of age. 

Duration of 
symptoms. 

Suppuration. 

Removal of 
appendix. 

Condition of appendix. 

Result. 

1 

Jan. 24th, 1906. 

F. 

24 

5 days. 

Encysted. 

No. 

_ 

Recovered. 

2 

Feb. 23rd tt 

M. 

12 

4 „ 

General. 

Yes. 

Gangrenous and perforated. 

Died. 

3 

March 25th „ 

M. 

30 

5 „ 

„ 

No. 

— 


4 

April 18th „ 

M. 

9 

3 „ 

,, 

,, 

Gangrenous and perforated. 

,, 

5 

May 16th „ 

M. 

8 

4 „ 


„ 

— 

„ 

6 

„ 20th „ 

M. 

15 

3 

Encysted. 

„ 

— 

Recovered. 

7 

July 13th ,, 

M. 

23 

5 „ 

•* 

Yea. 

Gangrenous and perforated. 

,, 

8 

August 8th ,, 

F. 

29 

4 

Localised. 

I. 

Gangrenous and perforated; concretion. 

,, 

9 

Sept. 9th „ 

M. 

19 

3 

Encysted. 

No. 

— 

„ 

10 

.. 29th „ 

M. 

19 

5 .. 

General. 

,, 

— 

Died. 

11 

Nov. 4th ,, 

F. 

16 

5 .. 

Encysted. 

Yes. 

Contained conoretion. 

Recovered. 

12 

Dec. 28th „ 

F. 

25 

3 „ 

General. 

•> 

Gangrenous and perforated. 

„ 

13 

Jan. 21at, 1907. 

M. 

19 

4 

„ 


Gangrenous and perforated ; concretion. 

Died. 

14 

„ 23rd „ 

M. 

26 

3 „ 

Absent. 

- 

Gangrenous; not perforated. 

•• 


Number of cases, 14. Died, 7. Mortality, 50 per cent. 


Table V.—Late Operations (i e., after fifth day). Hospital Cases. 


1 

Jan. 26th, 1906. 

M. 

64 

4 weeks (?) 

Encysted. 

No. 

_ 

Recovered. 

2 

Feb. 21st ,, 

M. 

12 

7 days. 

General. 

,, 


,, 

3 

22nd ,, 

F. 

13 

8 „ 

Encysted. 

Yes. 

Acute inflammation; concretion. 

,, 

4 

April 8th ,, 

»'■ 

10 

7 „ 

,, 

No. 


„ 

5 

June 17th „ 

F. 

37 

12 


,, 

— 


6 

Sept. 4th ,, 

M. 

7 

7 

General. 

Yes. 

Gangrenous. 

,, 

7 

21st „ 

M. 

39 

10 .. 

,, 

„ 

„ 

Died. 

8 

Oct. 2nd ,, 

M. 

28 

14 „ 

Encysted. 

No. 

— 

Recovered. 

9 

„ 3rd „ 

M. 

23 

14 „ 

„ 

,, 

— 

,, 

10 

„ 31st „ 

F. 

34 

9 „ 


,, 

— 

,, 

11 

Dec. 2nd ,, 

F. 

24 

10 ., 



— 

,, 

12 

Jan. 23rd, 1907. 

M. 

26 

6 .. 

” 

Yes. 

Gangrenous. 



Number of cases, 12. Died, 1. Mortality, 8 per cent. 


104° F. On the other hand, a subnormal temperature, 
especially if the fall has been sudden, often indicates that 
perforation has taken place, and the pulse-rate may not be 
increased under the same conditions. A high temperature 
and a slow pulse, or vice vena, are always unfavourable 
symptoms. An initial rigor is always a grave symptom and 
should be regarded as a danger-signal. Urgent vomiting or 
acute pain at the onset renders it probable that the attack 
will be a severe one. Painful rigidity of the abdominal wall, 
especially if general, when well marked in the early stage, is 
always a most important indication of the gravity of the 
attack and generally symptomatic of the existence of acute 
peritonitis. 

Another early symptom upon which I place great import¬ 
ance as indicative of the latter condition and pointing to the 
onset or the presence of the destructive form of appendicitis 
is the absence of abdominal respiration, the breathing being 
mainly or entirely thoracic. If the patient is told to take a 
deep inspiration, the abdomen being freely exposed to view, 
it will be found that there is either no movement whatever of 
the abdominal wall or only a very slight expansion at its 
upper part—viz., immediately below the sternum aDd lower 
margin of the ribs. Even this amount of movement is 
frequently absent and occasionally there may be noticed a 
slight in-drawing of the abdominal wall in this situation if 
the pain does not prevent the patient from taking a deep 
breath. When this state of the abdomen is present at the 
onset of the attack and there are in addition the three 
cardinal symptoms of appendicitis, viz., pain, tenderness, 
and rigidity of the abdominal wall, most marked over 
the region of the appendix, together with quiokened 
pulse and increased temperature, or even without much 
alteration in pulse and temperature, it is probable 
that the attack is, or will be, of a severe character— 
i.e., of the destructive type. This motionless condition 
of the abdomen during respiration was observed in all the 
cases recorded in Table I. and it was the main indica¬ 
tion which induced me to advise immediate operation even 


when there was little increase in the pulFe-rate or tempera¬ 
ture (as in Cases 1, 7, 9, and 10). I believe it is always 
indicative of the presence of peritonitis, and a reference to 
the cases in Table I. will show that in these circumstances 
serious changes were commencing, or had already taken 
place, in the walls of the appendix. 

The advantages of surgical interference in the early stage 
of acute appendicitis are as follows : 1, The infective centre 
—i.e., the appendix—can be removed in many cases before 
suppuration has taken place, and if it has not perforated or 
become gangrenous the operation is practically an aseptic 
one. 2. If pus has formed, even though not encysted and 
surrounded by a barrier of lymph, it will usually be found to 
be localised as yet to the neighbourhood of the appendix and 
small in quantity (Table I., Cases 1, 5, 8, and 10). In these 
circumstances its evacuation, together with the removal of 
the appendix, if followed by free drainage, will usually check 
the spread of the suppuration which otherwise so often tends 
to become general. 3. The operation being performed before 
the onset of general toxsemia, the common cause of death in 
fatal cases, is usually well borne by the patient. 4. The 
risks of the later complications of acute appendicitis, viz., 
subphrenic and hepatic abscess, empyema, parotitis, phlebitis, 
and infections in other parts of the body, are greatly mini¬ 
mised. In past years I have met with instancts of all the 
secondary complications just mentioned. 5. In the early 
stage the appendix—unless bound down by adhesions the 
result of a previous attack—lies quite free and is therefore 
easily removeable. In the later stages, especially in the less 
acute cases, it is often surrounded and imbedded in a deposit 
of lymph, which may form part of the wall of an abscess 
when the pus is encysted. In these circumstances, it is 
often not easy to recognise the appendix, and its removal is 
frequently difficult or impossible without breaking down this 
barrier of lymph, and thus running the risk of infecting the 
general peritoneal cavity. 

It is a question whether the rule of early operation in acute 
appendicitis might not with advantage be extended to all 
e2 








494 The Lancet,] 


CLINICAL NOTES. 


[Feb. 15, .1908. 


caseB, even when the initial symptoms are of a mild 
character and point to the attack being of the “simple” 
form, for it is never possible to predict with certainty what 
coarse the inflammatory process will take, and there iB 
always the risk of a termination in suppuration. Supposing, 
however, that this does not take place and the appendix is 
allowed to remain, it will probably be left more or less 
thickened and contracted or bound down by adhesions, and 
therefore in such a condition that sooner or later the attacks 
will almost certainly recur. If all cases of appendicitis are 
operated upon in the early stage, as soon as the diagnosis is 
established, I believe that the danger will not be any greater 
than that which attends removal of the appendix in the 
quiescent period following one or more attacks. In the 
latter circumstances appendectomy is frequently a com¬ 
plicated operation owing to the presence of adhesions, the 
result of the previous attacks, and the appendix may be so 
fixed and buried in these adhesions that its recognition, as 
well as its removal, are often attended with considerable 
difficulty. 

As regards the after-treatment in the cases recorded in the 
accompanying tables drainage was employed in every instance 
and even when suppuration had not taken place a small 
tube was left in the wound for 36 or 48 hours, perhaps rather 
as a safeguard than because it was absolutely necessary. 
When there was an encysted abscess or localised suppuration 
larger tubes and strips of gauze were inserted and a counter- 
opening was usually made in the loin, or through the vagina 
in females, when the pus tracked down into the pelvis. Care 
was always taken to disturb the parts around the area of 
suppuration as little as possible, so as not to break down any 
protective adhesions which might be forming. When the 
suppuration was general one or more openings were also 
made in the middle line or on the opposite Bide of the abdo¬ 
men ; and under the same conditions Fowler’s position, and 
Murphy’s method of saline injections into the rectum, were 
employed in some of the cases. 

Manchester. _ 


Cliniral Jlote: 

MEDICAL, SURGICAL, OBSTETRICAL, AND 
THERAPEUTICAL. 


CAVERNOUS NJEVU3: TREATMENT BY METALLIC 
MAGNESIUM. 

By John A. C. Mackwen, M.B., C.M., B.Sc. Glasg., 
F.F.P.S. Glasg., 

SURGEOX TO TilK ELDER HOSPtTAL, GOVAN; ASSISTANT SURGEON, 
GLASGOW ROYAL INFIRMARY I SFNIOR ASSISTANT To REGIUS 
PROFESSOR OF SURGERY, UNIVERSITY OF GLASGOW. 


My attention was first directed to the above mode of 
treatment by a paper on the subject by my friend Dr. 
Gavin McCallmn of Geelong, Australia, in which he reported 
one or two cases in which highly satisfactory results were 
obtained by the method to be described. 

The patient, a weakly girl, 15 months old, was first seen 
by me at the Elder Hospital in May, 1905, suffering from a 
large cavernous neevus of the right side of the face 
which occupied the whole substance of the cheek, being 
covered superficially by a layer of thin, white skin 
resembling that which is seen covering scars which 
have stretched, while internally it projected slightly 
into the cavity of the mouth, being covered by the 
mucous membrane which appeared healthy and of normal 
texture. The tumour was larger than a walnut normally, 
but increased considerably in size when the patient cried, 
while it diminished slightly on digital pressure. Slight 
arterial pulsation was felt. The patient was first operated 
on in July, 1905, then in January, 1906, and, lastly, in July, 
1936, so that a period of six months elapsed between each 
application. After the first operation the tumour increased 
in size for a few days succeeding the operation, became 
firmer, and conveyed a sensation of increased warmth 
to the tonch. It then gradually decreased in size 
and became distinctly firmer, presenting more definite 
ontline than it previously had done. Similar results 
followed the other two operations, but after the third 
operation I was still doubtful as to the entire success 


of the treatment; the tumour bad become distinctly 
smaller and firmer, but I was still uncertain whether some 
tumour tissue did not remain. The patient became ill 
shortly after the third operation, so that I did not see her 
again until November, 1907—over a year since the third 
operation—when I again had an opportunity of examining 
her. I now found that the tumour had entirely disappeared, 
the cheek presenting, on palpation, a thickening over the site 
of the tnmoar, due doubtless to the connective tissue which 
had formed as a result of the treatment. Not only had no 
scar resulted from the treatment but the skin over the 
surface, which it will be remembered was of a very unsatis¬ 
factory character when first seen, had slightly improved. 

The mode of treatment, which I modified slightly, con¬ 
sisted in preparing several needles out from magnesium 
ribbon. These were sterilised by boiling and were intro¬ 
duced by pushing with a pair of forceps into the substance of 
the tumour through a slight puncture in the .surface made 
with a bistoury. The needles were entirely buried in the 
substance of the tumour, no part being left projecting on the 
surface, and care beiDg taken to prevent perforation of the 
mucous membrane on the inner surface. Borne six or eight 
needles were introduced on each occasion into various parts 
of the tumour, striot asepsis being observed throughout, and 
the surface operated on was covered by a film of gauze with 
celloidin to exclude contamination after operation. The 
magnesium ribbon is a little troublesome to manipulate 
owing to its being both soft and brittle, but with a little 
patience these difficulties are overcome. I do not know of 
any other method which would have yielded an equally 
satisfactory result in this case, where the tnmoar was large 
and situated on the most prominent part of the face where 
scarring or change of contour would at once attract atten¬ 
tion. 

The beneficial action which the magnesium needles exert 
in such cases is probably due to two causes. In the first 
place, the needles exert a mechanically irritating effect on 
the walls of the vessels with which they come in contact, a 
constant movement being kept up both by the pulsation of 
the little arteries and by movements of the cheek. In con¬ 
sequence of this movement the endothelial lining of these 
vessels will be abraded and a white thrombus will form, as has 
been demonstrated bv Sir William Macewen to occur when 
an aneurysm is treated by his method of needling. This is 
the more important action. In the second place, magnesium, 
as is well known, is very readily oxidised, and this process of 
oxidation appears to take place very rapidly in the tissues ; 
indeed, so rapid was the process in the case here reported 
that it was difficult to detect the presence of the needles in 
the tissues some three or four days after their introduction. 
This, of course, is an important point in this method of treat¬ 
ment, as it enables one to bury the needles at the outset, 
thus permitting rapid healing of the minute surface woond, 
and the needle is removed after a few days by the oxidising 
action of the blood and probably the leucocytes. Daring 
the oxidising process, however, the magnesium probably 
causes the formation of small red thrombi, in addition to the 
white ones mentioned above. The embryonic fixed tissue 
cells in the white thrombi will rapidly become converted into 
adult connective tissue, while the red thrombi will to some 
extent be replaced by similar fibroblasts which will also 
become converted later into adult connective tissue. The 
connective tissue so formed will occlude the vessels in con¬ 
nexion with which it grew, and, by its subsequent contrac¬ 
tion, will obliterate the vessels in ils neighbourhood. Thns 
the ultimate resnlt is occlusion of all the vessels of the 
tumour by fibrous tissue formation, which ultimately will 
greatly diminish in bulk. 

Glasgow. 

A NOTE ON THREE CASES OF PLAGUE TREATED 
BY YERSIN’S SERUM. 

By Austin C. Dixon, L.R.C.P. Lond., M.R.C.S Eng., 

CHIEF MEDICAL OFFICER OF THE ANTOFAGASTA HOSPITAL. 


In the fourth Croonian lecture by Professor W. J. R. 
Simpson, reported in Thk Lancet of July 27th, 1907, the 
following remarks are made: “Great expectations were 
raised on the introduction of Y'ersin's serum but they have 
not been realised and a serum has yet to be discovered 
which while being germicidal in its action also possesses 
antitoxic properties." I must acknowledge that up to now 


c 


i 

i 

t 

s 

I 


a 

3 

e 


it 

a 

i: 

a 

BY 




* 

z 


JC 






Thi Lancet,] 


ROYAL SOCIETY OP MEDICINE: THERAPEUTICAL SECTION. [Feb. 15, 1908. 495 


I have not what one might call an extensive personal experi¬ 
ence of plague, as most of my cases are sent into the 
lazaretto here and then I lose Bight of them, bnt I should 
like to report the effect of Yersin’s serum in the few cases of 
foreigners that I have treated myself as I feel sure that this 
serum is maligned. 

Case 1.—The patient was a woman, aged 22 years. I was 
called to see her abont 4 p.m. Her temperature was 103° F. 
Her face was flushed and she was feeling very ill. I visited 
her at 8 a m. on the following day when her temperature was 
105°. I called in the medical officer of health who con¬ 
firmed my opinion that it was a case of bubonic plague. At 
12 noon we gave an intravenous injection of Yersin’s serum, 
the dose being 80 cubic centimetres. About two hours later 
the patient had a rigor. On the day after there was no fever 
and she was feeling much better. In this case the patient 
completely recovered except that she suffered from rheu¬ 
matism about 14 days later, the effects of the injection. 

Case 2.—The patient, a man, aged 50 years, was admitted 
to hospital as a case of typhoid fever ('!). His temperature 
was 102° F., the pulse was dicrotic, and the spleen was 
palpable. Two days later a bubo appeared in the left 
groin. The patient was given 40 cubic centimetres of serum 
intravenously with the effect that the temperature fell to 
normal, but he had no rigor. Two days afterwards the 
temperature again rose to 102°; the same dose was 
repeated and the temperature fell to 100°. The man 
died, however, in a comatose condition, and I believe 
that in this case I gave insufficient serum but was advised 
not to increase the doses. 

Case 3.—The patient, a man, aged 25 years, was seen at 
12 noon. His temperature was 106° F. in the rectum. He 
had been quite well the day before. I called in the medical 
officer of health who agreed that the man was suffering from 
bubonic plague. The patient was given an intravenous 
injection of 80 cubic centimetres of serum. His temperature 
on the next morning was normal. On the following day the 
temperature in the rectum was 104°. The dose was repeated 
and the temperature fell to 100° and kept so for two days, 
when he began to cough and to expectorate pneumonic 
sputum. This was examined microscopically and waB found 
to contain numbers of bubonic bacilli. On examination the 
right apex was found to be consolidated. 1 then thought the 
case almost hopeless and gave the patient an intravenous 
injection of 130 cubic centimetres of Yersin’s serum. Two 
hours later he had a Bevere rigor. The temperature on the 
following day was normal, there were much less cough and 
sputum, and the lung was better. After this the patient 
made an uninterrupted recovery except that about ten days 
later he bad rheumatism and fever, no doubt due to the 
injections. 

These are the three cases that I myself have attended and 
they seem to me to show that: (1) unless the patient has a 
rigor after the injections they have not had a large enough 
dose ; (2) that the doses advised are not nearly large enough 
for severe cases ; and (3) that there is no ill effect from large 
intravenous injections of Yersin’s serum. 

I am unaware what dosage is generally used in India, but 
I presume from about 20 to 40 cubic centimetres as per 
instructions. At the same time I am aware that three cases 
are insufficient to judge from, but I was anxious to give only 
those that I myself could vouch for, although I could get 
plenty more examples of large doses from the Chilian lazaretto 
in this town with excellent results. 

Autufsgasta, Chili. 

NOTE ON A CASE OF SEPTICAEMIA DUE TO 
PNEUMOCOCCUS; DEATH. 

By John Bell, L.R.C.P. Lond., M.R.C.S. Eng., 

StJPEHINTESDEST OF THE GOVERNMENT CIVIL HOSPITAL, HOKG-KOXG. 


AN Indian male, aged 22 years, was admitted to hospital 
under my care on Dec. 1st last, with a fluctuating swelling 
just below the left clavicle which he attributed to having tried 
to raise a very heavy box a few days previously. The abscess, 
containing about two ounces of pus, was opened on the next 
day and the case progressed well up to the 12th when there 
was still a small sinus about one inch in depth. The patient 
was most anxious to leave the hospital but he was kept in 
until the wound was completely closed. On the next day he 
complained of feeling chilly with pains all over and there 
were a few fine crepitations at the base of the right lung. 


His temperature in the morning was 99° F. and in the even¬ 
ing it was 100°. On the 14th he felt better, the tempera¬ 
ture in the morning being 98 4° and in the evening 100'8°. 
On the 15th he was very Berionsly ill. He had mnch pain 
and discomfort all over the abdomen, especially over the 
bladder, where there was a diffuse swelling extending to the 
flanks. There was slight delirium, the tongue was very dry 
and furred, and there were haemorrhages under the con- 
junctivse and petechial eruption all over the body. The 
temperature was 100 ■ 6* and the pulse was very small and 
quick. The wound looked well. A blood slide showed no 
plague bacilli or malarial parasites, but was full of normo¬ 
blasts. The patient was not anaemic. He rapidly succnmbed 
and died in the afternoon. 

Post mortem, the abdominal swelling consisted of a large 
extravasation of blood between the skin and the peritoneum 
through all the muscular layers and extending on both sides 
to the back to the level of the pelvic brim. Smears from this 
were full of typical pneumococci. The heart was covered 
with small petechiie, and the blood from the ventricle showed 
almost a pure growth of capsulated pneumococci. All the 
other organs were healthy and the wound was normal, 
though a scraping from the sinus also showed pneumococci. 
Dr. C. M. Heanley, Government bacteriologist, who was 
present at the time, kindly saw the slides and agreed with 
the diagnosis of septicaemia due to pneumococcus. 

The patient was a healthy, well-nourished Indian and the 
abscess was quite superficial and was treated throughont 
aseptically. It is difficult to understand why, when he was 
practically well, such a serious disease should arise which 
carried him off in 48 hours. 

Hong-Kong. 


gtebical Storiettes. 


ROYAL SOCIETY OF MEDICINE. 

THERAPEUTICAL AND PHARMACOLOGICAL SECTION. 

Nutmeg Poisoning .-— Art trio-sclera sis and its Causation . 

A meeting of this section was held at the Apothecaries’ 
Hall, Blackfriars, on Jan. 28th, Dr. T. E. BURTON Brown, 
the President, being in the chair. 

Professor A. R. Cushny gave an address on Nutmeg Poison¬ 
ing. He referred to the scanty recognition of this in English 
medical literature and noted the work of his former assistant. 
Dr. Wallace, in America, who found that cases of poisoning 
occurred exclusively from the use of the crude nutmeg or 
mace; in many instances it had been used as an aborti- 
facient, although it does not appear to have thiB action. As 
far back as 1576 Lobelius relates a case in which a woman 
was rendered delirious by nutmeg. The’ symptoms are 
drowsiness, stupor, diplopia; delirium frequently is present, 
and sometimes the first symptom is burning pain in the 
stomach, pnecordial anxiety, or giddiness. One case of 
death in a hoy occurred after eating two nutmegs. The 
symptoms resembled those caused by cannabis indica. 
Professor Cushny showed how the powerful poison was 
contained in the oil of nutmeg and it was the fraction 
Lwhich came over at 150° C. under 14 millimetres mercury 
pressure; from this several bodies have been isolated 
—e.g., myristicin. From experimental work Professor 
Cushny came to the conclusion that the symptoms were 
to be attributed to the action on the central nervous system, 
which was depressed but exhibited some indications of 
stimulation in the form of restlessness, slight convulsive 
movements, and tremor. The oil also had a marked local 
irritant action, whether given by the mouth or hypo¬ 
dermically. The stomach wall was found red and in¬ 
jected, the urine often containing albumin.—-Dr. Power 
(introduced by Professor Cushny) said that he had been 
working on the chemistry of oil of nutmeg, which he 
found a very oomplex mixture. He had isolated large 
quantities of myristicin which did not conform in its features 
with the substance described by Semmler under that name. 
He drew attention to the very small amount of myristicin 
contained in the quantity of nutmeg necessary to induce 
poisoning, this suggesting a doubt to his mind whether the 
symptoms were entirely due to this body.—Dr. J. GRAY 
DuNOANSON mentioned the case of a woman who aborted 
after taking, amongst other things, a ground nutmeg in gin; 




496 The Lancet,] 


MEDICAL SOCIETY OF LONDON. 


[Feb. 15, 1908. 


SLOT 


Bhe displayed the symptoms described.—Professor Cushny 
replied. 

Professor W. E. Dixon dealt with Arterio-ScleroBis and its 
Causation. He referred to two theories of causation—( a ) 
raising of blood pressure and (b) toxic influences, and showed 
that it had been established conclusively by experiment that 
arterio-sclerosis could be produced in the lower animals by 
simply compressing the abdominal aorta for one minute once 
or twice a day for a comparatively short period. The changes 
consisted in a drawing out of the elastic fibres and degenera¬ 
tion of the muscular coat, plaques of calcareous material 
being formed. He explained how this might be brought 
about in man owing to violent exercise, and more especially 
was this likely to occur as man grew older, as the rise of blood 
pressure was then greater after exertion than in youth. Pro¬ 
fessor Dixon also spoke of the effect of nicotine on the blood 
pressure, comparing the sudden high rise in the young non- 
smoker after his first cigar with the slight rise in the 
moderate smoker and the absence of effect in the habitual 
smoker. He concluded by stating that man produced a 
ferment, probably in his liver, which counteracted the effect 
of nicotine.—Professor Cushny hoped that the study of this 
subject might lead to some advance in treatment. He did 
not think that the raising of blood pressure in man by the 
administration, for example, of digitalis would give rise to 
these changes.—Dr. Savill stated that he was surprised to 
hear that the compression of the abdominal aorta for such 
short periods in small animals should give rise to so serious 
changes in the aortic arch as had been described by Professor 
Dixon.—Mr. Maken also spoke. 


OTOLOGICAL SECTION. 

Mlniire's Disease.— Primary Epithelioma (?) of the Tym¬ 
panum.—Exhibition of Cases and Specimens. 

A meeting of this section was held on Feb. 8th, Dr. 
Peter McBride, the President, being in the chair. 

Mr. H. Tilley showed a case of Extensive Development of 
Keloid in the Line of Incision made for Mastoid Operation. 
Various suggestions with regard to the occurrence of keloid 
were put forward by members of the section and also 
methods of treatment. Mr. Tilley proposed to try the x rayB 
and, if not successful, to excise the scar freely. 

Dr. D. R Paterson showed an unusual case of Cerebellar 
Abscess in a boy, aged 11 years, who had only been ill three 
weeks without any apparent sign of middle-ear suppuration. 
The chief symptoms were tenderness along the posterior 
border of the mastoid and optic neuritis. The abscess was 
opened by operation and the patient made an uneventful 
recovery without impairment of hearing. 

Mr. Sydney R. Scott showed an interesting series of 
Histological Preparations of the Human Cochlea. 

Mr. Arthur H. Oheatle showed a specimen of the Right 
Temporal Bone of a Man in which, owing to the anatomical 
arrangement of the cells, it was possible for pus in the 
antrum to reach the neck without passing through the 
mastoid process. 

Mr. Richard Lake read the notes of a case of M6ni^re's 
Disease in a girl aged 14 years.—It was suggested by several 
members of the section that the cause of the symptoms 
might be due to congenital syphilis. 

Mr. R. Sturgeon Cocke showed a Case for Diagnosis— 
namely, a girl, aged eight years, in whose left mastoid 
region was situated a hard swelling of about half the size of a 
pigeon’s egg, which had gradually increased in size since it 
was first noticed 15 months ago.— The members could not 
agree to a definite diagnosis, which was variously given as a 
calcified gland, a bony growth, an enchondrcma, a solid 
dermoid, or a new growth. Mr. Cocke was asked to report 
the result found at operation at the next meeting of the 
section. 

Mr. Hunter F. Tod showed the following: 1. A case of 
Vertigo in a man in whom the coordination tests, as 
suggested by von Stein, demonstrated a definite lesion of the 
semicircular canals on the right side. 2. An unusually interest¬ 
ing case of Lateral Sinus Thrombosis occurring in a boy aged 
eight years. A few days after the operation there were facial 
paralysis on the opposite side, paresis of the sixth nerve on 
both sides, and optic neuritis on the affected side. For a 
considerable period the boy was very ill and showed definite 
signs of basal meningitis. Convalescence waB slow and with 
this complete recovery of all the symptoms. Two months 
later optic atrophy was noticed on the left (the opposite) 


side which was now well marked; otherwise the boy was 
restored to complete health. 

Mr. A. L. Whitehead read notes of a case of Primary 
Epithelioma (?) of the Tympanum, following chronic sup¬ 
purative otitis media. The first symptom of the disease 
was an aural polypus which was very vascular and which 
recurred on removal. Eventually the mastoid operation was 
performed and the growth was found to extend deeply into 
the cochlea and petrous bone and forwards involving the 
orifice of the Eustachian tube. The haemorrhage during the 
operation was so profuse as to be almost alarming but was 
arrested by pressure. Eight weeks after the operation the 
wound cavity was dry and covered with epithelium. There 
had been no recurrence since the operation, performed 12 
months ago. The pathologist’s report stated that the growth 
had the structure of an atypical carcinoma. A microscopical 
section was referred to the Morbid Growths Committee for 
further examination. 

Dr. J. Barry Ball showed a case of a Pulsating Growth in 
the Left External Auditory Meatus in a man aged 73 years. 
The patient bad consulted Dr. McBride ten years ago 
who noticed a small growth in the meatus. Since then 
it had increased slowly and occasionally there had been 
a sharp attack of hsemorrhage. The growth filled the 
meatus and protruded slightly from the orifice; there was a 
distinct expansile pulsation in it which was communicated 
to the auricle and the pre-auricular region. The growth was 
presumably angeiomatous in nature.—The question of tying 
the external carotid artery was discussed but the opinion of 
the section was that owing to the age of the patient and the 
duration of the growth it would be wiser to do nothing. 


MEDICAL SOCIETY OF LONDON. 


Exhibition of Cases. 

A meeting of this society was held orf Feb. 10th, Dr. J. 
Kingston Fowler, the President, being in the chair. 

Dr. F. de Havilland Hall showed a case of Ascites 
treated by Epiplopexy. The patient, a man aged 35 years, 
was admitted into the Westminster Hospital on Nov. 7th, 
1907, complaining of swelling of the abdomen. He gavo a 
history of a chancre five years ago ; four years ago he had 
right-sided pleurisy and was at home for eight weeks. He 
stated that he was a heavy drinker until about the age of 30 ; 
since then he had drunk on an average four or five pints of 
beer daily and occasionally spirits. About 12 months ago he 
noticed that he was getting thinner and since that time there 
had been gradual loss of flesh. Four months ago he noticed 
that be was getting fuller about the abdomen and the swelling 
had steadily increased np to the time of admission. On admis¬ 
sion the patient was thin and sallow. The liver was palpable 
for about four fingers’ breadth below the costal margin ; the 
surface was hard and irregular. There was no jaundice. 
The abdomen was distended with free fluid. On Nov. 11th 
and 26th and Dec. 17th the patient was tapped and 9 pints 
5 ounces, 10 pints 8 ounces, and 16 pints respectively were 
drawn off. On Jan. 7th Mr. W. G. Spencer made a vertical 
incision about two inches long three inches below the ensiform 
cartilage. The liver was examined and presented white 
lumps which were regarded as either of syphilitic or malig¬ 
nant origin, probably the former. Another incision was 
made in the median line below the umbilicus and a drainage- 
tube inserted ; a portion of the great omentum was sutured 
to the upper wound. On the next day a large quantity of fluid 
escaped through the drainage-tnbe ; the tube was removed five 
days later. Since the operation the patient had been treated 

with liquor hydrargyri perchloridi and iodide of potassium._ 

In answer to a question by the President, Mr. Spencer Baid 
that patients who had been thus operated on showed 
enlargement of the superficial veins, sometimes to such an 
extent that a photograph could be taken of the veins, 

Mr. W. H. Battle showed a case of Diffuse Cancellous 
Osteoma of the Femur following Fracture in a boy, aged 
three and a half years. He was admitted to the Rochester 
Hospital for a fracture of the right femur on July 11th 
1907. The fracture, which was situated Blightly below the 
middle of the shaft, was caused by a fall from a fence. On 
August 1st it was noticed that there was an unusual amount 
of swelling of the thigh ; on the 11th this had increased 
and extended the whole length of the shaft of the femur and 
measured 14 inches in circumference. On the 14'h an 
examination of the growth was made under an anaesthetic 
and a piece was removed. This was examined and consisted 


stung 

as? it pi 
ipiKtil 
.■us: tit 
last I 

j® 

arid l 

! taigc 
tuiictl 

Hast 
Lt. i 

r iXE5t( 

aef Ice 
Tsl, 
at t!» 
i:b 
Kilih). 

atecdit 
«lEfflBr, 
T3iT!a 
Ike 
if tsio 
tttiobec 
~111 
:asu 
SDsk 

ibspil 

- 

lasted f 
’iitlkt 
5kl!*] 

Q a eii 

3 btiif 

*4* * 

Elicit) 

'E«e!e 

^for 

■Wk 

■kHa 

■list 

hr. 

-'M 

’*kl 

hi 






The Lancet,] 


SOCIETY FOR THE STUDY OF DISEA8E IN CHILDREN. 


[Feb. 15, 1908. 497 


at one end of well-formed bone, at the other of young con¬ 
nective tissue, and in the middle showed newly formed 
cartilage in process of ossification. The swelling continued 
to grow until the beginning of December when it measured 
19 inches ; since that time there had been diminution in size. 
The patient had made no complaint of pain. The tumour 
was a large fusiform swelling of the right thigh which 
tapered off below but had a more marked ending above. 
The bone was completely surrounded but the tumour was 
less marked posteriorly. It was of stony hardness and of 
even surface throughout. The thigh measured 143 inches at 
its greatest circumference, the left limb only measuring 
7i inches. There was slight apparent lengthening. The boy 
was rather thin but not unhealthy-looking and presented no 
signs of tumour elsewhere. In the Transactions of the 
Society, Vol. XXV., p. 327 (1902], there was a repro¬ 
duction of a photograph of a similar tumour which deve¬ 
loped in an older brother, also as a result of fracture of the 
femur (left). The thigh was amputated at the hip-joint. 
Rapid recovery followed. In 1903 he had a tumour of the 
right femur, of the size of an orange and of the same 
structure as the original growth, as shown by the x rays. 
In 1907 the femoral tumour had disappeared, but be had a 
similar tumour of the right tibia. The original growth was 
found to be of pure bone without sarcomatous elements. 

Dr. C. E. Beevor showed a case of Prolonged Ataxy after 
Diphtheria. The patient was a boy, aged 15 years, who on 
April 10th last was detained at a Metropolitan Asylums 
Board hospital for four weeks suffering from diphtheria. In 
the third week of illness the patient had occasional difficulty 
in swallowing and fluids regurgitated through the nose. 
This lasted for one week. On leaving the hospital he was very 
weak in the legs. He had diplopia for a day or two after 
leaving the hospital. He had had some dyspncea and palpi¬ 
tation on exertion. There was some “incoordination” in the 
arms. In the upper extremities there were relative anaesthesia 
to cotton-wool and relative analgesia to pin-prick extending 
from the fingers to the elbows and shading off on passing 
up the limb. In the lower extremities there was stocking 
type of relative anaesthesia and analgesia. The “joint sense” 
and muscle pain sense were impaired. The upper extremity 
tendon jerks were absent. The knee-jerks and ankle-jerks 
were absent. The gait was ataxic, the line of progression 
deviating equally to right and left. The gait was stumbling ; 
the feet were lifted rather high and brought down flat with 
considerable force. He was unable to stand with the eyes 
closed when the feet were together. The case was very 
unusual for the length of time (ten months) from the attack 
of diphtheria that the symptoms had lasted, and such cases 
were rare. At the present time there was no definite paralysis 
but marked ataxy. 

Mr. C. Gordon Watson showed a patient, aged 11 years, 
who had been operated on for Perforation in Enteric Fever. 
The patient was admitted on Feb. 19th, 1907, to the Metro¬ 
politan Hospital on the fifth day of the disease under the care 
of Dr. Cautley. Perforation took place on the twenty-sixth day 
of the disease at 2.10 P.M. Laparotomy was performed within 
an hour. There were free gas and intestinal contents in the 
peritoneal cavity. The perforation was about 18 inches from 
the ileo-csecal valve ; it was closed and a second ulcer on the 
point of perforating was sutured over. The operation was 
completed in 21 minutes. Marked general improvement 
followed the operation.—Dr. Bertrand Dawson deprecated 
too far-reacbiDg conclusions being drawn from one case. In 
the event of perforation taking place it had to be considered 
that the patient might get well without operation.—Dr. 
F. ;J. Poynton described a case of enteric fever in which 
the abdomen was opened where no perforation h<d occurred 
but the abdomen was full of fluid swarming with typhoid 
hacilli.— Dr. E. Cautley said that the advisability of 
operating for perforation in enteric fever must depend in each 
instance on the particular circumstances of any given case. 

Dr. W. Essex Wyntkr showed a case of Partial Obstruction 
of the Superior Vena Cava in a man, aged 43 years. There 
were cyanosis and venous engorgement of the bead and 
arms, with well-marked clubbing of the fingers, and the liver 
was enlarged. There was no recognisable affection of the 
lungs or heart and the urine was normal. A loss of weight 
of 7 pounds was made good during a month's stay in hospital. 
The condition appeared to be referable to partial obstruction 
of the superior vena cava, either by thrombosis or some 
dilatation of the first part of the aortic arch, though the local 
signs were not obvious. Polycytboemia had been considered 
but it was hardly supported by the blood count. 

Mr. H. J. Waring showed a case of Traumatic Myositis 


Ossificans. The patient, a boy, aged 17 years, was admitted 
to St. Bartholomew’s Hospital on account of backward dis¬ 
location of both bones of the right forearm. The dislocation 
was reduced and an internal angular splint applied. Sub¬ 
sequently there was considerable limitation of movement at 
the right elbow-joint and a distinct hard swelling was dis¬ 
covered in the right antecubital fossa, on the deep aspect of 
the biceps and bracbialis anticus, the brachial artery being 
pushed to the inner side. On operation this was removed 
from the deep aspect of the brachialis anticus and was not 
found attached to the bone.—The case was discussed by 
Dr. Cautley, Mr. F. C. Wallis, and Mr. Watson who 
referred to the 87 cases of osseous formations in and abo it 
muscles due to injury described by Mr. Robert Jones and Mr. 
David J. Morgan. 

Mr. Wallis showed a case of Tumour treated by X Rays. 
The patient, a woman, aged 39 years, was admitted to 
Charing Cross Hospital suffering from respiratory obstruc¬ 
tion due to pressure on the trachea cansed by a growth. The 
growth was first noticed six months previously to admission 
and she felt some pain at the root of the neck and there was 
also some swelling. This increased until she had some diffi¬ 
culty in breathing. She also had great difficulty in swallowing 
and was losing flesh. When admitted her breathing was diffi¬ 
cult and distressing. She sat up in bed, leaning well forward 
and having an anxious expression. There was a large swell¬ 
ing above the mediastinum, making the chest and throat one 
continuous line. There was another swelling in the left 
Bupraclavicnlar fossa and the trachea was pushed over to the 
right side for nearly one and a half inches. The cephalic 
vein in the left arm was very prominent and the glands in 
both axilla: were large, moveable, and hard. Percussion 
showed that the growth extended into the anterior medias¬ 
tinum as far as the second intercostal space and the breath 
sounds in both lungs were generally deficient. The move¬ 
ments of the vocal cords were normal. The patient com¬ 
menced x ray treatment on Jan. 15th and this was continued 
daily for over 14 days. Since Feb. 1st she had had three 
exposures a week with marked beneficial results which 
became obvious after the first week and a steady improve¬ 
ment had continued ever since, so that the woman could now 
breathe easily in the semi-prone position and could lie on her 
side. She slept well and could swallow and the growth was 
rapidly disappearing. A blood count showed that the 
patient was not suffering from splenic leukaemia and the 
growth in the opinion of Mr. Wallis was a lymphosarcoma. 
The growth had not been examined microscopically.— 
Dr. J. H. Drysdale related a case of sarcoma that im¬ 
proved under x ray treatment but eventually resulted fatally. 
He thought that the tumour described by Mr. Wallis might 
be a lymphadenoma.—Dr. R. C. B. Wall discussed the case 
from the point of view of Hodgkin’s disease, and after Dr. 
W. H. Willcox had suggested that the tuberculin reaction 
might have been tried Mr. Wallis replied. 

Mr. Wallis also showed a case of Unnnited Fracture of 
the Femur with a Hoefftcke’s splint applied. 

Dr. Robert Hutchison showed a case of Splenomegalic 
Polycythaemia and Dr. Willcox a boy with Symmetrical 
Polyarthritis of the Hands. 

Dr. Wall showed a case of Syphilitic Infiltration of the 
Superior Mediastinum. 

Dr. Morgan Dockrell showed three cases of Ul¬ 
erythema. _ 

SOCIETY FOR THE STUDY OF DISEASE 
IN CHILDREN. 


Congenital Hypertrophic Stenosis of the Pylorus.—Exhibition 
of Cases. 

A meeting of this society was held on Jan. 17th, Mr. 
Sydney Stephenson being in the chair. 

Dr. George Carpenter read notes of a case of Congenital 
Hypertrophic Stenosis of the Pylorus which he had treated 
in conjunction with Dr. D. J. Munro of Brixton and which 
bad recovered under medical treatment, dieting, lavage, 
and drugs being the methods employed. He described the 
course of the case fully and then discussed the pathology 
and treatment of the condition. He considered that hyper¬ 
trophic stenosis of the pylorus was a congenital abnormality 
of development and not a secondary muscular spasm, and 
maintained that similar cases should receive more thorough 
medical and dietetic treatment and that surgical intervention 
should not be invoked in the early stages. We hope to 
publish Dr. Carpenter’s paper in full in a future issue. 




498 Thb Lanott,] 


LIAERPOOL MEDICAL INSTITUTION. 


[Feb. 16, 1908; 


Dr. Edmond Cautley read a paper on the Pathology of 
Congenital Hypertrophy of the Pylorus in Relation to Treat¬ 
ment. Acceptmg the view that there is such an affection as 
pyloric spasm and that the action of the pylorus is that of 
the closed door which only opens in response to duodenal 
stimuli, he argued that there was no evidence that spasm 
could cause hypertrophy. Almost all physicians had found 
antispasmodlc drugs of no value in treating pyloric hyper¬ 
trophy, a remarkable fact if the symptoms were due to spasm 
grafted on to, or causing, hypertrophy. Moreover, spasm 
might occur at any age, and yet these cases of hypertrophy 
were peculiar to the first few months of life, and there was 
no evidence of spasm at a later age causing hypertrophy. 
Recovery from pyloric spasm under medical treatment, in 
cases mistaken for true hypertrophy, had led to an unduly 
favourable estimate of the value of medical treatment in true 
hypertrophy. The latter affection varied from a degree of 
hyperplasia which was fatal unless treated surgically, down 
to a slight hyperplasia which was compatible with life, if no 
secondary effects occurred. These effects—viz., dilatation of 
the stomach, gastric catarrh, and occasionally acute oedema of 
the pyloric mucosa—were due to contraction of the muscle. In 
mild cases the degree of contraction might prevent sufficient 
nutritive food passing through the pylorus and yet not set up 
the secondary symptoms. Three of his cases had been of this 
type and under medical treatment had succumbed to 
marasmus, although food was present in the intestines 
after death. It was these cases in particular that made a 

S srson critical of the assumed value of diet and lavage. 

rugs he had found useless. A diet of whey or albumin 
water, carefully regulated, would suit such cases for a time 
but as soon as the strength of the food was increased the 
secondary symptoms arose. Oa the assumption that the 
condition was induced by hyperchlorhydria cases had been 
treated by undiluted cow’s milk. Such a food had proved 
useless in his hands and he suspected that the successful 
cases were due to pyloric spasm. Recent observations by 
Miller and Willcox supported the view that there is no 
excess of acid in these cases and all clinical and pathological 
evidence was in favour of the weak nutritive fluid rather 
than undiluted milk. Lavage would be useful in hyper¬ 
chlorhydria and pyloric spasm but could hardly be expected 
to be of value in cases of mild hypertrophy without secon¬ 
dary symptoms. It seemed unnecessary if food was passing 
through the pylorus, if vomiting was absent, and if there 
was little or no dilatation. There were undoubted cases of 
this type. It was of great value in curing secondary dilatation 
and gastritis, but it only cured these secondary effects and 
not the hypertrophy and might place the child in the status 
quo ante. Then if the degree of hypertrophy and contraction 
was compatible with life the child might recover. He re¬ 
garded it as of vital importance to differentiate spasm from 
hypertrophy and thought that the medical treatment of true 
hypertrophy should not be unduly prolonged. The greater 
the degree of marasmus previously to operation the smaller 
was the chance of the child's recovery. 

Dr. G. A. Sutherland protested against the assumption 
that if pyloric stenosis were cured medically it must have 
been in such a mild form that it would have recovered 
without treatment. Operation was a very serious matter and 
many infants who had stood the operation died afterwards 
from bowel trouble of some sort. He did not think that for 
a complete diagnosis one should be able to feel a pyloric 
tumour, as the pylorus was a very uncertain thing to feel in 
an infant. The diagnosis could be made if vomiting, consti¬ 
pation, wasting, and marked visible peristalsis were present. 
Where trouble arose when breast milk was given the fault 
was not with the milk but with the manner of feeding. Small 
feeds of the most digestible materials were required and if 
there was a residue ot food left in the stomach alter washing 
out for a day or two the infant was not having suitable 
food. 

Mr. J. P. Lockhart Mummery said that it was scarcely 
possible to have a more unsuitable subject for a severe 
operation. The child was very young and badly nourished 
and had probably been vomiting all the nourishment given 
for some days before. Very few cases died on the table. 
The only patients in whom the prospect of operation was 
good were those seen early before there had been wasting and 
in whom there was a fair amount of fat. 

Dr. Charles W. Chapman said that in the condition 
under discussion there was a great deal of irritation causing 
the closure and he was therefore surprised that no one had 
suggested the administration of carbonate of bismuth. It 
might be given freely in as much as teaspoonful doses. 


Mr. Hugh Lett said that the members were much indebted 
to the readers of the papers as the subject was one of great 
importance. Surgical treatment was a very serious matter 
and in many cases by the time the surgeon was called in the 
condition was practically hopeless. The physician should be 
clear at the beginning of his treatment how long he would 
continue medical measures, lest by unduly prolonging them 
the prospects of operation were affected. He advocated tho 
claims of gastro enterostomy as being simpler than pyloro¬ 
plasty and safer than Loreta’s operation. 

Dr. Reginald H. Miller suggested that the symptoms of 
pyloric stenosis were entirely referable to spasm. First, 
because of the onset of the disease. At the Clinical Society 
of London last year 40 cases were collected and in 70 per 
cent, of them the onset did not occur until the third or fourth 
week of life. He had a case in which diarrhoea preceded 
the onset of the symptoms. It was true that many babies 
vomited from birth but not sufficiently to cause wasting, 
and the well-marked constipation was frequently absent 
during the first two or three weeks of life, lhat suggested 
that there was not marked blocking at the pylorus as 
a congenital lesion. Again, even though the baby were 
not saved by lavage and careful dieting, he or she 
usually died from diarrhoea, showing that the pylorus 
was once again patent and that somathing had happened, 
for presumably the spasm had been relaxed. Such cases 
strongly simulated the real condition which Dr. Cautley 
referred to, and he (Dr. Miller) thought that they were quite 
identical. 11 was difficult to say what was the cause of the 
spaBm, but he thought that it was due to a congenital defect 
in the gastric juice, and he had tried to find what that defeot 
was in the observations alluded to by Dr. Cautley; he 
believed the so-called hyperacidity was not the cause. It 
would be a very engaging idea if it were so. Hyperacidity 
was found in babies who ran a different course, generally 
getting well in a few weeks. The hyperacidity of pyloric 
spasm occurred in older and less wasted children, the tongue 
was clean, and there was no true peristalsis so that the 
viscus stood up on palpation. There was Mr. Clinton T. 
Dent's well-known foetus in whioh the pylorus was found 
hypertrophied. He regarded spasm of the pylorus as the 
entire cause of the symptoms of the condition, if not of the 
disease itself. 

Dr. T. R. Whipham Bhowed a case of Congenital Heart 
Disease in a girl, aged 17 years, who showed no cyanosis or 
clubbing. 

Dr. J. Porter Parkinson showed a case of Synovitis of 
the Knee-joint without pain or tenderness in a boy, aged 
seven years. The patient was the subject of congenital 
syphilis and the effusion followed periostitis of both tibke. 

Dr. Sutherland showed : 1. A case of Cretinism. The 
patient, a boy, aged nine years, was seen in November, 1907, 
when typical signs of cretinism were present. He improved 
markedly under thyroid treatment. Growth in the long 
bones was very delayed and pituitary extract had been given 
without any benefit so far. 2. A case of Tuberculous Peri¬ 
tonitis in a girl nine years old. When first seen in September, 
1907, the case seemed hopeless. There had been signs of 
tuberculous peritonitis for live months. The patient, who 
was wasted and in a stuporous condition, suffered from 
diarrhoeiand had delirium at night and hallucinations during 
the day. She was now convalescent and the signs of active 
tuberculosis had subsided, although the abdomen was still 
distended. 

Dr. McMaster (for Dr. L. G. Guthrie) showed a case of 
Acute Polioencephalitis following Measles. The patient, a girl, 
aged five years, was well nourished and intelligent but had 
spastic diplegia. There were no ocular symptoms. There 
was weakness of the muscles of the back so that she could 
not sit upright and could not hold her head up. The condi¬ 
tion simulated one of congenital spastic diplegia. 

Mr. Lockhart Mummery showed acase of Supernumerary 
Auricles in an infant, on both sides of the head, situated just 
in front of the external auditory meatus in the position of 
the inter-maxillary cleft. 


LIVERPOOL MEDICAL INSTITUTION. 

The Physics of the Mitral Regurgitant Murmur. 

A meeting of this society was held on Jan. 16th, Mr. 
Thomas H. Bickerton, the President, being in the chair. 

Dr. T. Ii. Bradshaw read a paper on the Physics of the 
Mitral Regurgitant Murmur, especially with regard to its 
audibility at the heart’s apex. He assumed the correctness of 





The Lancet,] 


LIVERPOOL MEDICAL INSTITUTION. 


the views held by George Balfour, Cbaveau, Marey, and others 
that murmurs were due to the vibrations of the ‘'fluid veins ” 
formed in the space beyond the narrowing. The difficulty in 
explaining tbe mitral regurgitant murmur on this theory was 
that it was heard at a point (the apex) in the opposite direc¬ 
tion to the “ fluid vein,” which was directed towards the 
auricle; no explanation quite satisfactory had ever been 
offered. Dr. Bradshaw’s explanation was that the sonorous 
“ fluid vein ” lay between the two curtains of the mitral valve 
and that its vibrations transmitted to the cone of blood 
passed through the thin walls without damping and set up 
vibrations in the ventricle. The vibrations were heard best 
at the apex, because the walls of the ventrioles were thinned 
at this spot and this spot was most accessible to auscultation. 
He exhibited an apparatus constructed to show that sonorous 
vibrations could under similar conditions be conducted in a 
retrograde manner.—The paper was discussed by the 
President, Sir James Barr, Professor L R. VVilberforce, 
Dr. J. Li.oyd Roberts, and Dr. It. J. M. Buchanan, and Dr. 
Bradshaw replied. _ 

The Production of Pseudo arthrosis at the Ifip-joint .— Volk 
marm's Isoha-mic Paralytit.—Paralytic GUcan’O-earns .— 
The Diagnosis and Treatment of Eotopic Gestation. 

A meeting of this society was held on Jan. 30th, the 
President being in the chair. 

Mr. Robert Jones described his operation for the Produc¬ 
tion of Pseudo arthrosis at the Hip pint without disarticula¬ 
tion of the femoral head. The great trochanter was first 
separated from the shaft by a broad osteotome and the neck 
■of the femur either divided or removed, and the trochanter 
was screwed on to the head of the femur which lay in the 
acetabulum. The operation might be employed in all 
varieties of bony ankylosis but was eminently suited for 
■old people with malum coxa; senilis where the shock of dis¬ 
articulation was serious. Mr. Jones also described his pro¬ 
cedure in the treatment of Volkmann’s Ischaemic Paralysis 
and his operation in Paralytic Calcaneo-cavus.—The com¬ 
munication was discussed by the President, Mr. W. T. 
Thomas, Mr. G. P. Newbolt, and Dr. J. H. Abram, and 
Mr. Jones replied. 

Dr. H. Briggs read a paper on the Diagnosis and Treatment 
of Ectopic Gestation mainly founded upon a clinical study 
of 124 cases of interrupted early gestation marked by 
physical signs and symptoms at or before the end of the 
second month. Deducted from an inclusive total of 139 cases, 
all of them treated by operation, the 124 oases left 15 
others, nine at from two to six months, two at six months, 
three about the full term, and one nine years after the full 
term, not included in the paper. The earliest disturbances 
amongst the 124 early ectopic gestation sacs occurred after 
intervals of six, 10, and 18 days beyond the cessation of a 
previous normal and regular menstruation. For the group 
of clinical symptoms and Bigns indicative of these dis¬ 
turbances Dr. Briggs 15 years ago had instituted and since 
adopted the term peritoneal crisis. He maintained that the 
symptoms and signs of sudden onset were often moderate or 
mild and that even trivial, locally recurrent p-iins, together 
with slight, irregular menstrual and intermenstrual blood loss, 
were not to be construed as harmless or insignificant until 
the physical signs bad been closely watched or waited 
for. A more prompt appreciation of their significance and 
of what may lie before the patient would lead to earlier and 
easier and safer operations and to the more frequent recogni¬ 
tion (with the Trendelenburg position for operation) of 
“ unruptured tubes ” and a little free intraperitoneal blood 
even in cases where the acute peritom al crisis had been 
recent and sevsre. To postpone operation was to incur 
adhesions and hsematocele sacs in their various forms The 
peritubal (hanger and Taylor) and the parat.uhal (Sampson 
Handley) hmmatocele sacs for their intact removal must be 
in a suitable physical condition ; earlier and later in their 
course the physical conditions might defy intact removal. 
Intact removal was not indispensable, but the handling of 
organised and organising tissues, especially of adherent 
blood clots, or simply draining them, did not diminish tie 
post-operative risks. Localised luematocele sacs as intra- 
peritcneal formations subsequently to originally free intra¬ 
peritoneal haemorrhages possessed a stage at which there was 
both free and localised blood; the free blood outside 
the hrematocele sac in process of absorption might be 
accepted as evidence of secondary rupture of the tubal or 
baematocele sac. Dr. Briggs believed that the older 
statistics of the prevalence of tubal rupture were inaccurate 


[Feb. 15,1908. 499 


iu consequence of the frequency with which gestation sacs 
were torn or ruptured by the fingers of the operator. In the 
future the continued use of the Trendelenburg posture, 
lending sight and light to the lower abdomen, would show, 
as it had shown in hie more recent experience, that gestation 
sacs before operation were rarely ruptured. Werth and 
Taylor and Bland-Sutton had established their respective 
contributions to the process of tubal abortion. Dr. Briggs 
produced old gestation sacs, nine years old downwards, to 
demonstrate what may remain in a latent or an active 
form in the patient after apparently successful expectant 
treatment. Daring the first ten years up to the end of 
1897 one vaginal and 20 abdominal sections, compared 
with the second ten years 17 vaginal and 101 abdominal 
sections, denoted a change from expectant to operative 
methods in his practice. He showed from nine of his cases 
bilateral lesions, on one side a tubal gestation sac and on tbe 
other a pyosalpinx once ; a small ovarian cyBt twice ; and old, 
adherent, inflamed tubes six times, masking the diagnosis of 
ectopic gestation from the symptoms. A three years old and 
a recent tubal pregnancy on opposite sides coexisted in one 
case. A second tubal pregnancy on the opposite Bide had 
been treated by a second operation in three of his patients. 
Dr. Briggs referred to a paper which he himself read in 
1897 in which he had produced evidence that intraperitoneal 
haemorrhage and htematoiele were occasionally associated 
with lesions other than those of ectopic pregnancy. The very 
rare rapid fatalities associated with tubal rupture formed a 
very small class of their own ; operative treatment if at hand 
was almost excluded by the brief space of time available. ‘‘To 
operate,” says Dr. F. H. Champneys, “duriDg the state of shock 
is in many cases to kill the patient.” Dr. Briggs said that he 
had invariably acted on this principle and he showed a 
series of ectopic sacs successfully removed from patients 
after they had recovered partially or wholly from a peri¬ 
toneal crisis. The severity of a peritoneal crisis was no 
certain measure of the amount of hemorrhage. He was of 
opinion that, with this exception, delay in the operative 
treatment of ectopio gestation increased its dangers. There 
were two deaths lollowing operative treatment amongst his 
124 cases: (a) after an unusually troublesome and risky 
operation amidst dense adhesions in a patient who had 
refused operation for appendage disease three months pre¬ 
viously ; and ( h ) after the operation for abdominal drainage 
of a very large hsematocele in a very anaemic woman ; death 
resulted from anaemia —The paper was discussed by the 
President, Dr. T. B. Grimsdai.e, and Dr. J. Gkmmej.i,, and 
Dr. Briggs replied. 

Ascites and Tumours of the Oeary.—Exhibition of Specimens. 

A meeting of the pathological section of this society was 
held on Feb. 6'h, the President being in the chair. 

Dr. E. Emrys Roberts read a paper upon Ascites and 
Tumours of the Ovary. After a brief historical sketch of 
the subject he pointed out that the tendency of modern 
Investigation was to assign to the cells of the peritoneum a 
more active idle in the production of ascibs than was 
formerly thought to be the case. Malignant disease of the 
peritoneum might possess an irritative or toxic property and 
the ascites might be called a peritonitic exudation as truly 
as in the case of infective peritonitis. In certain cases the 
ascites might possibly be the product of the cancerous growth. 
Ascites accompanying tumoursof the ovary might r* suit from 
certain necrotic changes in the tumours or from torsion of 
their pedicles. At other times the fluid might be accounted 
for by concurrent disease, while in certain tumours the 
ascites was actually the product of the epithelium of these 
new growths, as, for example, superficial papillomata and 
eystomata with ruptured walls.—Dr H. Briggs thought that 
the needful work in reference to hydroperitoneum and 
papillomatous growths had yet to be done. So far the 
evidence was inconclusive. 

Dr. John Hay showed a Saccular Aneurysm of the Aorta 
of the size of a small orange situated beyond the origin of 
the left subclavian arterv. Death was due to rupture into 
the left pleural cavity. Blood had previously leaked into the 
anterior wall of the pericardial sac forming a large htematoma 
in the tissues of the pericardium and leading to dyspnoea. 
The patient survived the rupture for four days. 

Mr. G. F. Nkwbolt showed a Volvulus of the Small 
Intestine removed from a boy, aged 10 years, who was 
admitted with symptoms of intestinal obstruction. The upper 
part of the jejunum was twisted around a large caseous 
me enteric giand which had been torn open by the torsion 





500 The Lancet,] LEEDS AND WEST RIDING MEDICO-CHIRURGICAL SOCIETY. 


[Feb. 15,1908. 


of the bowel, and peritonitis was present. An end-to-end 
anastomosis of the resected gut was performed bnt the patient 
only lived 36 boars after the operation. 

Mr. F. T. Paul and Mr. Frank A. G. Jeans showed : 
1. Hydatid Cyst of Retrorenal Tissue. The kidney, which 
was Btretched over the cyst, was removed with it. 
There were no urinary symptoms. 2. A Chronic Ileo-colic 
Intussusception from a man, aged 23 years. The operation 
involved removal of the ileum, caecum, the ascending, and 
half the transverse, colon. 3. A Carcinoma of the Trans¬ 
verse Colon. An immediate end-to-end anastomosis had been 
attempted with fatal result. 

Dr. R. J. M. Buchanan showed specimens of Myelocytes 
from a case of Myelogenous Leukaemia. The cells had been 
washed twice with sodium citrate solution and once with 
normal saline solution in the centrifuge. On staining the 
films with Leishmann’s stain the myelocytes showed long 
flagella projecting from the surface and wei e more granular, 
the granules responding to the stain in the same marner as 
the nuclei. In some of the flagella a few granules could 
be seen, while into others strands of nuclear chromatin 
extended. These flagella did not resemble pseudopodia and 
the cells in which they occurred were slightly if at all 
amoeboid. 

Professor A. M. Paterson exhibited Specimens and Models 
illustrating the Normal Form of the Stomach, and variations 
from the normal type, including several examples of "hour¬ 
glass ” stomach resulting from hypertrophy of the circular 
muscular coat of the organ between the cardiac and pyloric 
portions. 


LEEDS AND WEST RIDING MEDICO- 
CHIRURGICAL SOCIETY. 


The Treatment of Qattric Ulcer.—Exhibition of Caset 
and Spcoiment. 

A meeting of this society was held on Jan. 31st, Dr. J. 
Allan, the President, being in the chair. 

Dr. A. G. Barrs and Mr. B. G. A. Moynihan opened a 
discussion on the Treatment of Gastric Ulcer. 

Dr. Barrs said that the rapid rise and striking success of 
the surgical treatment of gastric ulcer had invested the 
subject with a new interest and a greater importance, whilst 
the responsibility of the physician had proportionately 
increased, for with him still rested, and very properly so, 
the duty of determining in any given case whether medical 
or surgical treatment should be adopted, and it was only by 
maintaining him in bis position of judge of first instance 
that unnecessary, and therefore unjustifiable, operations were 
to be avoided. The first and by far the most important 
question the physician had to decide in the treatment of 
any case of gastric ulcer was whether the case was one for 
medical treatment at all. He said that was a question 
to which he had up to a certain point no difficulty in 
making an answer which he thought would be generally 
accepted. The following cases, he thought, should be 
handed over to the surgeon without delay: (1) all perforations 
or suspected perforations ; (2) all cases in which visible and 
palpable signs were present, due either to perigastritis or 
dilatation ; (3) probably all male cases ; (4) many of the 
older female cases, in which gastric ulcer was rarely got rid 
of without operation and in which duodenal ulcer was not 
infrequently present; and (5) all cases which, though having 
no visible or palpable signs, resist prolonged and efficient 
medical treatment, especially those with repeated hmmat- 
emesis, even though the hfcmatemesis was small in quantity. 
Where no definite lesion in the stomach was detected when 
the abdomen was opened he would suggest that no gastro- 
entero-tomy should be done. No cases of first hsematemesis 
should be treated by operation and he thought that in no case 
of repeated hscruatemesis should an operation be performed 
during the actual bleeding. He said this because the 
surgeon’s present method of dealing with haematemesis was 
not scientific. He (the surgeon) could not help it but it was 
usually impossible for him to deal directly with the bleeding 
point. When all these had been disposed of the physician 
was left with a large class of cases, represented most 
commonly by the young unmarried woman, frequently a 
domestic servant but rarely a cook, whose complaint was of 
months, or possibly years, of great suffering (frequently 
with sti iking intermissions) from severe gastric pains which 
were usually, but not always, aggravated by food and 


relieved by vomiting, with or without occasional and profuse 
hsematemesis along with profound anaemia and cachexia. 
These young women were, as a rule, poor meat-eaters by 
nature, and many of them bad had their teeth destroyed by 
tbe medicinal use of iron. Of physical signs in the abdomen 
in these cases there were none save superficial sensitiveness 
in Head's gastric area and tenderness on pressure in the 
epigastrium. The area of tenderness was, as a rule, quite 
definite and easily covered by the end of a thumb. This 
was the type of case which it was customary to treat 
by medical means and apparently with much success. Almost 
all of these patients were entered as " cured ” when they 
left the hospital. But gastric ulcer was a very inveterate 
and long-drawn-out disorder, and many of the so-called 
"cures” were, he was afraid, very temporary affairs. 
Patients returned again and again, especially the older ones, 
until, as a last resort, gastro-enterostomy bad to be done; 
so that in regard to these cases he would say that medical 
treatment should always be tried for a reasonably long 
period of time; but if frequent relapses occurred and 
above all if frequent hemorrhages—large or small—occurred 
gastro-enterostomy should be done. But his experience of 
the surgical treatment of the intractable cases of this class, 
without definite physical signs, had not been without its 
disappointments, for it was obvious that the more definitely 
mechanical the causes of the symptoms were the more certainly 
were they relieved by the purely mechanical procedures of 
the surgeon ; that was to say, surgery was most successful in 
cases where the ulcer had produced mechanical defects in 
the stomach. What then should be regarded as efficient 
medical treatment? The most essential part of medical 
treatment was prolonged and complete rest in bed ; without 
that all other means were of no avail whatever. To make 
a diagnosis of gastric ulcer, whether it turned out to be right 
or wrong, and, at the same time, to allow the patient to be 
out of bed, was, to his mind, an unpardonable inconsistency. 
The moment a patient was even suspected of gastric ulcer 
she should be put to bed. He was not permitted to enter 
into the question of diagnosis but he would like to say 
that they ought not to insist upon tbe presence of 
haematemesis or even of vomiting before making a 
working diagnosis of gastric ulcer. Having put the 
patient to bed what next was to be done? The general 
public, and possibly many of tbe profession, still thought 
that diet was the most important thing in the treatment of 
gastric disorders. As time went on his system of dietetics 
became simpler and simpler, and he thought that any adult 
patient (except perhaps a diabetic subject) who could not 
take ordinary articles of diet—that is, solid food—had 
better take no food at all and lie in bed and drink water 
until he could. He never ordered milk for patients with 
gastric ulcer ; he repudiated entirely the old practice of 
saying to a patient with gastric ulcer, " A milk diet or your 
life.” He wished they could see the same reduction in the 
milk bills of the hospitals as recent years had seen in their 
alcohol bills. He could not understand how they as a pro¬ 
fession could go on countenancing milk drinking in bulk by 
adult patients and the public at large, knowing as they did 
that it was probably the surest way of introducing the 
tubercle bacillus as well as other pathogenic organisms 
into their bodies. Bulk was a much more important con¬ 
sideration in the food of a patient suffering from gastric 
ulcer than kind, and small meals of meat and stale bread (if 
they could be taken rvithovt pain and not unlett), along with 
water in any reasonable quantity to drink, was the food which 
he usually suggested, but if there were vomiting no food 
should be given, only plain fresh water to drink. He never 
used nutrient enemata or nutrient suppositories, bnt if 
vomiting prevented the taking of water b? the mouth 
normal saline injections or injections of a solution of glucose 
should be employed. Enemata of any kind were not in¬ 
frequently very distressing to patients and might induce 
vomiting. No patient with gastric ulcer should be allowed 
to leave her bed until she had taken ordinary mixed solid 
food at the ordinary meal times for ten days at least, ten 
days of food not only without pain but with enjoyment. He 
never ordered any form of artificial or artificially digested 
food for anybody, or any of the so-called d gestives. For 
medicine he had great faith in bismuth carbonate in large 
doses given in plain water and not in the gummy mixtures 
which were at one time in vogue. It should be given 20 
minutes before food was taken into the stomach. If there 
was very much pain a little morphine—say five or ten minims 
of the solution of morphine—could be given along with the 




The Lancet,] 


EDINBURGH MEDICO-OHIRURGICAL SOCIETY. 


[Feb. 15,1908. 501 


bismuth powder. If there was constipation, and there 
usually was, a rhubarb pill or some other simple vegetable 
laxative might be given twice or three times daily after food, 
so as to insure a natural action of the bowels once daily with¬ 
out straining and without purging. He did not give saline 
purges in gastric ulcer. Local applications of heat to the 
abdomen gave ease to the patient. All severe forms of 
counter irritation, such as blisters and mustard poultices, 
he never used ; iron was most undesirable for patients suf¬ 
fering from gastric ulcer, however anmmic they might be. 
In the treatment of biematemesis he adopted the same plan : 
absolute rest of body and mind, by morphine if necessary, 
and water drinking sufficient to allay thirst, not by tea¬ 
spoonfuls but three or four ounces at a time He had no 
faith in so-called haemostatic drugs in internal bleeding, but 
saw no objection to the use of such harmless and tasteless 
things as chloride of calcium, for example. Suprarenal 
extract might be, perhaps should be, used, but it was a 
powerful substance and should be given with care. Patients 
suffering from recent and severe haematemesis were never 
hungry and therefore did not require food. After three 
clear days from the cessation of the hjematemesis food such 
as meat, eggs, and stale bread might be given, if the patient 
wished but not otherwise. After biematemesis the patient 
should be kept in bed until the anaemia had largely, if not 
entirely, disappeared. 

Mr. Moynihan dealt with the Surgical Treatment of 
Gastric Ulcer. He differentiated between acute ulcer, in 
which only the mucous surface of the stomach was as a 
rule involved, and chronic ulcer, in which the destructive 
and reparative processes had together involved all the coats 
of the stomach, so that the ulcer was a visible, palpable, and 
demonstrable lesion. In acute ulceration surgical treatment 
was never necessary on account of hmmorrDage and rarely on 
account of perforation. In his own series of 37 cases of per¬ 
forating ulcer there was only one in which the ulcer was 
acute ; in the remainder it was a chronic ulcer, the symptoms 
of which had been present for months or years and had been 
recently more acute. Gastro-enterostomy in addition to 
closure of the ulcer was called for if there were other 
ulcers or if the closure of the ulcer was likely to 
cause obstruction. Hasmorrhage in chronic ulcer rarely 
called for urgent operation ; an interval of freedom from 
bleeding should be chosen. Excision of the ulcer, or its 
infolding, the vessels supplying the ulcer being secured, and 
gastro-enterostomy were usually to be practised. Chronic 
ulcer of the stomach or of the duodenum was held to be 
a condition which should in all cases be treated by operation. 
The difficulty in some cases in arriving at a diagnosis was 
referred to and the opinion expressed that in most cases an 
exact diagnosis was attainable, and that in maDy the 
position of the ulcer could be predicted. If, however, after 
the abdomen had been opened, an inspection of it revealed 
no lesion, there was no indication for any operation upon the 
stomach itself. In no circumstances whatever and in 
compliance with no persuasion, however insistent, should 
the surgeon consent to perform gastro-enterostomy in 
the absence of definite demonstrable organic disease. 
If an ulcer were found near the pylorus, on either 
side, gastro-enterostomy should be performed, and, if 
possible, the ulcer should be infolded, to prevent per¬ 
foration or haemorrhage, both of which had occurred 
after gastro-enterostomy. If the ulcer was on the lesser 
curvature in the cardiac half of the stomach it should 
be excised ; gastro-enterostomy in such cases gave only slight 
and temporary relief. When multiple ulcers were present 
in the pyloric region, or when a doubt existed as to the 
malignancy of the condition, Rodman’s operation, excision 
of the ulcer-bearing area, was indicated. The method of 
gastro-enterostomy which gave the best results was the 
posterior operation, the jejunum being applied almost 
vertically to the stomach, and the anastomosis being made 
as close to the flexure as possible. 

The President, Dr. J. E. Eddison, Mr. E. Solly, Mr. 
W. R Bates, Mr. J. Stewart, Mr R. Lawford Knaggs, 
Mr. N. Porritt, Dr. A. Christie Wilson, Dr. E. S. Leaver, 
Mr. H. Collinson, Mr. H. H. Greenwood, and Dr. H. 
Secker Walker took part in the discussion, and Dr. 
Barrs and Mr. Moynihan replied. 

Mr. H. Littlewood showed: 1. A patient suffering from 
Pyloric Stenosis on whom gastro-enterostomy had been per¬ 
formed in Jane, 1907. The patient’s weight before opera¬ 
tion was 3 stones 7 pounds, and the present weight was 
7 stones 12* pounds. 2. A specimen of Thrombosis of some 


Vessels in part of the Transverse Colon producing Intestinal 
Obstruction. 3. A Gall-bladder, with Stones, removed from 
a girl 18 years of age. The gall-bladder was contained in a 
complete mesentery extending from the liver to the colon. 

Dr. J. B. Hellier showed a Sarcomatous Growth removed 
from an Old Abdominal Cicatrix. 

Mr. J. F. Dobson showed a specimen from a case of 
Abscess in the Great Omentum with Diffuse Peritonitis. 
Almost the whole of the omentum was removed. 

Specimens and cases were also shown by Mr. Walter 
Thompson, Dr. Carlton Oldfield, Mr. E. Ward, Mr. 
Knaggs, the President, and Mr. Moynihan. 


EDINBURGH MEDICO-CHIRURGICAL 
SOCIETY. 


Removal of Submaxillary Gland.—Electrolyiis in Medicine 
and Surgery. — Empyema. 

A meeting of this society was held on Feb. 5th, Dr. 
George Hunter, Vice-President, being in the chair. 

Mr. F. M. Cairo demonstrated a patient after removal of 
a Submaxillary Gland. The patient had been shown at the 
previous meeting as one from whom Mr. Caird had removed one 
half of the tongue for carcinoma. The submaxillary gland 
after this became enlarged and cirrhotic but Mr. Oaird did 
not think that it was the seat of cancer. Most of the 
surgeons present at the meeting recommended removal as 
they thought that it was malignant. The gland was removed 
and though examined carefully by pathologists no trace of 
malignant disease was found. It was merely an inflamed and 
cirrhotic gland. This was importantas regards the prognosis. 

Dr. Dawson F. D. Turner read a paper on Electrolysis in 
Medicine and Surgery. He said that the human body was an 
electrolyte, and electrical currents were only conveyed 
through it by the migration of ions (electrified particles of 
matter). Only those drugs which broke up into ions conld 
be made use of—e g., aqueous solutions. Oils, alcohols, 
and glycerines did not form ioDS; the spiritus chloroformi 
and the glycerinum acidi carbolici could not be introduced 
electrolytically ; for this reason they were more toxic in 
aqueous solutions when taken by the mouth. If an 
individual were to place each hand in a separate 
basin of salt water, and if these were connected with 
the terminals of a source of electric supply, then at the 
anode or basin connected to the -j- pole the body would lose 
its anions and receive cations, while at the cathode or basin 
connected with the pole the body would lose its cations 
and receive anions. The anions were constituted by the acid 
radicle or elements and the cations by the metallic radicle 
or metals. Thus oxygen, chlorine, sulphion, and hydroxyl 
were anions ; while hydrogen, sodium, and copper were 
cations. When sodium chloride was dissolved in water its 
molecules dissociated into ions or particleB with opposite 
electrical charges ; the anions were charged negatively and 
would therefore be attracted to the anode, and the cations 
were charged positively and would be attracted to the nega¬ 
tive pole or cathode. In this case Na + was the cation and 
Cl — was the anion. At the anode the body would yield up 
chlorine and receive sodium, while at the cathode it 
would give up sodium end receive chlorine. Between each 
electrode there would be a migration of ions, the Cl — ions 
would be moving to the anode and the Na -f ions to the 
cathode. If a piece of raw beef were taken and electrodes 
applied to either side with some blotting paper soaked in a 
solution of potassium iodide under the — electrode and some 
blotting paper soaked in starch between the + electrode and 
the beef, it would be found that on passing a current the 
blotting paper at the -+- pole would become blue, showing 
that iodine had been carried through the beef. In the same 
way metallic ions might be conveyed into the tissues of living 
beings. A rabbit might be poisoned by having strychnine 
carried into its tissues from the anode moistened with the 
salt of this alkaloid. To what useful purposes could this 
introduction of ions into the body be put? Rodent ulcer, 
parasitic affections, sinus and fistula, ankylosis, sclerosis, 
fibrous adhesions, strictnre, tic douloureux, neuralgia, 
sciatica, and rheumatic and gouty conditions were 
all benefited by this treatment. Lreduc reported the 
complete cure at a single sitting of a case of rodent 
ulcer by the introduction of the zinc ion from sulphate 
of zinc. As a rule, however, more than one application 
was necessary. The ulcer should be cleaned aud from 



502 The Lancet,] 


EDINBURGH MEDICOCHIRURGIOAL SOCIETY. 


[Feb. 15, 1908. 


eight to ten layers of the lint cut a very little larger than the 
size of the uloer should be soaked in a 5 per cent, solu¬ 
tion of zinc sulphate. The positive electrode (of zinc) muBt 
be connected with this and the negative pole to a basin 
of salt water into which the patient’s hand is placed. The 
current must be gradually raised to from 40 to 60 milli- 
amperes or as much as the patient can bear conveniently and 
continued for 30 minutes. At the end of this time the surface 
of the ulcer would be whitened and dry. Another applica¬ 
tion might be made in a week or a fortnight. Many cases 
had been successfully treated by Dr. Turner in this way. 
Chronic ulcers were also amenable to the zinc ion. In 
fibrous ankylosis and sclerosis the chlorine ion or hydroxyl 
OH would be found of service. A case of Dupuytren's 
contraction of the fingers of 15 years’ duration which bad 
yielded to this treatment was shown. Even sclerosis of 
the spinal cord could be attacked and cases of spastic 
paralysis which had been treated by Dr. Turner in this 
way had benefited remaikably. A case of tic douloureux 
which had proved refractory to other remedies yielded 
to the electrolytic introduction of the salicylic ion.— 
Dr. A. D. Websikr and Dr. Hunter took part in the 
discussion. 

Mr. Albert E. Morison read a paper on 100 Consecutive 
Cases of Empyema. As regards the physics of pleural 
effusions he said: 1. That the intrapleural pressure was 
positive in purulent eifusions, while in normal conditions the 
pressure was negative. 2. That an effusion into the pleural 
cavity first showed itself as an area of dulness (a) just below 
the angle of the scapula, (i) in the left axilla between the 
fifth and eighth ribs, (e) in obliteration of Traube's semi¬ 
lunar tympanitic space, and (rf) in the right front near the 
angle made by the cardiac and hepatic lines of dulness. 3. 
That a disappearing effusion was last manifest in the axillary 
line between the fifth and eighth ribs. 4. That the root 
of the lung was its fixed point, and that with increasing 
effusion the lung became compressed round it. 5. That 
the re-expandiDg lung last touched the ohest wall at a 
point diagonally farthest from its fixed point—i.e., in the 
axilla about the fifth interspace. This was the point of 
election for incision and drainage in cases of general 
purulent effusion and was the site of natural evacuation in 
cases of empyema necessitatis. 6. The lung did not tend to 
collapse on its fixed point when air was admitted into the 
pleural cavity, the intrapulmonary pressure being quite 
sufficient to maintain the two layers of pleura in contact, 
except for a small area round the point of entrance of 
the air. As regards the causes of empyema he said that: 

1. Fleuro-pneumonia caused 91 per cent, of his cases. 

2. Fleuritis was the cause in 4 per cent. It was 
generally agreed that if pleural effusions became puru¬ 
lent septic infection through dirty needles was almost 
invariably the cause. 3. Tubercle of the lungs was the 
cause in 3 per cent, and empyema followed a pneumo¬ 
thorax. 4. Septic disease of the abdominal organs accounted 
for only one case. 5. Streptococcic or staphylococcic 
infection of the lung. One case, due to osteo¬ 
myelitis of the ribs, had occurred in his practice. 
Mr. Morison discussed at length the diagnosis of empyema 
and then considered the prognosis. This, he said, was as a 
rule good so far as life was concerned, the mortality in his 
series of cases being only 3 per cent. Natural cure might 
take place by : 1. Absorption of pus ; this occurred in one 
case in which the parents of a child refused operation, the 
case being verified by puncture. 2. Spontaneous evacuation 
through a bronchus resulted in the cure of two cases, while 
in ten cases large quantities of pus had been expectorated 
prior to operation. 3. Discharge of pus into organs adjacent 
to the pleura ((esophagus and stomach). This could only 
occur where the accumulation was large and the disease 
piolorged. 4 Spontaneous evacuation through the chest 
wall (empyema necessitatis) occurred in five cases, sub¬ 
sequent operation being required. This was the most unsatis¬ 
factory of all forms of spontaneous evacuation. It usually 
occurred through or above the fifth interspace and oedema of 
the chest wall was a common signal. Recovery might follow 
in a few cases but the majority died from exhaustion or 
waxy disease. Four of these cases were cured by Estlander's 
operation, and the fifth by ordinary incision and drainage. 
5. Surgical treatment offered the best results both immediate 
and remote. Mr. Morison’s cases proved that uncomplicated 
empyema treated with proper surgical care was not a serious 
disease. Death in his three fatal cases was due to bronchitis, 
marasmus, and cerebro-eplnal meningitis respectively. The 


perfect recovery of those operated on was also most satisfac¬ 
tory and months afterwards when examined, exoept for the 
scar, it was impossible to say which side had been aifeoted. 
The average duration of treatment from the date of incision 
to the completion of healing was 32 days. In the treatment 
aspiration was only of service where the dyspncea was great 
or where some complication rendered operative interference 
inadvisable. Whenever these were overcome operation should 
be performed. As regards operation it was advisable to 
administer a general anaesthetic to children while adults 
might be operated on with much greater safety under 
the influence of local anaesthesia. Chloroform was the 
best anaesthetic but the patient must never be moved 
from the dorsal position. The position of the pus should first 
be located by the needle and the site of incision which Mr. 
Morison usually selected was in the sixth interspace just 
in front of the posterior axillary line. A vertical incision 
was made through the skin and a horizontal one 
through the muscles along the upper border of the seventh 
rib into the pleural cavity ; sinus forceps were then intro¬ 
duced and the wound was dilated by withdrawing them open. 
An indiarubber tube a quarter of an inch in diameter and 
two inches long was introduced and prevented from slipping 
in by a safety-pin being passed through its free extremity. 
As soon as the discharge became small the tube was cut in 
half. The wound was dressed with corrosive sublimate wool 
and changed twice or thrice during the first day and subse¬ 
quently once daily, and later every second day. Resection of 
the rib was needful in some cases but generally was meddle¬ 
some surgery. As helping the expansion of the lung 
the patient was encouraged, as soon as out of bed, 
to make inspiratory efforts (running upstairs, playing 
wind instruments, &c.). The conclusions to be drawn were 
that (1) pleuro-pnaumonia was the most frequent cause of 
empyema; (2) that empyema rarely followed pleurisy with 
effusion ; (3) that in adults empyema was more likely than in 
children to be secondary to serious lung disease ; (4) that the 
diagnosis of empyema was not always easy ; (5) that the 
exploring needle should be used in all doubtful cases and in 
more than one situation; (6) that there was no danger in 
using the needle with proper care ; (7) that the immediate- 
prognosis in uncomplicated empyema by incision and 
drainage was good; (8) that the remote prognosis was 
excellent, no deformity following and no sequelre resulting p 
(9) that careful asepsis must be carried out; and (10) that 
resection of the rib was needful in some neglected cases but 
generally was meddlesome surgery.-Dr. J. O. Affleck. 
expressed bis approval in the main of Mr. Morison’s conten¬ 
tions.—Dr. W. Russell said that he was glad Mr. Morison did 
not remove a portion of rib in operating and yet got such good 
results. Mr. Morison had not referred to one special means 
of investigating difficult cases following pneumonia—namely, 
the leucocyte count. When a pneumonia was succeeded by 
empyema there was a great bound upwards in the number of 
leucocytes ; in his last case there was a sudden rise from 
25,000 to 40,000 or 45,000. It was not always easy to 
be satisfied that there was not pus in the pleural cavity. 
Dr. Russell did not think that bronchial breathing was ever 
heard over fluid, but it was present over compressed lung: 
immediately above fluid. As regards acute foetid empyema, 
he did not think that it was necessarily secondary lo¬ 
an abdominal lesion. The majority of acute foetid 
empyemata occurred on the left side and commenced 
as cases of diaphragmatic pleurisy and owed their 
factor to the proximity of the colon on the left side.— 
Mr. Cairo said that in the case of children it was 
obviously wise to use a general anaesthetic and it was rarely 
necessary to excise a portion of rib in such patients. In the 
case of adults it was better to employ a local anaesthetic and 
to remove a portion of rib.—Dr. Alexander James said that 
physical signs were of little importance if the empyema were 
small and localised, but he advocated the use of the exploriag 
needle frequently. He thought that a great many cases of em¬ 
pyema discharged through a bronchus and cured themselves- 
naturally.—Dr. Alexander Goodall and Dr. Hunter took 
part in the discussion.—In his reply Mr. Morison said tbat 
be never resected the rib unless the case was septic and that 
be obtained quite sufficient drainage without this. He 
thought that bronchial breathing oould be heard, suid 
especially in ohildren, when the layer of fluid was thiu. He 
had met with oases of foetid empyema on the right side and 
was of opinion that they were the result of lymphatio 
infection from abdominal abscesses. It was much more 
common to meet with a mixed inlection in adults, and such, 




The Lancet,] 


A5SCULAPIAN SOCIETY.—REVIEWS AND NOTICES OF BOOKS. [Feb 15,1908. 503 


■were not bo rapidly^ re covered from as those due to simple 
pneumococcal infection. 


m British Balneological and Climatological 

Society. —A meeting of this society was held on Jan. 29th, 
at 20, Hanover-square, London, Dr. A. F. Street (Westgate- 
■on-Sea) being in the chair.—Dr. R. Fortescue Fox re-intro¬ 
duced the adjourned discussion on the paper of Dr. 
W. Edgecombe (Harrogate), on Blood Pressure in Spa 
Practice, which was read on Dec. 11th, 1907. He dwelt 
upon the importance of vaso-motor tone as a factor in 
arterial blood pressure. Abnormalities of pressure were, 
in fact, in the first instance nervous disorders, and balneo¬ 
logical treatment, here as elsewhere, took effect to a 
large extent through the nerve centres. The effect 
of baths (sub-thermal) at a temperature between that 
of the blood and the Bkin was unquestionable in 
reduoing excessive vaso constriction and therefore blood 
pressure. Dr. Fox described a hereditary type of 
“poor circulation” in gouty families, for which hyper- 
thermal spa baths afforded the best treatment. In middle 
and later life a judicious course of cooler baths relaxed 
arterial spasm and delayed for many years the development 
of incurable high tension. In disorders of the climacteric 
and other vaso-motor ataxias spa treatment was usually effi¬ 
cient, but sub-thermal baths must be employed with a seda¬ 
tive effect in view.—Mr. J. P. Lockhart Mummery said that 
he had done a lot of experimental work upon blood pressure 
and that in his opinion it was advisable to use only the pulse 
obliteration point (systolic pressure) and that the so-called 
diastolio pressure was quite useless and untrustworthy, and 
there was no proof that it was diastolic pressure; in fact, 
experimental evidence was opposed to its being diastolic 
pressure. He gave the figures from a series of experi¬ 
ments showing that the systolic pressure as estimated 
by the Riva-Rocci instrument is correct to within two 
millimetres of Hg. He also pointed out that the Riva- 
Rocci instrument with a straight manometer tube is the 
most trustworthy, and that with the U tube any 
error of reading was doubled.—Dr. Alfred Mantle (Harro¬ 
gate) said that disturbances of the peripheral circula¬ 
tion materially affected the general blood pressure. 
Several types of circulation were notioeable. Cold 
subjects having a tendency to an abnormal contraction 
of the peripheral circulation were met with, and as a result 
of a diminished quantity of blood in the cutaneous reservoir, 
there was an increased amount in the splanchnic and other 
areas which in time might produce gastric, hepatic, 
renal, or cardiac complications. In another type the peri¬ 
phery was dilated, and such people were always warm, and 
he had observed them to be more subject to cutaneous 
diseases, also to glycosuria. The importance of what might 
be called the “skin heart” in regulating the blood pressure 
was too little appreciated.—Dr. William Ewart referred to 
the prevailing view that the tortuosity of arteries is the 
result of long-continued high pressure. In his experience 
tortuosity sometimes occurred in hypotensive subjects and 
should not therefore be accepted as positive evidence 
of high tension.—Dr. Street said that abnormalities of 
blood pressure were undoubtedly due to vaso-motor disorder, 
but peripheral vaso-motor abnormality did not connote 
serious disturbance. The wide variation of individual 
vaso-motor control in man was illustrated by a considera¬ 
tion of the functions of the vaso-motor system in the 
woodpecker, the sloth, and marine mammalia generally. 
If arterial tortuosity was the result of high tension, what was 
the cause of the tortuosity common in superficial veins in the 
lower extremity ?—Mr. C. W. Buckley (Buxton) said that the 
treatment of the early stages of high blood pressure by sub- 
tbermal baths, as suggested by Dr. Fox, was most important 
and at certain continental spas had been made a speciality. 
The treatment of gout in Buxton for generations had followed 
those lines, showing that empirical methods were based on 
sound principles. Referring to the remarks of another 
speaker, he pointed out that there were many English 
springs of great value as diuretics and that it was not 
necessary to go abroad for such waters. 

ASsculapian Society. — A meeting of this 

society was held on Feb. 7th, Dr. W. Langdon Brown, 
the President, being in the chair.—Dr. T. G. Stevens read 
a paper on the Nature and Treatment of Puerperal Eclampsia. 
After defining the condition and enumerating its classical 
symptoms he said that scanty urine and a low urea 


coefficient were more important signs than the amonnt 
of albumin. As regards pathology, the most widely 
accepted view was that of auto-intoxication, the mother 
poisoning herself by the effects of constipation and by the 
products of metabolism. The liver failed to alter the toxins 
formed by metabolism and the kidneys were unable to 
excrete them, so albuminuria and eclampsia were produced. 
Post mortem, there was necrosis of the renal epithelium 
with fatty and granular degeneration—i.e., the kind of 
kidney found in diphtheritic poisoning. The liver nearly 
always showed small hemorrhages and patches of necrosis 
and a fatty degeneration as seen in acute yellow atrophy. 
Death might be directly due to the toxins, to oedema of the 
lungs, to sepsis as the result of operation, or to poisoning, 
by such drugs as strychnine, morphine, and pilocarpine 
The prognosis was bad if the fits were more than 15 in 
number, if the temperature progressively rose, if the urine 
was almost suppressed, and if delivery could not be 
quickly performed. In the treatment of fits morphine 
was the best method and it should be given in large 
doses as there was no danger to the kidneys, for 
morphine dilated the renal blood-vessels and caused diuresis. 
Half a grain hypodermically should be given at once, and if 
in two hours the patient was not under its influence another 
quarter of a grain should be given. Chloroform did not abolish 
fits but only decreased their violence. The toiiemia ought 
to be treated by infusion of saline solution, croton oil, 
washing out the stomach and the colon, and venesection in 
a full-blooded plethoric patient. Delivery stopped the fits in 
54 per cent, of the cases, so if the patient was in labour she 
should be delivered as soon as possible. Dr. Eardley L. 
Holland, who took part in the discussion, advised the German 
method of immediate rapid delivery, whatever the stage of 
labour, without any preliminary palliative measures. The 
cervix could be rapidly dilated with Bossi’s dilator, but if it 
were still intact vaginal Caesarean section should be per¬ 
formed. He laid it down as a rule that if the first con¬ 
vulsion were severe rapid delivery ought to be done, but if 
the first convulsion were mild then palliative measures might 
be tried. 


Jidrwtos attir Satires of $aoks. 


Anatomie und Aetiologie ier Genitalprolapse beioi H'ciJf. 
(Anatomy and Etiology of Prolapse of thr Female Genital 
Organs.) By Dr. Josef Halban and Professor Julies 
Tandt.br. With 60 plates and 44 figures in the text. 
Vienna and Leipsic: Wilhelm Braumiiller. 1907. Pp. 
273. Price, paper, M.18 ; M.15. Bound, M.21; M.17.50. 

The work already published by Professor Julius Tandler 
and Dr. Josef Halban on the “ Topography of the Ureters ” is 
of so high an order of merit that we began the perusal of this 
work with a feeling that it was sure to be of great value and 
interest. Nor are we at all disappointed. The book con¬ 
tains a very full and extremely able account of the anatomy 
and etiology of prolapse of the uterus, preceded by a descrip¬ 
tion of the normal position and means of support of the 
female pelvic organs, and followed by some considerations on 
the treatment of prolapse of the uterus by pessaries and by 
operations. 

From their anatomical researches the authors come to 
the conclusion which anyone who has studied the subject 
would expect—namely, that all the tissues connected on 
the one side to the uterus and on the other to the pelvic 
walls play a part in the fixation of the pelvic organs. The 
structures, however, which overcome the tendency to pro¬ 
lapse of the pelvic organs resulting from an increase in the 
intra-abdominal pressure, and which play the most important 
part in maintaining the position of the pelvic contents, 
are the muscles of the pelvic floor. How important a 
part they play is well illustrated by the conditions 
met with in cases of congenital prolapse dependent on 
the presence of a spina bifida in which the fourth sacral 
nerve is involved. We need hardly say that the conclu¬ 
sions arrived at do not in any way favour the theory 
which has recently been put forward that the supports of 





504 Thh Lancet,] 


REVIEWS AND NOTICES OF BOOKS. 


[Feb. 15, 1908. 


the uterus are mainly to be found in the connective- 
tissue sheaths of the vessels. The description given 
of the anatomy and etiology of prolapse of the pelvic 
organs is founded on a careful examination of no less than 
40 specimens of this condition, all of which were very 
exhaustively studied either by means of sections or of 
dissections. A large part of the work consists of 60 plates 
illustrating 34 of these cases. These full-page plates, many 
of them coloured, are beautifully reproduced and are of the 
highest artistic and scientific value. 

The anatomical changes which occur in all the various 
structures involved in cases of prolapse are considered in 
full detail and then the authors pass on to the most 
interesting part of their work—namely, that dealing 
with the etiology of this common condition in the female. 
As a result of their anatomical and other researches the 
authors favour the following explanation of the occurrence 
of prolapse of the uterus. They believe that a prolapse 
will occur when the opening normally existing in the pelvic 
floor is insufficiently closed so that it forms what may be 
termed a “hernial aperture.” Any increase in the intra¬ 
abdominal pressure tends to force through this aperture all 
those organs or parts of organs which may be situated over it 
or in its immediate neighbourhood. If, for example, the 
whole of the uterus is placed over the opening, total prolapse 
of that organ will result from such increased intra-abdominal 
pressure ; while if a part only of the uterus is so situated 
some form of partial prolapse is likely to occur. The intra- 
abdominal pressure tends to force through the imperfectly 
closed opening in the pelvic floor that part of the uterus 
lying over it, but the rest of the organ by the same 
pressure will be firmly pressed against its underlying 
supports and so retained in its position. The natural resistance 
to any descent of the pelvic organs is derived from the 
support which they receive from the bony walls of the pelvis 
and the muscular pelvic diaphragm. Any injury leading to 
stretching of these soft parts and insufficiency of their 
normal power of supporting the pelvic organs and closing 
the aperture in the pelvic floor will inevitably produce a 
tendency to prolapse, as will also a deficiency in the bony 
walls of the pelvis, as is exemplified in cases of split pelvis in 
which secondary prolapse is not uncommon. On such a theory 
not only can all the common forms of prolapse be readily 
explained but the anatomical changes which are found in 
the different tissues affected can be adequately accounted 
for. It accounts for the elongation of the cervix and of 
the body of the uterus which is so often met with, for the 
different degrees of descent of the anterior and posterior 
vaginal walls, for the varying degrees of hypertrophy of 
the anterior or posterior lips of the cervix, and for the 
occurrence of congenital prolapse, especially when associated 
with spina bifida. 

The book must be read to appreciate the large amount of 
evidence which is adduced in support of the theory put 
forward ; for this we must refer our readers to the work 
itself and to a careful study of the illustrations of actual 
cases and dissections. Finally, after a chapter on the experi¬ 
mental study of the causation of prolapse of the uterus the 
authors consider shortly its treatment by pessaries and 
various operative methods. 

The book is one of great interest and value, the amount 
of work which it embodies is prodigious, the illustrations 
are most excellent, and the whole work is worthy of the high 
reputation of the writers. 


The Standard Family Physician. Three volumes. London 
and New York : Funk and Wagnalls Company. 1907. 
The title page to thiB publication is so striking that we 
have not oopied its contents under the title of the work as is 
our usual custom when considering books sent to us for 


review. The work is termed “A Practical International 
Encyclopaedia of Medicine and Hygiene, especially prepared 
for the Household.” It is stated to have been “edited by" 
Sir James Crichton-Browne, M.D., LL.D., F.R.S., Sir 
William H. Broadbent, Bart., K.C.V.O., M.D., F.R.S., 
Dr. Alfred T. Schofield, Professor Karl Reissig (Hamburg), 
and Dr. Smith Ely Jelliffe (New York), “ with the assistance 
of many European and American specialists in the treat¬ 
ment of diseases and experts in medicine and snrgery.” 
Reproductions of photographs of Sir James Crichton-Browne, 
the late Sir William Broadbent, and Dr. Schofield respectively 
appear as frontispieces to the three volumes into which the 
work is divided. The work commences with an unsigned 
article on “ The Family Physician ” ; then follows a paper by 
Dr. Schofield entitled ‘ 1 The Journey of Life and the Laws of 
Health" ; next appears a reprint of Sir James Crichton- 
Browne’s Cavendish lecture on “ Dreamy Mental States and 
next a contribution by the late Sir William Broadbent on the 
Prevention of Consumption and Other Forms of Tubercu¬ 
losis, written in a popular manner and containing informa¬ 
tion likely to be useful to lay readers. 

The next portion of the work is taken up with an article 
entitled “Structure and Functions of the Healthy Human 
Body.” The information contained therein would be redund¬ 
ant to a medical practitioner and useless to a lay reader. The 
remainder of the publication is devoted to a sort of medical 
dictionary, stated (in an advertisement) to be "the greatest 
international work of medical reference for the home that 
has ever been produced.” Perhaps the less said about this 
strange production the better. We admit that some of 
the information given may be useful “in the home,” 
but a large portion is likely to be only misleading 
and to give rise to unnecessary alarm to those not acquainted 
with medical science. Some of the directions given are 
peculiar. For instance, under the heading “Death” we 
find the following : “ Quiet and consolation should surround 
the dying person. He should be kept clean and comfortable 
until he has drawn his last breath, and even after that.” 

The volumes are profusely illustrated. Many of the 
diagrams are, in our opinion, totally unsuited for a work 
“for the home,” and some are liable to give rise to false 
impressions, especially the diagrams supposed to illustrate 
“areas of pain.” The books when sent to The Lancet 
Offices were accompanied by an advertisement. We feel sure 
that the physicians whose names appear on it could not have 
been cognisant of the manner in which their participation in 
the publication would be made use of. 


The Hygiene of Armies (Ilf j.i 'TyLeivys tCjv SrpaTtvydruo'). By 

S. K. Zavitzianos, M.D. Corfu : A. Lantza. Pp. 253. 

Dr. Zavitzianos deals in this Interesting book very 
thoroughly with the numerous aspects of an important 
subject. Though written in Greek, and more especially in 
relation to the Greek army, the book may be said to be of 
general interest, a careful and minute study of records and 
official reports having enabled the author to marshal a great 
array of facts and statistics in relation to the practical work¬ 
ing of the Army Medical Services in all European countries, 
as well as in Japan, Persia, Siam, and the United States, 
from about the time of the Crimean war to the present day. 
The author’s survey of the hygienic conditions prevailing in 
the different armies in peace and war time, but especially 
the latter, and his Btudy of the subject generally have 
resulted in a firm conviction on his part that no great 
measure of success can be obtained in the medical 
treatment of troops by the system of employing a medical 
staff exclusively devoted to military service and un¬ 
supported by civilian cooperation. Basing his statement on 
known events in almost all recent wars, he affirms that no 
army medical service organised in this way has been, or is 




Tub Lancet, j 


REVIBW8 AND NOTICES OF BOOKS. 


[Feb. 15, 1008. 505 


ever likely to be, really efficient. The scheme proposed by 
Dr. Zavitzianos for the Greek army is to abolish the army 
medical service altogether and to organise a service of 
civilian medical men, to be called upon in time of war or 
whenever needed, not exclusively attached to the army but 
able to practise independently, and therefore with oppor¬ 
tunities of keeping pace with new scientific developments 
and with liberty to specialise. This scheme is worked out 
and supported by many arguments, and the suggestion and 
discussion of it form the main purpose of the book which 
concludes with chapters on military buildings, on the food 
and clothing of troops, and on their intellectual development. 

Dr. Zavitzianos intends to publish a French translation 
of his book shortly and we are glad to learn this from him. 
French is more or less known to most medical men and 
many of our readers would, we think, like to have the 
information in “The Hygiene of ArznieB ” before them. The 
similarity of Dr. Zavitzianos's views with those expressed by 
the Director-General of the Royal Army Medioal Corps, Sir 
Alfred H. Keogh, in so many medical centres is noticeable, 
though our circumstances and those in Greece are so 
different. Of course there can be no idea with us of dis¬ 
pensing with our excellent army medical service, the hope 
is to reinforce it by an adequate and economical reserve. 


Immune Sera: A Concise Exposition of our Present Know¬ 
ledge Concerning the Constitution and Mode of A ction of 
Antitoxins, Agglutinins, Hcemolysins, Bacteriolysins , 
Precipitins, Cytotoxins, and Cpsonins. By Dr. Charles 
Fbederick Bolduan, Bacteriologist, Research Labora¬ 
tory, Department of Health, City of New York. Second 
edition, rewritten. London : Chapman and Hall, Limited. 
New York: John Wiley and Sons. 1907. Pp. 154. 
Price $1.50. 

This little book gives a very clear and satisfactory account 
of the various bodies which are known to exist in immune 
serums. It starts with a short historical account of the 
subject and then describes the mode of preparation of 
diphtheria antitoxin. Ehrlich’s theories as to the relations of 
toxins and antitoxins are next set forth and also the opposing 
views of Arrhenius and of Bordet. It is very properly 
stated that at present the exact truth is not determined. 
Agglutinins, bacteriolysins, bmmolysins, and precipitins are 
next discussed and the practical applications of our know¬ 
ledge of these bodies to the recognition of blood¬ 
stains. Some good diagrams are given to explain the 
nature of group-agglutinins. Cytotoxins are briefly dealt 
with and the value of opsonic determinations is criticised; 
the author is impressed with the degree of error inseparable 
from the methods employed and also with the divergence 
between the clinical course of many cases and the fluctuations 
of the opsonic index. Three puces are devoted to the subject 
of snake-venoms but no allusion is made to the interesting 
work of Eyes in isolating the lecithids of cobra poison, 
chemical compounds of lecithin with the copula or 
amboceptor present in the venom. The final section is 
deyoted to a discussion of the phenomena of serum-sickness 
in man and of the allied, if not identical, condition termed 
anaphylaxis as observed in experiments on animals. Dr. 
Bolduan appears to greater advantage as an original author 
than as a translator and gives a very readable account of the 
difficult and highly technical matters with which he deals. 
We commend the book to all who are desirous of gaining a 
first acquaintance with recent work in the field of immunity. 


LIBRARY TABLE. 

A Text-book of Organic Chemistry. By A. F. Holleman, 
Ph.D., F.B.A.Amst. Translated from the third Dntch 
edition by A. Jamieson Walker, Ph.D. Heidelberg, B.A. ; 
assisted by Owen E Mott, Ph.D. Heidelberg. Second 
English edition rewritten. London: Chapman and Hall, 


Limited. New York : Wiley and Sons. 1907. Pp. 589. Price 
10*. 6 d. net —The multiplicity of organic compounds is an 
invariable stumbling-block to the student commencing to 
read organic chemistry and he had far better take as a first 
course a book which, like the one under review, presents a 
limited number of facts and yet gives prominence to the 
theory underlying the subject than one in which so many 
apparently disconnected details are dealt with. Professor 
Holleman’s text-book is deservedly popular, the original 
Dutch edition having been translated into an English, 
a German, a Russian, and an Italian edition respectively. 
The success which has so far attended its publication 
is due, we thick, to the author's gift of discriminating 
between principles and facts which are immediately 
essential to the beginner's grasp of the subject and those 
which, at all events, in his early studies, only conspire to 
upset, so to speak, his mental digestion by reason of their 
wealth and intricacy. Throughout the story is told step by 
step in simple terms, and it is not easy to preserve, as is done 
in this text-book, a continuity of treatment with such a vast 
subject as the chemistry of the carbon compounds. The 
present edition also is in touch with the results of recent 
developments, for in the chapter on the constitution of 
benzene the recent researches on this subject are discussed, 
which would appear to show that not one of the graphic 
formula; suggested affords a completely satisfactory explana¬ 
tion of observed facts. The chapter on pyrrol also has been 
made to fall into line with the fruits of investigation 
contributed by Professor Ciamician in a recent lecture before 
the German Chemical Society. The nature of reactions is 
interpreted in the light of the theory of "ions." The 
translation is ably done and we have only noted two 
misprints, one in the author’s preface to the first edition and 
the other in the heading on p. 447. It may be remarked 
also that the translator has retained the word “ proteids " 
which English physiologists and chemists have agreed to call 
“ proteins.” 

Die Experimentelle Diagnostik, Serumtherapie und Prophy- 
laxe dir Infehtionskranhheiten. (Experimental Diagnosis, 
Serum-therapeutics and Prophylaxis of the Infectious Dis¬ 
eases.) Von Stabsarzt Professor Dr. E. Marx. Second edition. 
Berlin : August Hirschwald. 1907. Pp. 398. Price 8 marks.— 
We are glad to welcome a second edition of Professor Marx’s 
little book. The main features of the former edition are 
preserved but the author has added chapters dealing with 
the general principles of immunity and with infections due 
to the bacillus fusiformis and to trypanosomes. He has also 
added an index which materially increases the value of the 
volume. Advances in knowledge since the first edition 
appeared have been so great as to necessitate the rewriting 
of much of the contents and the size of the whole has in¬ 
creased by just 100 pages, or about one-tbird of its original 
bulk. The particular specimen before us is marred by the 
bad sewing which used to characterise nearly all foreign 
paper-bound books and which we hoped was becoming less 
common. Well bound in cloth it should make a handy book ; 
the print is clear and the use of black type for headings 
facilitates reference. 

Tests and Studies of the Ocular Muscles. By Ernest E. 
Maddox, M.D. Edin., F.R.C.S. Edin., Ophthalmic Surgeon to 
the Royal Victoria Hospital, Bournemouth. With 110illustra¬ 
tions. Second edition. Philadelphia ; The Keystone Publish¬ 
ing Company. 1907. Pp. 261.—We welcome the second 
edition of Dr. Maddox’s well-known treatise on the ocular 
muscles. It is doubtless due to the exigencies of copyright 
that the book has been published in America. Whilst we 
regret the necessity it has the compensation of bringing 
more nearly to the notice of American ophthalmologists a 
level-headed presentation of the subject which contrasts 
favourably with the many indigenous productions, some of 




506 Thi Lancwt,] 


REVIEWS AND NOTICES OF BOOKS.—NEW INVENTIONS. 


[Feb. 15,1906. 


which we have recently reviewed. It is a pleasure to find that 
the book remains essentially the same as in the first edition. 
It has not been overweighted with new matter and it still, 
better than most books, enables the reader to distinguish 
between facts and the inordinate accretions of conjecture. 
No better introduction to the subject could be placed in the 
student's hands. 


JOURNALS AND MAGAZINES. 

Proceedings of the Royal Society of Medicine. Vol. I., 
Nos. 2 and 3.—The excellent start which the Royal 
Society of Medicine made with the first number of its pro¬ 
ceedings has been well maintained in its successors. It is 
not our purpose to review these publications at any length 
as the paperB and cases with which they deal have aB a rule 
been reported in our columns before their appearance in 
the society’s literature. The second number records many 
interesting cases in the Clinical, Dermatological, and Laryngo- 
logical Sections, the last part of the important debate on 
Pneumonia, followed by a paper on the Pathology of Epi¬ 
lepsy, by Dr. Alfred E. Russell, with the subsequent dis¬ 
cussion, in the Medical Section, and in the remaining sections 
the following cases: The X Ray Diagnosis of Renal and 
Ureteral Calculi, by Dr. G. Harrison Orton; Medical Inspection 
in Schools : the Gloucestershire System, by Dr. Myer Coplans; 
Pubiotomy, by Dr. Thomas Wilson ; An Analysis of 274 Addi¬ 
tional Cases of Goitre Removed by Operation, by Mr. James 
Berry ; the Therapeutics of Indigestion, by Dr. William Murray; 
Some Tropical Diseases and the Remedies required for their 
Treatment and Prophylaxis, by Mr. James Cantlie • A 
Contribution to the Study of the Relationship between 
Avian and Human Tuberculosis, by Mr. S. G. Shattock, Dr. 
C. G. Seligmann, Mr. L. S. Dudgeon, and Dr. P. N. Panton; 
Some Experiences with the Tuberculin Ophthalmic Reaction, 
by Mr. L. J. Austin and Dr. Otto Griinbaum ; Abscess of Bone 
caused by an Intermediate Bacillus (P.) allied to B. Para- 
typhosus, by Dr. F. G. Bushnell ; Some Notes on the 
Growth of the Jaws, by Mr. J. T. Carter; and the 
Effects of Chronic Suppuration in the Molar of a 
Horse, by Mr. J. G. Turner. In the January number 
(No. 3) there are reports of cases and specimens from 
the Clinical, Dermatological, Laryngological, Obstetrical, 
Otological, and Surgical Sections ; a Presidential Address to 
the Otological Section, by Dr. Peter McBride, dealing with 
the development of aural surgery; a discussion on the 
Diagnostic Value of the Roentgen Rays in Diseases of the 
Chest, introduced by Dr. A. Stanley Green, and amongst the 
papers are the following: On the Present Means of Com¬ 
bating the Plague, by Professor W. M. Haffkine, O.I.E., 
and Protection of India from Invasion by Bubonic Plague, 
by Dr. J. Ashburton Thompson; Some Peculiarities of 
Cerebral Gummata, by Dr. J. S. Collier ; the Supports of the 
Pelvic Viscera, by Dr. W. E. Fothergill ; a Case of Com¬ 
plete Gastrectomy, by Mr. B. G. A. Moynihan ; Cases of 
Cholecystectomy, by Mr. J. D. Malcolm ; the Action of 
Digitalis on the Human Heart, by Dr. James Mackenzie; 
and the Reminiscences of an Apprentice Fifty YearB Ago, by 
Mr. W. Soper. 

The Journal of Nervous and Mental Diseases (New York).— 
In the December, 1907, issue of this journal there is an 
interesting paper by Dr. Lewellys Barker and Dr. Frank 
J. Sladen of Baltimore on Acrocyanosis Chronica Anaesthetica 
with Gangrene ; its Relations to Other Diseases, especially 
to Erythromelalgia and Raynaud’s Disease. AIbo among 
the proceedings of the American Neurological Associa¬ 
tion reported in this number will be found a discus¬ 
sion on Heredity in Diseases of the NervouB System, 
in which many well-known authorities expressed their 
opinions. The subject is viewed from a wide stand¬ 
point and the report of the proceedings will be 
found instructive to anyone collecting data on this topic. 


The account of the New York Neurological Society contains 
a discussion on the Antisyphilitic Treatment of Tabes and 
Paresis, and most of the speakers were agreed that this form 
of treatment was very unsatisfactory in these diseases and 
indeed that in many instances it aggravated rather than 
relieved the symptoms ; further, that probably in most of 
those oases in which permanent good was derived the con¬ 
dition was rather one of pseudo-paresis than the true disease. 
This number also contains other matter of instruction and 
interest. 


Jnfotttiotts. 


X RAY PLATES. 

Wb are glad to find that at last a really serious effort is 
being made to produce a satisfactory x ray plate in this 
country. We have received from Ilford, Limited, Ilford, 
London, E., samples of x ray plates which as regards the 
ultimate result quite equal and even excel that of any 
imported plate we have ever tried. They give full density, 
plenty of contrast, and abundant detail. It must be 
admitted, however, that they require a rather longer 
exposure than Borne plates of foreign make. While the 
length of exposure is a matter of secondary importance 
in most cases, there is no doubt that other things being 
equal radiographers will unquestionably use those plates 
which require the least exposure, cot only as an extra 
precaution against any undesired epilation or dermatitis 
but in the radiography of fidgety people and ohildren, 
the saving of time generally, and on account of the 
reduced wear and tear of x ray tubes. No doubt in due 
course emulsions will be prepared having a greater sensi¬ 
tiveness to the x rays. 

There would appear to be some confusion in the 
minds of the makers as to the relation that exists in 
the sensitiveness of the haloid salts of silver to ordinary 
daylight and to the rays from an x ray tube. As a 
matter of practical experience we have found that all 
ordinary photographic plates, whether “process,” “slow," 
“ extra rapid,” or by whatever term they are described, have 
about an equal sensitiveness to the x rays, the “ rapid ” 
varieties not necessarily being more rapid than the slower 
grades. Another noteworthy fact is that it is difficult, and at 
times impossible, to get sufficient density when an ordinary 
photographic plate is used for radiographic purposes. This 
seems to be due to the thinness of the coating, which, though 
thick enough for the purposes of ordinary photography, does 
not react correspondingly under the influence of the x rays. 
To get over this difficulty thicker coatings have been used, 
and while this scheme answers up to a certain point the 
fact remains that some x ray plates of foreign manu¬ 
facture produce results with comparatively brief exposures 
such as we have been unable to obtain with plates of 
British manufacture. In justice to the Ilford x ray plates 
we should say that in every case where we have used both 
an Ilford plate and one of the best obtainable plates of 
foreign origin upon the same part of the same patient and 
under exactly similar conditions exoept the length of 
exposure, the resulting negative has been better in the case 
of the Ilford. In all cases the plates were fully exposed, so 
that longer exposure in either case would have been detri¬ 
mental. We welcome and recommend the Ilford x ray plates. 
Ilford, Limited, appear to be working along the proper lines 
and we fully expect that before very long we shall have 
available an x ray plate of home manufacture at least the 
equal of any other. 


University of Cambridge.—T he following 

appointments have been made:—Electors to the following 
Professorships: Anatomy, Dr. D. MacAlister ; Medicine 
(Downing), Sir Lander Brnnton ; Physiology, Dr. W. H. 
Gaskell; Surgery, Mr. H. H. Clutton ; and Pathology, Dr. 

L. Humphry.—Dr. Humphry has been coopted a member 
of the degree committee of the Special Board for Medicine. 
—Mr. Raymond Johnson, M.B., B.S. Lond., F.R C.8. Eng., 
has been appointed an Examiner in Surgery for the Third 

M. B. in place of Mr. H. G. Barling who is unable to 
examine.--Mr. J. S. Gardiner, M.A. of Cains College, has been 
reappointed demonstrator in animal morphology for five years. 


L 

It 

a 

1 

J 

K 

a 

E 

ti 


it 

a 

a 


a 


9 


i 

a 

I 

iii 

1 

* 

E 


II 


K 

Cl 


ft 

!■ 

i 

* 

* 

r 

i 









598 The Lancet,] 


PELVIC CONTRACTION. 


[Feb. 15, 1906. 


and carried ont by Major George Lamb, I.M.S., Captain 
W. Gi.bn Liston, I.M.S., and the other members of the 
working commission of the committee both by means 
of plagne-stricken rats kept in experimental “go-downs” 
and by observations in private houses. These experi¬ 
ments proved conclusively that the rat does spread plague 
through the agency of the fleas which have bitten it. 
The other piece of evidence has been brought forward by 
Dr. J. Ashburton Thompson, the permanent head of the 
Department of Public Health in New South Wales, whose 
report on the mode of spread and prevention of plague in 
Australia appeared in abstract in The Lancet of Oct. 19th, 
1907, p. 1104. He demonstrated that in the Sydney epi¬ 
demics there has always been a close association between 
plague in rats and man, the one preceding the other, and 
that the chronicity of the epizootic is an important clue to 
the recurrence of the disease in man. Dr. Thompson does 
not consider the common European rat, Mas decumanus, 
immune from the possibility of acquiring plague but fully 
accepts the doctrine of the spread of plague by the fleas 
which infest the rat. Another disease which has been cer¬ 
tainly laid to the score of Mus decumanus is trichinosis 
which is fortunately very rarely seen in this country but is 
a serious menace to those peoples who habitually eat half- 
raw and often rat-fed pork. 

The chief indictment which Sir James Crichton-Browne 
brought against the English rat was the economic one when 
he said:— 

No more destructive animal existed. Nothing came 
amiss to its chiselling teeth and insatiable maw. It made 
heavy depredations on fields of corn, on stack-yards, 
granaries, and ship cargoes; it devoured eggs, killed poultry 
and game, made unwelcome visits to dairies and pantries, 
butchers’ shops, and bakeries ; it gnawed through lead pipes, 
causing household floods, and it was even suspected of arson 
by nibbling the insulating material on crossing electric wires 
and so short-circuiting them. 

This is doubtless all very true and even the most tender¬ 
hearted of animal lovers would scarcely urge as a serious 
excuse for such conduct that the rat must gnaw not only 
for food but in order to keep down his rapidly growing 
incisor teeth which otherwise might kill him by a literal lock¬ 
jaw ; but to our minds the indictment of the rat on the score 
of his menace to public health is far heavier than any that 
can be brought on the score of his mischievous propensities. 
It is interesting to note that the rat has not been always 
an object of execration. Amongst Scandinavian and Teutonic 
races rats and mice were reverenced as being the souls of 
the dead, while Baring-Gould in his paper on the famous 
Bishop Matto myth, shows that the army of rats which 
devoured the unfortunate prelate undoubtedly symbolised 
the host of poor wretches burnt by him in the 
barn. He points oat, however, that Bishop Hatto 
was a most maligned and kind-hearted man, and 
that stories of similar character have been told of pro¬ 
minent personages in Scandinavia, Switzerland, Bavaria, 
Poland, and even Asia. Baring-Gould thinks the origin 
of them may have been human sacrifices of chieftains by 
savage tribes in time of famine, the victims being given as a 
propitiation to be devoured by hungry rats. If rats were 
not liked in ancient days they would seem to have been 
respected, and this feeling still obtains among primitive 
or superstitious folk. It is certainly present in India, to 
her misfortune. 


We consider that the public attention which has been 
called by modem scientific work to the peril which rats 
form to a community is a matter of great importance to our 
Empire, and we welcome the formation of a league for their 
extermination, hoping that the public mind will not relegate 
the scheme to the ranks of the faddists. But the new asso¬ 
ciation has an enormous task before it if its members seek 
to exterminate the countless millions of rats, of which 
most are inaccessible, in the British Empire. An 
agressive policy has, it is true, been successfully carried 
out in places. In The Lancet of Oct. 19th, 1907, p. 1099, 
we commented on the observations of Lieutenant-Colonel A. 
Buchanan, I.M.S., on the relation between the keeping of cats 
and the incidence of plague in Indian villages. He is con¬ 
vinced that cat-keeping abolishes the rats and consequently 
plague. The rat-catcher and his dog are time-honoured means 
of aggression, and another instance of the militant method has 
been successfully adopted in Jamaica where mongooses have 
been imported and have completely cleared the sugar planta¬ 
tions of rats by destroying their young, thereby saving a large 
proportion of the sugar crop. The experiments of the 
Plague Commission and the experience of Dr. Thompson, 
which he has laid before the Epidemiological Section of the 
Boyal Society of Medicine, 1 tend to show that the most neces¬ 
sary means of meeting the rats in fighting plague is prophy¬ 
lactic and consists in rendering dwellings, and especially 
food-stores, rat-proof. Captain V. B. Nesfield, I.M.S., 
has recently supplemented this suggestion by another, that 
the winter store of grain should be kept in detached 
granaries and not in native dwelling-houses. The crusade 
against rats, however, will not rest content with entrenching 
itself against the enemy’s hordes, and it seemB likely 
that science has provided us with a most potent weapon of 
offence in the form of a bacteriological virus intensely fatal 
to rats which readily feed on bait which has been charged 
with their doom. We have before us the prospectuses and 
testimonials of two preparations which are said to be 
poisonous to rats, setting up a quickly fatal disease, but to 
be harmless to man and the domestic animals. There is 
certainly a good deal of evidence adduced in their favour 
but an extended series of observations will be necessary 
before the efficacy of such measures can be proved. 


Pelvic Contraction. 

It is a matter for congratulation that amongst the women 
of this country oases of contraction of the pelvic measure¬ 
ments are not met with very frequently. Unfortunately, no 
recent investigations upon this point have been carried out 
by English observers in a sufficiently large number of cases 
to enable us to predict with certainty what percentage of 
such pelves will be met with in every 100 cases of labour. 
The marked discrepancies existing in the figures which have 
been collected by foreign observers are to be explained very 
largely by the fact that the definition of what constitutes a 
contracted pelvis is not a matter of entire agreement 
amongst obstetric writers. The one most commonly accepted 
is that which defines a pelvis as contracted when the degree 
of contraction is sufficient to interfere with the normal 
mechanism of labour although it may not retard the birth of 


1 TheLaxcst, Dec. 7th, 1907, p. 1611. 



The Lancet,] 


PELVIC CONTRACTION. 


[Feb. 15, 1908. 509 


the child. Even in different localities in the same country 
very striking differences in the frequency of the occurrence 
of such a pelvis may be met with. The statistics of the 
Rotunda Hospital in Dublin show that on an average 1 per 
cent, of the women confined at that institution have a con¬ 
tracted pelvis, while in Glasgow it has been computed that 
one in every ten women suffers from a defect of this kind. 
Foreign observations show a very wide difference, varying 
from a frequency of 6 per cent, in Greifswald to one of 
22 per cent, in Konigsberg. In America Whitridge 
Williams computes that every tenth to fourteenth white 
and third to fifth black woman has an abnormal pelvis. 
The statistics we have quoted, insufficient though they be, 
show that this complication of labour is not a very common 
one in this country, yet it occurs often enough to be met with 
by every practitioner. It is, however, not the well-marked 
cases which are difficult to recognise and to treat, it is 
rather the lesser degrees of contraction, first suspected 
perhaps towards the end of a prolonged or obstructed 
labour, which so often lead to disaster. “To be forewarned 
is to be forearmed ” is a maxim which holds with special 
force in this cause of delayed labour, for such a condition 
as a general rule can be easily recognised if looked for, 
and when found is not difficult to treat properly. It is, 
however, when it is not recognised, and attempts often 
wrong in principle have been made unsuccessfully to deliver 
the patient, that so much danger may ensue not only to the 
life of the mother but also to that of the child. The 
recognition of a bony deformity of the pelvis sufficient 
to alter the mechanism of labour or even to cause 
obstruction during delivery is not a matter of great 
difficulty to the properly trained practitioner, nor 

does it entail any unnecessary risk to the patient. 
A preliminary examination of the abdomen and the 
careful measurement of the external pelvic diameters, 
readily carried out without any pain or riBk to the woman 
are usually sufficient to enable a fairly certain diagnosis to be 
made as to the presence or absence of any marked contrac¬ 
tion of the bones of the pelvis. Not only can this be done, 
when the abdomen is examined, as it always should be 
about the end of the seventh month of pregnancy, 
but at the same time the practitioner can determine 
whether the foetal head is engaged in the pelvic brim or not, 
a very valuable guide to the relative proportions of the 
pelvis and the head. There are, it is true, a few very un¬ 
common causes of pelvic obstruction which cannot be re¬ 
cognised without an internal examination, such as tumours 
of the pelvic bones or, more important still in view of the 
great danger which they may cause to both mother and 
child, ovarian cysts or fibroid tumours in the pelvic cavity. 

In a primiparous patient the measurements of the external 
diameters and the relation of the presenting part, especially 
when the head is over the pelvic brim, are of the utmost value 
and importance ; this is also the case in a multipara, but here 
there is another important factor to be considered—namely, 
the obstetric history. It is, however, necessary to remember 
that this is not always a safe guide, since the degree of 
difficulty encountered in successive labours in the same 
patient may be of a very varied character, and especially is 
this the case in the lesser degrees of pelvic contraction, since 
it is more particularly in this type of case that a very slight 


alteration in the position or the shape of the presenting part 
of the foetus may make all the difference between a 
comparatively simple and a difficult delivery. A considerable 
interest attaches to a review of the various methods which 
may be adopted in treating these cases not only because of 
their importance and the often difficult problems which have 
to be solved but also because such a survey reveals curious 
and unexpected differences in different countries in the 
treatment of what would appear to be identical conditions, 
A good example of this is to be seen in the favour 
which is extended to the operation of symphysiotomy 
in France and to a lesser degree in Germany and the dis. 
favour with which this operation is regarded by most English 
obstetricians. The recent revival of the operation of 
pubiotomy has led to the publication of a large amount of 
literature on this branch of obstetric treatment, and it 
will be very interesting to see whether this operation 
makes better headway in this country than has the com¬ 
panion operation of symphysiotomy. English teachers of 
midwifery are accustomed to regard the treatment of cases 
of pelvic contraction by the induction of premature labour as 
a very good one, and yet in France this means of overcoming 
the difficulty meets with but little favour and it is not 
practised to the same extent in Germany that it is in this 
country. It is strange that on a matter upon which it 
might be surmised that there would not be any great differ¬ 
ence of opinion the practice in these countries should 
vary to so large an extent. It is unlikely that obstetricians 
of different nationalities will ever look at such matters 
from precisely the same standpoint when even two 
practitioners of the same nationality may find it diffi¬ 
cult to agree upon the same line of treatment. The 
operation of the induction of premature labour presents, 
it seems to us, many advantages; it is easy to carry out, 
entails tut little risk to the mother, and if postponed 
to as late a date as possible in the pregnancy compatible with 
the delivery of a living child is attended with good results as 
regards the saving of the life of the child. It has been said 
that premature children do not grow up and if they do are 
not healthy, but we know of no well-founded grounds for 
any such statements. Obviously the mortality of premature 
children must not be compared with that of full-term 
children born of healthy mothers, but with that of children 
born of the same mother after the adoption of the various 
operative procedures which enter into competition with the 
induction of premature labour. 

The final decision as to the best course to pursue in 

cases of this kind calls for an exact knowledge so 

far as it can be obtained of all the factors which have 
to be taken into account and each case must be 
judged separately. It is not our purpose to discuss 

the merits and demerits of the different procedures 

which may be necessary to effect delivery but rather to 
call attention to the great necessity for the recognition 
of this complication of labour and for carrying out 
an examination of the abdomen in all pregnant women 
at any rate once during the last two months of the 
pregnancy. The number of cases of pelvic contraction 
which are only recognised at the time when the difficulty 
occurs during the course of the labour must still be very 
numerous ; indeed, we know it to be so, and the consequent 




510 Thb Lancet,] 


THE SALARY OF COUNTY MEDICAL OFFICERS OF HEALTH. 


[Feb. IS, 1908. 


risk to the life of the mothers and of the children is con¬ 
siderable. We may hope that the new conditions which in 
the future will attend the clinical teaching of midwifery may 
render the training which the student receives in the practice 
of this important subject more nearly on an equality with 
that which he has received for many years in the subjects of 
medicine and surgery. Such teaching muBt include the 
care of the pregnant woman during her pregnancy and the 
necessity for a careful investigation of all the conditions 
which may influence her labour and the safety of herself and 
her child. No case of pelvic contraction or pelvic obstruction 
theoretically should be allowed to come into labour with 
the condition unrecognised and no patient should be allowed 
to pass through her pregnancy without having been 
examined, at any rate, by the abdomen and an attempt 
made to forecast the course of her delivery and to 
foresee any difficulties which are likely to arise. Such 
perfection in the practice of midwifery is, we well 
recognise, almost impossible of attainment, but if we do 
not aim at a high standard we shall not even attain to a low 
one. We hope that at any rate one of the chief features in 
the clinical teaching of midwifery, soon, we trust, to be 
made compulsory for all students, will be the great import¬ 
ance of the examination of such patients not only when their 
labour has come on but also some weeks beforehand, so that 
preventive medicine may be allowed to play a part and the 
delivery when it does take place may be conducted with the 
minimum of danger to the mother and the child. At the 
present time this is not done even in most of the extern 
lying-in charities attached to our medical schools but we 
look forward hopefully to the time when it will be considered 
just as neglectful to allow an expectant mother to run the 
risks of a labour with a contracted pelvis which has not been 
recognised because not looked for, as it would be to allow 
her to run the risk of acquiring some acute infectious disease 
from the contagion of which no attempt has been made to 
guard her. _ 


^nnotatinns. 


11 Ne quid utmli.” 


THE SALARY OF COUNTY MEDICAL OFFICERS 
OF HEALTH. 

The Norfolk county council, having decided recently to 
appoint a county medical officer of health, indulged in a 
lively debate as to what was a fair remuneration to pay that 
official. The committee which was appointed by the council 
to consider and to report on the matter made the recommenda¬ 
tion that the salary should be £450 a year, rising by annual 
increments of £25 to a maximum of £600. Mr. S. Oldman 
told the council that this decision of the committee was 
practically unanimous, but the Earl of Kimberley said that 
his statement was absolutely incorrect and that he himself 
had fought desperately against it. Mr. Eustace Gurney 
moved that the salary should commence at £700, rising by 
annual increments of £<l5 to a maximum of £850. He 
pointed out that the new officer would be responsible for the 
sanitation of 300,000 people and have the supervision of 
the medical inspection of 55,000 school children. The county 
wanted a thoroughly experienced and practical man, and 
such a man would not be attracted by the terms which the 
council was asked to offer. The motion was strongly opposed 


by several members from the point of view of safeguarding 
the ratepayers’ interests, although it was pointed out that 
their best interests would not be safeguarded unless a first- 
class man were secured for the post. The most interesting 
contribution that was made to this little squabble was a 
saying of Mr. Barrett Lennard who is reported to have 
remarked that “he had come prepared to move that they 
paid a lower salary than was recommended. If they wanted 
a really good man they would have to offer a salary of from 
£2500 to £5000 a year. He thought a suitable medical 
officer could be obtained for £350 or £400 a year.” Either 
Mr. Barrett-Lennard has a poor opinion of the chance of 
finding his ideal sanitarian or else he is more liberal in his 
views than in his practice in the matter of paying one when 
he has found him ; in either case his argument seems a 
delightfully innocent non lei/uitur. After a considerable 
discussion, in which the party in favour of paying liberally 
fought a losing battle vigorously, it managed to get the 
committee's recommendation raised by £50. Several speaker* 
alluded to the salaries paid to those officials by the few 
counties which employ a medical officer of health and it 
is interesting to compare some of them. Essex pays £1003 
and special fees to an officer with charge of a county which 
includes the teeming district of West Ham and is responsible 
altogether for 816,500 people. Surrey, with 519,520, pays 
£800, as do Lancashire with 1,123,850 and the West 
Riding of Yorkshire with 1,460,860 people respectively, 
whilst Derbyshire, with 646,000, pays its medical officer 
£700. Only two county councils pay their medical officers a 
smaller sum than this last. If we are to compute the salary 
on a basis of population alone the offer of the Norfolk council 
seems fairly proportionate ; but it must be considered that a 
county medical officer is a highly trained specialist in his own 
profession, and in addition has important and responsible 
administrative functions which recent legislation has made 
much more arduous, and, moreover, that his emoluments 
from the post are his only source of earned income. We are 
therefore in entire accordance with those gentlemen who 
tried to obtain a liberal remuneration for the new medical 
officer of a large county. They only lost their motion by 33 
votes to 25. _ 

AMALGAMATION OF THE HAMPSTEAD GENERAL 
HOSPITAL AND THE NORTH-WEST 
LONDON HOSPITAL. 

As is well known to all our readers it has been suggested' 
by King Edward’s Hospital Fund that a staff of consulting- 
physicians and surgeons should be appointed for the 
Hampstead Hospital. This course has been adopted after 
considerable negotiation, an account of which will be found 
in our columns, and although there are many circumstance* 
in the situation which impel us to take a contrary view 
from that of King Edward's Fund we see no way out except 
that which is being taken by the governing body of the 
Hampstead Hospital. A farther suggestion from the King’* 
Fund of amalgamation between the Hampstead General 
Hospital and the North-West London Hospital, accom¬ 
panied by an offer of substantial financial support for 
the amalgamated institution, has ultimately resulted in 
the amalgamation being agreed to. As a consequence of 
these changes vacancies have been declared for two physi¬ 
cians and two surgeons to have charge of the beds in tbo 
new building of the Hampstead Hospital. Mr. Edmund 
Owen, who is already consulting surgeon to the Hampstead 
Hospital, has consented, in response to a request made 
to him by the council of the amalgamated hospital, to- 
accept the post of surgeon on the acting staff during 
the transitional period caused by the change in con¬ 
stitution of the medical staff, and there thus remain 
three posts to be filled up on the acting staff—two 
of physician and one of Burgeon. The contributory 




This Lancet,] 


LOBD LISTER AND THE MART KINGSLEY MEDAL. 


[Feb. 15, 1908. 511 


beds, where the treatment can be supervised by any 
practitioner, will remain in active working', bnt in other 
respects the hospital will lose its original cottage hospital 
character and be managed upon the usual hospital lines. A 
forcible letter from Dr. Lewis G. Glover, which we printed in 
oar issne of Jan. 18th, p. 186, well expresses what we mast 
all feel at an evolution which appears to divide the medical 
profession straitly into classes and to minimise the excel¬ 
lent work done by the late staff of local general practitioners. 
Bat the unanimity of opinion of the Hampstead medical men 
was arrived at too late to have its proper effect upon the 
public and npon the executive of the King’s Hospital Fund 
—a matter which is of considerable regret to ourselves. 


LORD LISTER AND THE MARY KINGSLEY 
MEDAL. 

At a special meeting of the Liverpool School of Tropical 
Medicine held recently it was resolved to present Lord Lister 
with the Mary Kingsley Medal which was struck by the 
school for presentation to distinguished savants and others 
who have aided the cause of combating disease in the 
tropics. Special interest attaches to the presentation of this 
medal to Lord Lister from the fact that his lordship formally 
opened the Liverpool School of Tropical Medicine on 
April 21st, 1899. At that time the expenditure of the 
school was £350 per annum ; in the nine years that have 
elapsed the school has spent on its expeditions and research 
work alone over £60,000. The medal was forwarded to 
Lord Lister with the following letter :— 

The Rt. Hon. Lord LiBter, O.M. 7th February, 1908. 

My Loro.—W e have the honour to forward, under separate 
cover, the Mary Kiugsley Memorial Medal on beliali of the Liverpool 
Incorporated School of Tropical Medicine. 

The School much regrets that it has not been 'possible to arrange 
for a deputation to wait upon your lordahip to present the medal in 
pereon. 

No words of ours are required to amplify t-ho esteem in which your 
magnificent achievements are held throughout the world. The Mary 
Kiugslev Memorial Medal ltaa been founded for the purpose of 
recognising the work of those who have accomplished much in the 
cause of tropical medicine. No one haB accomplished more for this 
cause, or indeed for the whole cause of medicine, than yourself. The 
School feels honoured that your lordship has consented'to receive the 
medal. We remain, 

(Sgd.) Helena. Hon. President. 

Alfred L. Jones. Chairman. 

Rupert Boyce. Dean. 

Alan Milne, Secretary. 

The following is Lord Lister’s reply:— 

Dear Mb. Mii.ni,— I have duly received the Mary Kingsley 
Medal, with a letter signed by the lion. President, Chairman, and 
Dean, and by yourself as Secretary of the Liverpool School of Tropical 
Medicine. 

I beg to return my profound thanks for this highly prized gift and 
for the exceedingly geuerous terms in which it is conveyed. 

Believe me, very sincerely yours, 

(Sgd.) Lister. 


THE FEEBLE-MINDED CRIMINAL. 

A pamphlet has recently been published by the city of 
Birmingham education authority containing a number of 
papers read at a Conference of After-Care Committees which 
was held in that city last November. One of these papers, 
dealing with the problem of the feeble-minded criminal, was 
contributed by Dr. H. B. Donkin who, as one of H M. Com¬ 
missioners of Prisons, is able to speak on this question with 
the combined authority of the physician and the practical 
administrator. Starting from the fact, painfully familiar to 
all who have had to do with the work of the special schools for 
mentally defective children, that the large majority of such 
children cannot by any system of training be made capable 
cf eventually supporting themselves, Dr. Donkin points out, 
as a very obvious inference, that a good many of them are 
likely, following the path of least resistance, to drift into the 
criminal class. And he states that, as a matter of fact, 
amongst the prisoners technically known as “convicts"— 
i.e., those sentenced to penal servitude as distinguished from 
mere imprisonment, and therefore guilty as a rule of 
relatively grave offences—a very large proportion are found 


to be congenitally feeble-minded. To illustrate the hopeless 
recidivism which characterises individuals of this type when 
they have once embarked on a criminal career he cites the 
case of a prisoner who was first convicted when seven 
years old and who had no less than 28 convictions re¬ 
corded against him before he had reached the age 
of 24 years. Amongst the minor offenders who are 
committed to local prisons the proportion of persons of 
weak mind cannot be stated positively but Dr. Donkin 
would put it at from 10 to 15 per cent, at the lowest 
estimate. The committal of these feeble-minded persons 
to prison is indefensible but it is also at present inevitable; 
there is no place other than the prison for the weak-minded 
law-breaker who cannot be certified “insane.” The result 
is that “feeble-minded prisoners, male or female, oscillate 
vaguely between the streets, the poorhouse, the asylum, the 
gaol, and the maternity wards; and the less patently 
idiotic they are the greater the evils they cause and suffer.” 
In pleading for some more rational way of treating these 
unfortunate beings in their own interest and in that of 
society, Dr. Donkin takes occasion to apply a much 
Deeded corrective to the pseudo-scientific rubbish about 
the “born criminal” and the “inheritance of crime” 
which has done so much to discredit the genuinely 
scientific study of this social problem. The relation of 
heredity to crime is, he points out, simply through mental 
defect. In the case of a weak-minded criminal what may 
be inherited is not criminality but the incapacity to acquire 
the elements of good or social conduct; and it is this in¬ 
capacity to develop the higher and more complex associa¬ 
tions, and not any specifically vicious tendency, that makes 
the imbecile succumb to the temptations of an evil environ¬ 
ment. Given better surroundings, a considerable proportion 
of these defectives would not become criminals at all. It is 
probable indeed that very many, especially of the higher 
grade imbeciles, might almost as easily be trained in a 
harmless as in a harmful direction, though all require con¬ 
tinuous regulation and control from outside. 


HYGIENIC IMPROVEMENTS IN THE PROCESS OF 
CHINA SCOURING IN THE POTTERIES. 

We have received an interesting paper from Dr. Frank 
Shulllebotham of Newcastle-under-Lyme in which he 
discusses the improvements which from time to time have 
been introduced in the process known as china scouring and 
which have been directed towards minimising the dangers to 
the health of the operatives arising from the inhalation of 
dust. Hitherto the process has been regarded as one of the 
most unhealthy branches of the pottery industry but at the 
present time the conditions under which china scouring is 
carried out make it, as Dr. Shulllebotham says, a 
comparatively harmless operation. Scouring consists in 
removing the roughness from articles of ware occasioned by 
the adherence of particles of flint used in the saggars 
in the firing oven. It was originally carried ont in 
primitive fashion by girls who rubbed off the particles 
of flint with a bard brush or if that was not 
sufficient the surface was sand-papered. This opera¬ 
tion produced clouds of dust which was inhaled by 
the workgirls, the sharp angular particles causing irrita¬ 
tion of the mucous membrane of the smaller bronchial tubes 
and the pulmonary alveoli, and in quite a short time fibrosis 
of the longs might be produoed. About 20 years ago a fan 
was introduced which greatly improved the ventilation of the 
workshops and at about the same time manufacturers began 
to sconr the ware with brushes. Sand-papering, however, 
could not be dispensed with as a finishing process. In 1894 
the use of a fan was made compulsory by the Home 
Office and certain regulations were applied in regard 
to the operatives wearing overalls, head coverings, and 




512 The Lancet,] 


THE EXCLUSION OF FAT FROM THE DIET. 


[Feb. 15,1908. 


so on, and to the provision of lavatory accommodation, 
the systematic cleaning of the workshops, and so forth. 
These special rales were extended in 1898 so as to include a 
compulsory medical examination once in each month by the 
certifying factory surgeon and the use of exhaust fans for 
the removal of dust was enforced. Daring the last ten 
years these rules have been in operation and with a most 
satisfactory result. The medical evidence brought before 
the Departmental Committee on Compensation for Indus¬ 
trial Diseases showed that fibrosis of the lungs among 
potters, including china scourers, is now a comparatively 
uncommon disease and is found only in isolated instances. 

It was admitted that china scouring was the occupation in 
which the operative might incur most risk of contracting 
this disease, but it speaks highly for the present conditions 
of employment when such a marked diminution in the 
number of cases of fibrotic lung is so evident. It has been a 
matter of considerable difficulty for some years past to 
obtain a typical pathological specimen of fibrosis of the lungs 
from a potter. The process of china scouring recently has 
undergone almost a revolutionary change by the introduction 
of a machine which will entirely dispense with hand labour. 
The machine consists of a steel cylinder, the interior of 
which is divided into recesses into which fit skeleton cages 
containing the ware which has to be scoured. The 
cageB are similar in transverse section to the recesses 
in the front frame of the cylinder, but they vary in 
the interior to suit the size and shape of the pieces of ware 
to be carried in them. Previously to filling the machine with 
ware a weighed quantity of broken pitchers, ground and 
screened to a standard size, is placed in the cylinder. When 
the cylinder is filled it is caused to rotate about 15 revolu¬ 
tions per minute, and in this way the broken pitchers will 
be carried in a shower between the articles in the various 
cages and thus the ware will be thoroughly scoured. The 
fine dust produced in carrying out this procedure is drawn 
from the interior of the cylinder by an air-current 
through it which is induced by a centrifugal fan. This 
method has now been adopted by many of the largest 
china manufacturers in the country. The advantages of the 
machine, Dr. Shufflebotham concludes, are: (1) that it scours 
the ware more effectively than by the revolving brush and 
gives a smoother surface, and makes it easier to detect bad 
pieces of ware ; (2) that it dispenses with the sand-papering 
process ; (3) that it reduces the number of operatives 
engaged in this process (who have hitherto scoured with the 
revolving brush and sand-paper) by one-fourth ; (4) that it is 
a more economical process ; and (5) that the worker is not 
exposed in any way to dust. It may be regarded as an 
entirely harmless process. It can be applied to all kinds 
of ware except those of irregular shapes, which would be 
liable to break in the machine. These articles are best 
scoured by the sandblast. _ 

THE EXCLUSION OF FAT FROM THE DIET. 

Physiological considerations would imply that many 
minor ills of the body would be avoided if only care were 
taken to include a sufficiency of fat in the diet. Fat, we 
know, is about the most compact form of fuel which we possess 
while it exercises a favourable effect upon the processes of 
the in'ettinal tract. In excessively cold countries a rich 
fatty dbt is indispensable, for fat is the only food substance 
which will rapidly replace the heat lost by the body, and 
travellers in the Arctic regions have related that they 
could only be kept warm and comfortable by a generous 
supply of fatty food, in comparison with which the effect of 
extra clothing was inappreciable. The tendency of to-day in 
many quarters is to exclude as much as possible the fatty 
portions of animal foods. Pieces of fat are carefully cut off 
the slice of ham, mutton, or beef, and only the lean parts 


are eaten. Indeed, for some unaccountable reason the eating 
of fat is regarded by not a few as positively vulgar. Suoh 
an attitude, of course, displays an ignorance of physio¬ 
logical facts. Cold feet, bauds, fingers, ears, and chilblains 
would in many instances b * avoided under a generous diet 
of fatty food. A digestible fat favours nutrition consider¬ 
ably ; it spares much waste of the tissue-forming elements 
of food. When lean meat alone is given large quantities 
are required in order that nutrition and waste may balance 
one another, but if fat be added the demand for flesh is 
less. Besides, therefore, giving an advantage in regard 
to making good the repair of the body, the use of fat is 
economical from the point of view of pounds, shillings, and 
pence. The absorption of large quantities of fatless meat again 
tends to overload the blood with nitrogenous waste products- 
In anaemic persons the partaking of an easily digested fat 
is commonly followed by the best results, nutrition is greatly 
improved, and the condition of the blood is often restored 
to normal. It is well known, again, that easily absorbable 
fats, such as butter, cream, cod-liver oil, bacon fat, 
and dripping, are especially valuable to sufferers from 
wasting diseases. The introduction of the old-fashioned 
and well-prepared suet pudding into the diet is in perfect 
accordance with scientific teaching, and from the dietetic 
point of view, especially in the feeding of young growing 
people, does probably a really beneficial service to the 
country. The assumed aversion to fat on the part of a 
great many people is silly and mischievous, for there can 
be little doubt that a reasonable proportion of fat in the 
diet is calculated to preserve the standard of health. 
Cases of true repugnance or intolerance do of course exist 
but on the whole they are rare. 


THE INACCURATE DOSAGE OF MEDICINES. 

The National DruggUt (an American journal) for 
December calls attention to the variation in capacity of 
ordinary medicine bottles, as shown by a careful examina¬ 
tion of one dozen each of two, four, six, and eight-ounce 
oval bottles of best quality that were purchased on the 
American market. Each of these 48 bottles, when suit¬ 
ably filled, was found to hold more or less than the 
correct volume of liquid, the greatest error amounting 
to 18'3 per cent, of the correct volume. The two-ounce 
bottles held from 95 to 176 minims more than the reputed 
volume; in the case of the four-ounoe bottles the excess 
varied from 77 to 190 minims ; the six-ounce bottles held 
from 188 to 366 minims too much liquid ; while the eight- 
ounce size showed a nearer approach to accuracy, ranging 
from a deficiency of 144 minims to an excess of 134 
minims. It is noteworthy that the greatest variations 
were found in the smaller bottles, in which an error is 
of more consequence than in the larger sizes. In view 
of these facts it is evident that the pharmacist should 
select his prescription bottles with the greatest possible 
care or else abandon the prevalent custom of regarding 
tho bottle as holding the proper quantity of liquid and 
filling directly into the bottle. The past three decades have 
witnessed great advances in the method of preparing 
and especially of standardising medicines, but this 
advantage is liable to be rendered nugatory by the failure 
to divide the ingredients of a prescription into the indi¬ 
cated number of doses. And this is only one of the sources 
of error incidental to the qnestiofl of the dosage of medi¬ 
cines. It has often been pointed out in The Lancet that 
the capacity of domestic spoons varies within very wide 
limits. Graduated medicine glasses are relatively seldom 
employed, with the result that the patient usually takes 
considerably more or less of the medicine than was intended 
by the physician. But the public will continue to use the 
domestic spoon so long as medicines are ordered to be taken 




The Lancet,] 


THE STATUE OF SIR THOMAS BROWNE AT NORWICH. 


fFEB, 15, 1908. 513 


by spoonfuls. The difficulty could be met by the adoption 
of the following simple plan. In writing prescriptions let 
the doses be given in drachms, half ounces, and ounces. 
The patient, being ignorant of the equivalent in spoonfuls, 
would then be obliged to procure a proper measure. At 
present the situation is *'Gilbertian.” A correct diagnosis 
and a nicely balanced prescription, dispensed from the 
purest drugs standardised to a high degree of accuracy, are 
muddled, or possibly rendered useless or dangerous, by the 
use of inaccurate medicine bottles and still more inaccurate 
domestic spoons. 


THE STATUE OF SIR THOMAS BROWNE AT 
NORWICH. 

In the year 1903 the corporation of the city of Norwich 
informed the committee of the Sir Thomas Browne Memorial 
that the corporation would provide a site for the statue of 
Sir Thomas Browne in the garden which has just been laid 
out in the Haymarket. The statue was accordingly pro¬ 
vided by the subscribers at a cost of upwards of £1000 and 
was unveiled on Oct. 19th, 1905, by Lord Avebury. Recently 
the corporation of Norwich proposed to place lavatories 
and urinals behind, and in close proximity to, the statue 
and it is felt by many in Norwich that the collocation 
of the statue and the urinals is, to say the least 
of it, unsatisfactory. A memorial has therefore been 
drawn up, which has been largely Bigned by medical 
men and others both in Norwich and in London, pray¬ 
ing th.e corporation not to proceed with the scheme for 
erecting the lavatories and urinals on the site allotted to the 
statue. We earnestly hope that the corporation will accede 
to the prayer of the memorialists and will find some other 
and more appropriate site for the proposed lavatories. 

LUMBAR PUNCTURE IN THE MENINGEAL 
FORMS OF ENTERIC FEVER IN 
CHILDREN. 

In the Gazette Mebdoinadaire des Sciences Medicates de 
Bordeaux of Jan. 26th Dr. Ch. Rocaz and Dr. Firmin Carles 
have published an important paper on the therapeutic value 
of lumbar puncture in the meningeal forms of enteric fever 
in children. In children enteric fever is often complicated 
by meningeal symptoms. In some cases these are slight and 
fugitive and of only secondary importance; in others they 
are more marked and persistent and occupy the first place 
among the clinical manifestations. For a long time 
writers discussed these meningeal symptoms and insisted 
on the variability of the prognosis according as 
there existed true meningitis or meningeal symptoms 
without an anatomical substratum (meningism). The 
introduction of lumbar puncture has given a new 
interest to the question. From the clinical standpoint 
four types of meningeal manifestations in enteric fever in 
children may be distinguished. In the first, towards the end 
of the second week appear intense headache, repeated vomit¬ 
ing, and constipation (which may replace the pre-existing 
diarrhoea). Cutaneous hyperesthesia, irregularity of pulse 
and respiration, various vaso-motor troubles, and retraction 
of the head follow. Ocular symptoms (inequality of pupils, 
strabismus, and ptosis) are rarer and of more serious 
prognosis. After some days these symptoms may disappear 
but sometimes they terminate in death. In the second type 
the complete "tableau ” of acute cerebrospinal meningitis is 
presented. In addition to the symptoms described Kernig’s 
sign appears and rigidity of the neck and spine, as 
marked as in acute cerebro-spinal meningitis, follows. 
The rigidity may extend to the limbs and the hands 
and feet may assume the attitude of tetanus. This 
is one of the most frequent types. The third type 


is rarer. The attack presents from the first the com¬ 
plete “ tableau ” of tuberculous meningitis and erroneous 
diagnosis is easy. The fourth type is peculiar to infants. 
During an attack of enteric fever convulsions appearand lead 
to a rapidly fatal termination. Lumbar puncture has thrown a 
new light on the pathogenesis of these phenomena. It may 
yield (1) pus in which may be found the typhoid bacillus in 
pure culture, other microbes, such as staphylococci, or a 
mixture of the typhoid bacillus and other microbes; (2) a 
turbid or transparent liquid in which centrifugalisation 
shows microbes—the typhoid bacillus or others ; (3) a 
liquid which, though quite clear, contains abnormal 
cellular elements, usually abundant lymphocytes; and 
(4) a liquid of normal composition but flowing out in a jet, 
indicating abnormally high tension. In the first two cases 
the pathogenesis of the meningeal symptoms is manifest; 
the meninges are infected. In the third case it is logical to 
suppose that the meninges are irritated by microbial toxins 
which give to the cerebro-spinal fluid its cytological 
characters. In the fourth case also the hypersecretion of 
cerebro-spinal fluid is probably due to the same cause. 
M. Roger has shown the frequency of serous exudations 
under the action of various toxins. These facts also explain 
why lumbar punoture can be useful in the meningeal forms 
of enteric fever. Concetti, Netter, and many others have 
shown that repeated lumbar puncture is the best treatment 
of bacterial meningitis. The operation is therefore indicated 
in cases of enteric fever in which the cerebro-spinal fluid 
contains microbes. Each puncture removes some of the 
microbes and they are reproduced with difficulty as the 
cerebro-spinal fluid is a bad culture medium. They therefore 
soon disappear. If, on the other hand, the meningitis is 
Bimply toxic, the removal of a certain quantity of fluid 
charged with toxins cannot fail to have a favourable action. 
In the case of abnormally high tension puncture diminishes 
the pressure on the nervous centres and removes the resulting 
symptoms. The following is one of eight cases showing the 
value of lumbar puncture related by Dr. Rocaz and Dr. 
Carles. A boy, aged eight years, had a severe attack of 
enteric fever characterised by profuse diarrhoea, a tempera¬ 
ture of 103 • 6° F., rose spots, and so on. On the eighteenth 
day he complained much of headache, cerebral vomiting 
occurred, and the diarrhoea was replaced by constipation. 
The head was retracted, the neck was rigid, and Kernig’s 
sign was present. Lumbar puncture yielded 12 cubic centi¬ 
metres of clear fluid under high pressure. Cytological 
examination showed that this was of normal composition. 
All the symptoms of meningitis had disappeared on the 
following day and uninterrupted recovery followed. 


AN EXTRAORDINARY PROPOSAL. 

We have received a copy of an extraordinary work 
entitled, “Truth: Experimental Researches about the 
Descent of Man.” The author of this remarkable book 
is M. H. M. Bernelot Moens and we regret to see 
that he is to be assisted in his enterprise by Dr. H. M. J. 
Boshouwers, a medical man. The book, or pamphlet, is 
intended, we suppose, as a preliminary notice, and an appeal 
for pecuniary assistance in the prosecution of the work 
which these gentlemen intend to carry out in the Congo. 
Their aim is to furnish experimental proof of the view that 
man is a highly developed anthropoid ape, and for this 
purpose they intend to practise artificial fecundation of the 
females of the anthropoid ape with the sperm of man ; the 
gorilla and chimpanzee to be fecundated with negro semen. 
M. Moens also wishes to carry out experiments in the cross¬ 
ing of the anthropoid apes either by artificial or natural 
fecundation and to study human diseases, more especially 
syphilis, by means of experiments on these animals. The 
book is to be printed in Dutch, French, and German, and the 





Thh Lancet,] VENEREAL DISEASE IN RANGOON.—ANTI-SWEATING DEMONSTRATION. [Feb. 15, 1908. 515 


which appeared to be a pare lipoma. Tumours of the aterus 
are extremely common. Garlt in an analysis of 13,971 
tamonrs observed at the hospitals of Vienna found that 4115, 
or 29 percent., originated in the uterns. Williams found 
an almost identical percentage—viz., 28'7 in 13,824 caseB of 
tamonrs treated in four large London hospitals, but no 
example of lipoma is included. Seydel in 1903 found a lipo- 
fibromyoma of the size of a walnut in the uterus of a woman, 
aged 58 years, and after an exhaustive study of the literature 
could only find ten other cases of fatty tumour of the uterus. 
There were thus on record at this time four cases of lipoma, 
two of lipomyoma, and four of lipofibromyoma, the remain¬ 
ing case being described simply as composed of adipose 
tissue. In addition, there are three other cases in the litera¬ 
ture of this subject which were macroscopically of fatty 
appearance bat were not examined microscopically and were 
on this account excluded by Seydel. Dr. Ellis has studied 
the published accounts of these various cases and gives brief 
accounts of them. Apart from his own case he has been 
able to find no further instances. The ages of the patients 
in the 12 cases varied from 28 to 68 years. Several of the 
women were sterile, while one had 13 normal labours and 
three miscarriages. The histogenesis of these tumours is a 
point of some interest, since the normal uterus does not 
contain adipose tissue. It has been suggested that they 
arise by the muscle cells changing into fat cells but there is 
no evidence in support of suoh a metaplasia. The usual 
view is that they originate in rudiments of embryonic fat 
included in the uterus and their occurrence is taken as 
supporting Cohnheim’s view of the genesis of tumours. 


VENEREAL DISEASE IN RANGOON. 

The reports that have recently reached us concerning the 
prevalence of venereal disease in Rangoon are distress¬ 
ing. In the words of one of the officials of the municipal 
committee, “ sinoe the suspension of the C.D. Acts in India 
and Burma by orders from home we have now come to a 
pass which is truly intolerable.” The statistics that 
have been collected substantiate this assertion. Major 
0. E. Williams, I.M.S., the able health officer of the 
Rangoon municipality, instituted an inquiry at the instance 
of the committee to ascertain the extent to which venereal 
diseases were prevalent in Rangoon, the scope of which 
inquiry was limited to three points—namely, (a) the 
extent to which venereal diseases are prevalent in 
Rangoon at the present time, ( b ) a comparison of the 
figures for admission for these diseases at certain military 
and civil hospitals during the past ten years, and (of a 
comparison of the data obtained under the last point with 
those on record for other cities and cantonments in India 
and Burma. The sources of information on these points 
were the experience of medical men practising in Rangoon 
the medical records of the Rangoon garrison as shown in the 
annual sanitary reports published by the Government of 
India, and the tables appended to the annual sanitary reports 
of the Sanitary Commissioner with the Government of India 
and Inspector-General of Civil Hospitals, Burma, for the 
years 1896-1905. As a result of this inquiry it was ascer¬ 
tained that in the opinion of the majority of the medical 
practitioners in Rangoon, including all those who can 
claim to have an intimate and extended acquaintance 
with the people of this town, venereal diseases were 
more prevalent at the present time than formerly, that they 
are found in all classes of the population, and that they 
assume a very virulent type. Further, that youths of all 
classes are especially prone to contract the diseases, and that 
innocent women and children suffer from the results of 
direct and inherited infection, whilst the infant mortality is 
increased from this cause. The statistics of the military 
and civil hospitals in Burma, the health officer concludes, 


are open to criticism and do not throw much light on the- 
problem ; they indicate these diseases to be more prevalent- 
in Rangoon than in Calcutta and other Presidency towns, 
but that their prevalence on the whole tends to decrease. 
But the health officer considers the testimony of the 
medical men of the town to be the more valuable in 
forming a correct estimate of the prevalence of venereal 
diseases, the military returns referring to only a small 
section of the population living under special condi¬ 
tions, whilst those of the civil hospitals rest npon varying 
and uncertain elements of the population. 19 years ago all 
restrictions upon prostitution and the propagation of venereal- 
diseases were withdrawn, this being due to the interference 
of the Home Government. Compulsory attendance at the 
Lock Hospital in Rangoon ceased in August, 1888. 
Since that time infected women have been allowed to go 
on with their disease-spreading trade. 


ANTI-SWEATING DEMONSTRATION. 

On Tuesday evening, Jan. 28th, a meeting was held in 
Queen’s Hall to demonstrate against the evils of what is 
known as the sweated industries system. The meeting took 
place under the auspices of the National Anti-Sweating 
League, was very largely attended, and was presided over by 
the Bishop of Birmingham. A proposition to the following 
effect was introduced by Mr. Arthur Henderson, M.P., the 
newly made leader of the Labour Party in Parliament:— 

That this representative national demonstration calls the attention of 
His Majesty's Government to the evils arising from the gross under¬ 
payment of workers proved to exist in particular trades, and requests 
that Wages Boards on the lines of those suggested in the Sweated 
Industries Bill of Mr. Arthur Henderson be established in such 
trades. 

This motion was seconded and supported by Sir Charles 
W. Dilke, M.P., Father Bernard Vaughan, Miss Mary R. 
MacArthur, and Mr. G. Bernard Shaw. All the speakers 
dwelt upon the insanitary conditions under which the 
majority of those engaged in sweated industries live, con¬ 
ditions which act especially as regards women home-workers, 
and have a serious effect npon infant mortality and may also 
influence race deterioration. The Bishop of Birmingham in 
his speech alluded to an interesting point, that by the Mosaic 
law both the material and sanitary welfare of workers was 
carefully guarded, and that throughout the Bible the neces¬ 
sity of giving a living wage to all who toiled with their 
hands was emphasised. _ 

The Central Hospital Council for London has issued the 
report of its committee appointed last July to advise 
whether the constituent hospitals of the council, whicb 
represents all the larger hospitals, shonld take joint action to 
insure the purity of their milk supply. The committee 
recommends joint action and indicates to the hospitals the 
requisitions which it considers should be made binding npon 
those who contract to supply the hospitals with milk. The 
report will receive detailed notice from us—it is a highly 
important document. _ 

The Department of Public Health of Queensland in a 
bulletin dated Jan. 4th states that for the week ending 
Jan. 4th a fatal case of bubonic plague occurred at Brisbane 
on Jan. 3rd. The patient, a man, aged 53 years, living at 
Boundary-street, Spring Hill, and working on a coal hulk in 
the river, was admitted to the Brisbane General Hospital on 
Jan. 1st. The post-mortem examination of the viscera of the 
body showed that death was due to plague. This is Case 1 
of the current year. _ 

The 135th anniversary dinner of the Medical Society of 
London will take place at the Whitehall Rooms, Hotel 
M6tropole, on Wednesday, March 11th, at 7.30 p.m. Dr. 
J. Kingston Fowler, President of the society, will occupy’ 
the chair. 





516 The Lancet,] ANNUAL REPORT OF THE REGISTRAR-GENERAL FOR THE TEAR 1906 [Fbb. 15, 1908. 


e 

5* 


ANNUAL REPORT OF THE REGISTRAR- 
GENERAL FOR THE YEAR 1906. 

i. 

We have pleasure in announcing the appearance within 
the last few days of the Registrar-General’s report on the 
births, deaths, and marriages in England and Wales for the 
year 1906. OE the annual reports issued from Somerset 
House since the assumption of office by the present Registrar- 
General this is the sixth, and from the rapid survey of it 
which has hitherto been practicable we believe it to be a 
worthy addition to a series of essays on vital statistics 
hitherto unrivalled in any language. 

In his first report—namely, that for the year 1901—Sir 
William Dunbar availed himself of the opportunity afforded 
by the opening of a new century to arrange, and where 
necessary to modify, the information contained in previous 
reports so as to comply with modem requirements, whilst 
still retaining the means of comparison with data contained 
in the long list of annual volumes issued by his predecessors. 
For example, the method initiated by Major Graham was 
resorted to—namely, that of presenting those portions of the 
report which treat of mortality and its causes in the form 
of a letter for which his medical adviser is responsible. 
The reasons for this course are indicated in Sir William 
Dunbar’s first report, wherein, after graceful acknowledg¬ 
ment of the cooperation of medical men as the indispensable 
factor in the construction of vital statistics, he expresses the 
hope that our profession will view with approval an arrange¬ 
ment by which the information which they contribute 
gratuitously will in future be analysed and its significance 
indicated by the medical member of his staff. It is obvious, 
however, that reports of this nature possess a vital interest 
for the general public ; and therefore the Registrar-General, 
in his introductory remarks, properly and very usefully sum¬ 
marises, for the benefit of his non-medical readers, the more 
technical portion of Dr. Tatham’s letter, and this he does with 
discretion and without unnecessary detail. 

In noticing the successive reports of the Registrar- 
General since his assumption of office we have commented 
on the steady expansion of their scope from time to time. 
In the report before us, for example, we observe that under 
the bead of “international statistics” the data formerly 
published for the principal European countries other than 
our own have been extended so as to include particulars 
relating to general mortality, to the loss of life caused by 
the principal epidemic diseases, and to the fatality of 
pulmonary tuberculosis and of cancer. Accordingly, com¬ 
parison is now practicable between the mortality from these 
diseases in our own country and that of countries beyond 
the sea. In like manner the mortality of infants in our 
Australasian colonies and in some foreign lands may by this 
means be contrasted with that obtaining at home. A new 
feature in these reports is the appearance in the present issue 
of a series of well-designed diagrams illustrative of changes 
in the English Tates of marriages, births, and deaths, the 
facts presented being carried back to the earliest periods for 
which trustworthy statistics are available. Many persons 
there are to whom graphic representations of statistics appeal 
more strongly than would any tabular arrangement of 
figuies, which latter are sometimes passed over as too com¬ 
plicated for interpretation by any but expert readers. To 
such persons we commend for attentive study the excellent 
series of diagrams in this report. 

As might have been expected, the subject of infantile 
mortality which has been brought into prominence by the 
National Conference recently held in London is commented 
upon somewhat fully in the present report. Referring to 
the generally accepted statement, which until now has 
passed unchallenged, that whilst the mortality among 
adults has fallen steadily in recent years there has been 
no corresponding fall in infantile mortality, the Registrar- 
General assures us that this statement holds good only up to 
the close of the nineteenth century. For since the beginning 
of the current century there has been a break in the growth 
of infantile mortality which, with some fluctuations, he 
acknowledges to have prevailed throughout the previous 
decennium. Among infants in their first year of life the 
average mortality has shown a decrease since 1900 amount¬ 
ing to 11 per cent, on the rate of 1891-1900. He points out 


the important fact that about one-third of the total deaths 
at this early age are due to ante-natal influences, such as 
premature birth, atrophy, debility, and congenital mal¬ 
formations, a group of conditions that may be described 
under the general heading of “ immaturity.” Over and 
above these conditions be holds that the employment 
of women in textile and other industries, ignorance, 
careless and insufficient nursing on the part of mothers, 
and overcrowding and insanitary environments are im¬ 
portant factors in bringing about a high rate of infantile 
mortality. Passing reference is made to the Act for the 
notification of births which was passed in the last session 
of Parliament and the Registrar-General expresses the 
opinion that, if consistently carried out, a well-devised 
system of early notification of births, worked in connexion 
with the present registration system on the one hand, 
and with sanitary administration on the other, will serve 
as a most effective and lasting barrier with which to stem 
the tide of infant mortality. 

A prominent feature noticeable in this connexion is the 
evidence contained in the report of the pains taken by its 
author to present the information at his disposal in such a 
way as to avoid statistical fallacy, and this, in a highly 
technical matter like the present, is an object by no means 
easy of attainment. For example, in his remarks respect¬ 
ing the recent improvement in infantile mortality. Sir 
William Dunbar, after recounting the various conditions 
probably conducing to this favourable result, cautions his 
readers thus: "At the same time,” he says, “I think it 
right to refer to the special influence of summer tempera¬ 
ture and rainfall upon infantile mortality. For instance, 
the showery and exceedingly cool weather experienced in the 
past summer checked the rise in the rate of infant mortality 

that usually occurs in the third quarter of the year. It 

should accordingly be borne in mind that, speaking generally, 
throughout the last six years this country has experienced a 
cycle of favourable seasons and that for this reason before 
calculating upon a continuation of the present fall in 
infantile mortality it will be prudent to await a return of hot 
and dry summers in order that the extent may be ascertained 
to which existing sanitary arrangements in some of the 
manufacturing centres are able to withstand the onset of 
extreme heat and dryness without involving the inordinate 
sacrifice of infant life.” 

In the history of English vital statistics nothing stands 
out more prominently than does the unequal incidence of 
mortality among the infant section of the community. In 
illustration of this fact a chart is presented showing the 
distribution of infant mortality in the several registration 
areas. The chart shows that with slight fluctuation these 
areas show severally either a high or a low mortality through 
a long series of years. From a table contrasting the present 
with the past we learn that as compared with 30 years ago 
all the English counties except Essex and Monmouthshire 
have shown in recent years a considerable fall in mortality. 
On the other hand, of the 12 Welsh counties no fewer than 
nine show an increase of infant mortality during the last 30 
years. 

It has frequently been remarked in these reports that those 
areas of the country which comprise the districts of the 
mining, textile, and pottery industries show very badly in 
respect of infant mortality ; not only are the rates excessive 
in many of the larger towns of these districts, but they are 
equally so in the majority of the smaller towns. In proof of 
this a table is inserted showing that there are several groups 
of towns in close contiguity in Staffordshire, Cheshire, 
Lancashire, and Glamorganshire carrying on industries of 
one or another of the binds here spoken of, in no fewer than 
eight of which towns an average of about one in every five 
children born did not survive the first year of life. The 
towns alluded to are Bilston, Longton, Tunstall, Staly- 
bridge, Burnley, Farnworth, Ince-in-Makerfield, and 
Aberdare. Speaking generally, excessive waste of infant 
life is associated with a high birth-rate and with over¬ 
crowding, and it is probable that these conditions prevail 
more or less in the majority of the towns now specified. 
It should be observed, however, that there exist several 
towns which have a comparatively low birth-rate and little 
overcrowding, but in which, nevertheless, infant mortality 
is very high. Such towns not only produce feeble 
children but lose an immoderate proportion of those 
produced. The towns with low rates of infantile 
mortality may generally be described as superior resi¬ 
dential towns or suburbs, the birth-rates in which 


s 

jrj 

21 

3 

i 

X 

n 

r jt 

as 

jrt 

3tS 


ir. 

lOi 

Cl 

m 

hi 

M 

3fl 

2C*I 

{1 
» 

kti 

31! 

cc 

w 

i* 

*1 

S3 

E 

31 

sc 

Sr 

3 

»| 

ii 

21 


Pi 

j 

cl 

J 

3! 

) 

d 

u 




The Lancet,] 


MEDICINE AND THE LAW. 


[Feb. 15,1908. 517 


are conspicuously low, and there is no evidence of over¬ 
crowding. Among places of this sort there are two which 
deserve special mention—namely, Swindon and Burtonon- 
Trent, for the statistics of both these townB clearly prove 
that industrial urban conditions need not of necessity be 
inimical to infant life. 

In England at the present day there are numerous areas, 
urban as well as rural, where the rates are low and compare 
favourably with the lowest rates in the several foreign and 
colonial states. On the other hand, there remain many 
industrial centres where excessive rates indicate that the 
conservation of infant life is much neglected. Sir William 
Dunbar closes his remarks on this important topic with the 
following weighty words :— 

It may confidently be affirmed that In future any permanent reduc- 
tion in the mortality of young children in England and Wales, as a 
whole, will largely depend" upon a due recognition of parental responsi¬ 
bility, on the one hand, and, on the other, an improved health 
administration in these Industrial areas, particularly in that of 
numerous small towns. 

Closely associated with the foregoing subject, this report 
contains important information respecting the waning 
fertility of English mothers. The birth-rate in England 
and Wales attained the highest point on record in the year 
1876, and the mean rate of birth in the quinquennium follow¬ 
ing that year has been taken as a standard for comparison. 
Based on the proportion of births to the number of possible 
mothers, married as well as single—i.e., on the total number 
of women living at child-bearing ages—the fall since that 
period has amounted to more than 29 per cent., whilst the 
fertility of married women, based on the ratio of legitimate 
births to wives of conceptive ages, showed a decrease 
amounting to 25 per cent, within the same period. In other 
words, if the fertility of married women in proportion to 
their numbers had been identical in 1876 80 and in 1906 the 
legitimate births in 1906 would have exceeded by more than 
300,000 the number actually registered in that year. 

The Registrar-General has more than once admitted in his 
reports that the registers of birth as well as of death are 
capable of improvement, and in the present report he reverts 
to the subject. He finds, however, on consideration that 
fuither evidence is required of the desirability of including 
some possible improvements before embarking on the recon¬ 
structing of the registers for a total of more than 2000 
districts. As the existing registers give no information 
respecting the ages of mothers there are no means of ascer¬ 
taining the fertility of women at the several ages comprised 
in the child-bearing period. As a digression for a moment we 
may recall the fact that the Scottish registers at one time 
contained this information, which has been ably utilised in 
connexion with the subject of maternal fertility in that 
country. In England, nevertheless, there are sufficient 
grounds for stating that during the past 30 years about 
15 per cent, of the decline in the birth-rate (based on 
the proportion of births to the female population aged 
15-45 years) is due to the decrease in the proportion of 
married women of conceptive ages, and that over 7 per 
cent, is due to the decrease of illegitimacy. With regard 
to the remaining 78 per cent, of the decrease Sir William 
Dunbar pointedly remarks that although some of the reduced 
fertility may be ascribed to changes in the age constitution 
of married women there can be little doubt that much of it 
is due to deliberate restriction of child-bearing. 


MEDICINE AND THE LAW. 


Medical Certificates far School Children. 

Mr. Paul Taylor recently made the following observations 
at the Marylebone police-court with reference to the class of 
cases in which parents are summoned for the non-attendance 
of their children at school tbrongh illness as to which no 
medical certificate is forthcoming. The learned magistrate 
said : “ I look upon it as very important that the poor should be 
able to obtain such certificates without payment, and it would 
be of great assistance to me if they could. I am often told that 
these poor people really cannot afford to pay for a certificate. 
A hospital doctor should not be expected to give a free certifi¬ 
cate.” Mr. Taylor bad also said during a discussion as to the 
oourse which might be adopted that in his opinion there should 
be a public medical official paid out of public funds to give 
certificates for the purpose indicated and a witness from the 


education department of the London Connty Council bad 
intimated that some such suggestion had already been laid by 
him before the Council. The obvious necessity that there 
shonld be medical certificates in cases of absence from school 
through alleged illness will, no doubt, lead to provision being 
made some day for the obtaining of them by those too poor 
to pay for them themselves, but the question how they should 
be obtained and paid for is not very easy to answer. The 
provision of fees payable from public funds to the medical 
man attending the patient should commend itself to the 
medical profession rather than the institution of a public 
official to inspect and to certify with regard to cases nnder the 
treatment of a private practitioner. Snch a course would not, 
however, be without its drawbacks, and tbe question of 
expense is no doubt one which would be regarded as a serious 
one by the ratepayer, both generally and with regard to the 
comparative cost of any plans put forward. 

Fergusson v. the Malvern Urban District Council. 

After a trial lasting 11 days Dr. J. C. Fergusson has 
recovered a verdict for £7500 damages against the Malvern 
district council on the ground that an outbreak of enteric 
fever at the hydropathic establishment conducted by him, 
and in respect of which he has already had to pay heavy 
damages to various plaintiffs who contracted the disease in 
bis establishment, was due to the contamination of his water 
supply with sewage, for which contamination the council 
was responsible. Dr. Fergusson is to be congratulated on the 
result of the case and all the more so as the defence involved 
serious charges against him of want of care in the provision of 
water for tbe inmates of the house under his control. No fewer 
than seven questions were eventually left to the jury and it 
is to be observed that a point of law may be discussed here¬ 
after in tbe Court of Appeal upon the answers given to two 
of these, by which the jury found that the plaintiff bad no 
proprietary right in certain water to tbe contamination of 
which the enteric fever was ascribed and which flowed into 
his tank and that he had no licence to use it. By their other 
answers the jury found that the defendants were guilty of 
negligence in permitting sewage to escape from their sewer 
and that the plaintiff was not guilty of contributory 
negligence in permitting the contaminated water to be con¬ 
ducted to his tank as it was conducted ; that the escape of 
the sewage was the sole cause of the outbreak of enteric 
fever ; and that the outbreak would not have been prevented 
by reasonable care on the part of the plaintiff. 

£000 Damages for Libelling a Medical Practitioner. 

Two actions for libel brought by a medical practitioner 
against newspapers and arising out of the same facts were 
brought to a conclusion recently before Mr. Justice Darling 
in the King’s Bench Division. In the first the defendants 
(Edward Lloyd, Limited, proprietors of the Daily Chronicle) 
apologised and settled the action by payment of £25, 
which they had already paid into court, together with 
£100 to cover the plaintiff's costs. In the second action 
the Star Newspaper Company, Limited, were the defendants, 
and evidence was called on behalf of the plaintiff before a 
settlement was arrived at by which the defendants agreed 
to pay to the plaintiff £500 damages, with costs as between 
solicitor and client. The facts with regard to which the two 
newspapers involved bad published matter calculated to injure 
the plaintiff were of an unusual character and arose out of the 
crimes of tbe man Brinkley arrested in April, 1907, for the 
murder of Mr. and Mrs. Beck by poisoDir g and afterwards 
convicted and executed. It appears that when inquiry was 
instituted as to Brinkley's antecedents it was found that 
towards the end of 1906 a woman named Bums, living at 
the house where he was subsequently arrested, bad 1 ad a fit, 
and that the plaintiff, Mr. M. J. Williams, who had been 
called in to attend her, had found her already dead 
on his arrival. He had afterwards been asked by 
Brinkley to certify as to the cause of death but had 
naturally refused to do so and had given evidence at the 
inquest which followed after making a post-mortem examina¬ 
tion by the coroner's order. The evidence which he gave was 
to the effect that the deceased died from apoplexy end the 
jury so found. As no question of foul play bad arisen at the 
time of Mrs. Blume’s death and as no special inquiry with 
a view to detect poison had taken place it was thought 
desirable when the deaths of Mr. and Mrs. Beck occurred 
to ascertain whether evidence of crime could be 
traced in the former case also, and by the order 
of the Home Secretary Mrs. Blume's body was exhumed 



518 The Lancet,] 


LOOKING BACK.—VITAL STATISTICS. 


[Feb. IS, 1908. 


»nd was examined by Sir Thomas Steven non and Dr. 
French. At this second examination also the plaintiff was 
present. No trace of poison was discovered. The organs 
were found replaced in the usual manner in the cavity of the 
chest, with the exception of the brain which had no doubt 
disintegrated during the interval whioh had elapsed since 
the first post-mortem examination. The version of this not 
cnnatural circumstance which was printed in the Star was 
as follows : — 

Poison Drama. 

The Exhumation of Mr*. Blnme’e Body. 

It is reported that the exhumation of the body of Mrs. Blame of 
Mnxweltrond, Fulham, which took place at Brompton Cemetery a fort¬ 
night back, has proved abortive so far as the discovery of any trace of 
poison is concerned Sir Thomas Stevenson and his assistant were 
unable to make any examination of the organs, in which alone traces of 
poison, supposing it is present in the body, could ordinarily ho detected. 
Some parts of the organs which it is now desired to examine are, in 
fact, reported to be missing. It should be explained, however, that 
this circumstance does not reflect upon any person now concerned in 
the case, but may be a consequence of the lirst, post-mortem examina¬ 
tion which was made at the lime of the old lady's death. 

This involved so serious an imputation upon the plaintiff 's 
•conduct in connexion with the post mortem examination, for 
which be alone was responsible, that he was compelled to 
bring an action to vindicate his character, when he was met 
not only with the defence that the words were not oapable 
of the defamatory meaning which was assigned to them and 
were fair comment, but also that they were true in 
substance and in fact, this latter plea was aggravated, 
as the judge pointed out at the conclusion of the case, by 
the placing upon the record of " particulars of justification," 
including a list of portions of the body alleged to be 
missing in consequenoe of the plaintiff’s conduct. It 
is not surprising that in these circumstances it was 
felt desirable by the legal advisers of the defendant 
newspaper to settle the case by means of a substantial 
payment. A jury could hardly have failed to award heavy 
damages considering that the evidence of Sir Thomas 
Stevenson was that the whole of the remains had been 
found by him except the brain ; that the placing of it in 
the cavity of the chest with the rest of the parts removed 
for examination was proper and usual; and that the disinte¬ 
gration which had apparently taken place had not affected 
the result of the necropsy, which had not led to the 
discovery of any trace of poisoning. In addition the 
plaintiff had given evidence that his practice had been 
injured by the publication of the libel. The state¬ 
ment and the suggestion made when once shown to 
be erroneous would, indeed, have been very difficult to 
exouse and the Star could hardly have urged in its own 
defence an attitude sympathetic as a general role towards 
medical science or medical men. The effect of its mis- 
statement, moreover, was likely to extend beyond the 
individual medical practitioner whose sneoessful vindication 
of his character is a matter for personal congratulation and 
who would naturally find among bis poorer patients many 
readers of a halfpenny evening newspaper. The result of the 
paragraph quoted above might well be to increase the 
dislike and distrust evinced by many for the holding of post¬ 
mortem examinations upon the bodies of their relatives. 
This feeling of aversion is a natural one and it is highly 
undesirable that it should be increased by any suggestion 
that after post mortem examination the body in question will 
not receive complete sepulture like any other. 


Post-Graduate Medical Study Abroad.—T he 

French Association for Post-graduate Medical Study, which 
is known as the “ F..M.I.,” asks ns to state that it is organ¬ 
ising a tour of Inspection of the medical and sanitary 
institutions of Italy from April 12th to 28th. The places 
to be visited include Turin, Milan, Padua, Venice, Briogna, 
Florence, Rome, Naples, Pisa, Genoa, and San Remo. The 
organisation of the tour has been entrusted to Professor 
Pini, the corresponding member of the association in Italy, 
and he has the cooperation of the most eminent leaders 
of the medical profession in that country, including 
Baccelii, Bos-i, Bozzulo, Cozzoline. De Giovanni. Mangiagalli, 
Marlimuni, Alva, Pinzani, Vitali, and Zeri. The complete 
programme of the tour has been published in the January 
number of the journal “L’E M.I.,” the official organ of the 
association, and can be obtained, together with any other 
information that may be required, by sending a stamped 
addressed envelope to the secretary at the headquarters of 
the association, 8, rue Francois-Millet, Paris. 


fcooklna Bach, 


FROM 

THE LANCET, SATURDAY, Feb. 13th, 1830. 


CONSUMPTION OF NUX-VOMICA AND COCELUS-INDICUS. 

To the Editor of The Lancet. 

Sir.—A lthough I am no professional man, I have been a 
subscriber to The Lancet from its very birth, and am fully 
aware how useful it has been in exposing delnsion, fraud, 
and humbug. You have occasionally touched upon the 
sophistication or adulteration of what is taken into onr 
stomachs as nutriment. I do not believe all that the author 
of “death in the pot" advances, bnt the subject is an 
important one, and merits the most serious attention. 

By a return made officially from the Custom-house to the 
House of Commons ia the last session, and from other 
authentic documents in my possession, it appears, that, npon 
an average of some years there has been an annual importa¬ 


tion into Great Britain of 

IBs. 

Nux-vomica.30,000. 

CocnIaS'indicua .12,000. 


Now, Sir, I wish to ask of your medical and chemical 
readers, or wholesale druggists, what becomes of this 
enormous quantity of poison ; a trifling quantity Is employed 
in medicine, and for the destruction of vermin, and by 
poachers we know that a comparatively small quantity of 
these articles is also used ; but if there be any other open, 
honest, or avowed purpose to which they are applied in 
any part of the world, it would remove some very un¬ 
pleasant suspicions, and be very gratifying to many persons 
to be made acquainted with it. 

I am, Sir, 

Your most hnmble servant, 

Bath. February, 1830. 1 J. H. G, 

i The above letter (written 78 years ago) evidently refers to the 
adulteration of beer, but happily, owing to the provisions of the 
Adulteration of Food and Drugs Acts following on the labours of the 
Founder of The Lancet by his Analytical Sanitary Commission 
(commenced in the year 1851) and his personal inquiries, this adultera¬ 
tion is a thing of the past. 


VITAL STATISTICS. 


HEALTH OF ENGLISH TOWN8. 

In 76 of the largest English towns 9240 births and 6692 
deaths were registered daring the week ending Feb. 8th. 
The mean annual rate of mortality in these towns, whioh had 
been equal to 20 0, 18'5, and 18 Z per 1000 in the three 
preceding weeks, increased slightly to 18 3 in the week under 
notice. Daring the first six weeks of the current quarter the 
annual death-rate in these towns averaged 18 5 per 1000; the 
rate in London during the same period did nut exceed 
18 ■ 0 The lowest annual death-rates in the 76 towns 
last week were 6 -2 in Hornsey, 9 9 in Leyton and in 
Willesden, and 10 3 in York ; the rates in the other towns 
ranged upwards to 25 ■ 3 in Liverpool. 27 ■ 0 in Merthyr Tydfil 
and in Birkenhead, and 29 8 in Grimsby. The rate 
in London last week did not exceed 17'7. The 5692 
deaths registered in the 76 towns during the week under 
notice showed an increase of but 11 npon the number in 
the previous week, and included 447 which were referred 
to the principal epidemic diseases, against 409 and 441 in 
the two previous weeks ; of these, 192 resulted from 
whooping-cough, 73 from diphtheria, 71 from measles, 48 
from diarrhoea, 39 from scarlet fever, 24 from “ fever ” 
(principally enteric), but not one from small-pox. The 
deaths from these epidemic diseases in the 76 towns were 
equal to an annual rate of 1-4 per 1000, the rate from 
the same diseases in London being 13. No death 
from any of these epidemic diseases was registered last 
week in Blackburn. Walthamstow, Leyton, Hornsey, 
Coventry, or King's Norton ; the annual death-rates from 
these diseases in the other towns ranged upwards, how¬ 
ever, to 3 0 in Burnley and in Birkenhead, 3 6 in 
South Shields, 3'7 in Warrington, and 6'4 in Salford. 
The fatal cases of whooping-coogh in the 76 towna. 







Tot Lancet,] 


VITAL STATISTICS.—THE SERVICES. 


[Feb. 15,1908. 51J 


which had been 154 and 190 in the two pre¬ 
ceding weeks, further rose last week to 192 ; they 
caused annual death-rates eqnal to 2'1 in Sheffield, 2'2in 
Birkenhead, 2 '4 in Gateshead, 2 • 5 in Aston Manor and 2 - 9 
in Warrington. The 73 deaths referred to diphtheria showed 
also a further increase upon the numbers in the two pre¬ 
vious weeks, and included 21 in London, three in East 
Ham, four in Birmingham, two in Stockport, three each in 
Liverpool and in Manchester, nine in Salford, and three in 
Leeds. The deaths from measles, which bad declined from 
141 to 83 in the four preceding weeks, further fell last 
week to 71; this disease, however, caused death-rates equal 
to 1 • 3 in Preston, 1 • 4 in South Shields, and 1 ■ 5 in Burnley. 
The fatal cases both of diarrhoea and of scarlet fever showed 
a slight increase ; the annual rate from the latter disease was 
equal to 1 - 5 in Smethwick and 1 ■ 6 in Walsall. The deaths from 
“ fever ” were again below the average, but included six in 
Liverpool and three in Salford. The number of scarlet fever 
patients under treatment in the Metropolitan Asylums and 
London Fever Hospitals, which had steadily declined in the 
nine preceding weeks from 5581 to 3918, had further fallen 
to 3867 on Feb. 8th; during the week ending on that day 
433 new cases were, however, admitted to these hospitals, 
against 380 and 405 in the two previous weeks. The deaths 
in London referred to pneumonia and other diseases of the 
respiratory organs, which had been 499, 465, and 432 in the 
three preceding weeks, further declined during the week 
under notice to 395, but exceeded by 27 the corrected aver¬ 
age number in the corresponding week of the five years 
1903-07. The causes of 51, or 0'9 per cent., of the 
deaths registered in the 76 towns last week were 
not certified either by a registered medical practi¬ 
tioner or by a coroner. All the causes of death were 
duly certified in Leeds, Bristol, West Ham, Bradford, 
Newcastle-on-Tyne, Nottingham, and in 46 Bmaller towns. 
Seven uncertified causes of death were, however, registered 
last week in Liverpool and five each in Birmingham, 
Sheffield, and Manchester. 


HEALTH OF SCOTCH TOWNS. 

The annual rate of mortality in eight of the principal 
Scotch towns, which had been equal to 22-2 and 22 ■ 3 
per 1000 in the two preceding weeks, further rose to 23'5 in 
the week ending Feb. 8th, and exceeded by no less than 5 - 2 
the mean rate during the same week in the 76 English 
towns. Among the eight Scotch towns the death-rates ranged 
from 16'3 and 21-4 in Perth and Aberdeen to 25-4 
in Dundee and 31 4 in Leith. The 827 deaths in 
these eight towns exceeded by 42 the number returned 
in the previous week, and included 132 which were referred 
to the principal epidemic diseases, against 158, 142, and 
123 in the three preceding weeks ; of these, 64 resulted 
from measles, 32 from whooping-cough, 14 from diarrhoea, 
12 from " fever,” five from diphtheria, three from scarlet 
fever, and two from small-pox. These 132 deaths were 
equal to an annual rate of 3 7 per 1000, which exceeded 
by no less than 2 • 3 the mean rate last week from the 
same diseases in the 76 English towns. The 64 fatal 
cases of measles corresponded with the number in the 
previous week, and included 55 in Glasgow, three in 

Greenock, and two in Dundee. The 32 deaths from 

whooping-cough exceeded the number in the previous 
week by six ; nine occurred in Glasgow, eight in 

Edinburgh, six in Leith, and three in Dundee. Of 

the 14 deaths attributed to diarrhoea, seven were re¬ 
turned in Glasgow, three in Dundee, hnd two in Aber¬ 
deen. Of the 12 deaths referred to “fever,” seven were 
certified as cerebro-spinal meningitis and five as enteric 
fever ; these 12 deaths included seven in Glasgow and four 
in Dundee Tnree of the five fatal cases of diphtheria and 
two of the three of scarlet fever were returned in Glasgow. 
Both of the fatal cases of small-pox occurred in Leith. The 
deaths referred to diseases of the respiratory organs in 
these eight towns, which had been 178 and 179 in the 
two preceding weeks, declined to 171 in the week under 
notice, and were seven below the number from the same 
diseases in the corresponding week of last year. The 
causes of 22, or 2'7 per cent., of the deaths in these 
towns last week were not certified or not stated; in the 
76 English towns the proportion of these uncertified deaths 
last week did not exceed 0 9 per cent. 

HEALTH OF DUBLIN. 

The annual rate of mortality in Dnblin, which had been 


equal to 31-2, 29 5, and 26'5 per 1000 in the three pre¬ 
ceding weeks, further declined to 22 • 3 in the week ending 
Feb. 8th. Daring the first six weeks of the current quarter 
the death-rate in the city averaged, however, 26 • 7 per 1000, 
whereas the mean rate during the same period did not 
exceed 18'0 in London and 19 • 5 in Edinburgh. The 169 
deaths of Dublin residents registered last week showed a 
further decline of 24 from the high numbers in recent weeks, 
and included but four which were referred to the principal 
epidemic diseases, against nine and six in the two preceding 
weeks; these four deaths included two from ‘ 1 fever ’ ’ and one 
each from measles and whooping-cough, no death being 
registered either from scarlet fever, diphtheria, small-pox, or 
diarrhoea. These four deaths from epidemic diseases were 
equal to an annual rate of O'5 per 1000, the death-rate 
from the same diseases last week being 1 ■ 3 in London 
and 1 * 5 in Edinburgh. The 169 deaths from all causes in 
the city last week included 19 of infants under one year 
of age and 70 of persons aged upwards of 60 years; the 
deaths of infants showed a marked decline, but those of 
elderly persons were again exceptionally numerous. Six 
inquest cases and four deaths from violence were registered 
during the week, and 64, or 38'0 per cent., of the deaths 
occurred in public institutions. The causes of five, or 3 - 0 
per cent., of the deaths in the city last week were not 
certified ; in London the causes of all but three of the 
1629 deaths were duly certified, while in Edinburgh the 
proportion of uncertified deaths was 2 • 7 per cent. 


THE SERVICES. 


Royal Navy Medical Service. 

The following appointments are notified :—Fleet-Surgeon 
R. Miller to the President for Deptford Yard. 

Army Medical Service. 

Colonel John F. Williamson, C.B., C.M.G., is placed on 
retired pay (dated Feb. 6th, 1908). 

Royal Army Medical Corps. 

The undermentioned Captains to be Majors (dated 
Jan. 29tb, 1908):—Anthony H. Waring, William A. Ward, 
Edward W. W. Cochrane, Arthur H. Morris, Samuel A. 
Archer, and Robert W. Clements. 

Captain John I. W. Morris retires, receiving a gratuity 
(dated Feb. 8th, 1908). 

Lieutenant Charles P. Thomson is seconded for service 
with the Egyptian Government (dated Jan. 1st, 1908). 

Major F. G. Faichnie has taken up duty in the London 
District and Lieutenant G. De la Cour has left for India. 
Lieutenant-Colonel W. G. Birrell has embarked for 
Mauritius. 

The undermentioned Lieutenants are confirmed in that 
rank:—Winfrid K. Beaman, George F. Dawson, Thomas 
McC. Phillips, Harry V. B. Byatt, Harold S. Dickson, Gerald 
Petit, Forbes J. Stuart, John B. Hanafin, Harold Gibson, 
William R. O’Farrell, John A. Renshaw, Ralph de V. King, 
Cecil T. Conyngham, Dalziel B. McGrigor, Richard G. 8. 
Gregg, William A. Spong, Herbert W. Carson, Henry P. 
Hart, Francis T. Dowling, Richard F. O’T. Dickinson, 
Harold T. Treves, Arthur E. B. JoneB, Benjamin A. Odium, 
and Alexander Hendry. 

Royal Army Medical College. 

Colonel Douglas Wardrop to be Commandant and Director 
of Studies, vice Lieutenant-Colonel H. E. R. James, 
R.A.M.C. (dated Feb. 4th, 1908). 

Army Medical Reserve of Officers. 

Surgeon-Captain Charles G. Maclagan to be Surgeon- 
Major (dated Jan. 29th, 1908). 

Volunteer Corps. 

Rifle : 7th Volunteer Battalion, The Royal Soots (Lothian 
Regiment) : Supernumerary Surgeon-Lieutenant-Colonel 
J. B. Ronaldson (Brigade 8urgeon-Lieutenant-Colonel, 
Senior Medical Officer, 2nd Lothian Volunteer Infantry 
Brigade) is granted the honorary rank of Surgeon-Colonel, 
(dated Jan. 20th, 1908). 5th (Glasgow Highland) Volunteer 
Battalion, The Highland Light Infantry; Surgeon-Lieu¬ 
tenant-Colonel and Honorary Surgeon-Colonel Q. Chalmers 
resigns his commission, with permission to retain his rank 
and to wear the prescribed uniform (dated Jan. 21st, 1908). 



520 The Lancet,] HOSPITAL ALMONERS.—PLEURAL EFFUSION AND ITS TREATMENT. [Feb. 15, 1906. 


Territorial Force. 

In a printed reply circulated with Parliamentary papers on 
Feb. 7th, Mr. Haldane has informed Mr. Crooks that, as has 
already been announced in The Lancet of Dec. 14th, 1907, 
p. 1718, it is proposed to appoint Surgeon-Lieutenant Colonel 
(Hon. Surgeon-Colonel) P. B. Giles one of the medical 
officers of the 1st Herefordshire Rifle Volunteers, to the 
office of principal medical officer of one of the London 
divisions of the Territorial Force. He is (adds Mr. Haldane) 
commandant of the Volunteer Ambulance School in London, 
an institution which has been most successful in training a 
large proportion of the Volunteer medical officers. He resides 
near London. Seniority was not the determining factor in 
select in? oflicers for the appointments, but those officers best 
fitted to carry out the work were chosen, seniority being 
given its due weight. 

Deaths in the Services. 

Inspector-General of Hospitals and Fleets Sir John Denis 
Macdonald, KCB, F.R S., R.N., on Feb. 7tb, at Southall, 
aged 82 years. He entered the service as surgeon in 1849, 
was promoted to staff-surgeon in 1859, to fleet surgeon in 
1866, to deputy-inspector-general in 1875, to inspector- 
General in 1880, and retired sir years later. 

Surgeon-General William Henry Rean, Indian Army 
(retired), on Feb. 6th, aged 81 years. He entered the East 
India Company's service in 1853, and in 1857 served with the 
Madras Fusiliers in the attempted relief of Cawnpore. After 
the massacre he was appointed chief medical officer in 
charge of the standing hospital at Cawnpore, where he con¬ 
tracted cholera. After serving as deputy-surgeon-general 
at Kampti he retired in 1881. 

The Timet states that about 100 boys belonging to the 
training ship Impregnable at Devonport are in hospital, the 
majority suffering from influenza which is very prevalent 
throughout the port. 

A Royal Naval hospital is to be opened at Queensferry 
with a staff of one fleet-surgeon or staff-surgeon, one 
surgeon, one chief sick-berth steward, and two sick-berth 
attendants. 


Comspitknn. 


" Audi alteram partem.” 

HOSPITAL ALMONERS. 

To the Editor of The Lancet. 

Sir,—I n view of the letters of appeal from general prac¬ 
titioners and others that appear constantly in the daily 
papers against the deplorable abuse of the out-patients’ de¬ 
partments of our London and provincial hospitals, I venture 
to call the attention of your readers to a system which is 
slowly but surely gaining ground among the hospitals of this 
vast metropolis. The fact that the out-patients' departments 
are not only centres of startling abuse but also the means of 
pauperising a large proportion of the working classes has 
been brought before the public from time to time for the last 
30 years. 

About 12 years ago the Royal Free Hospital, recognising 
the responsibility incurred in this respect, created the post of 
almoner. A lady, duly qualified by experience and know¬ 
ledge and being intimately acquainted with the mode of 
living and ways of thought obtaining amongst our poorer 
classes, was appointed to the post. Her duties were : 1. To 
interview all new patients to the hospital after such patients 
had been seen by a member of the staff and to investigate 
thoroughly each case by means of outside visitors and 
societies. 2. To report to the authorities all cases which 
were not suitable for free medical treatment. 3. To provide 
from the funds of the Hospital Samaritan Fund, in coopera¬ 
tion with outside charities, all surgical instruments, con¬ 
valescence, Ac., recommended by the medical staff except in 
such cases where the patients or their family were able to 
provide such instruments and treatment themselves. 4. To 
ensure that the home conditions of the patients should, so 
far as possible, be suitable, and that the directions of the 
physicians or surgeons as to diet, fresh air, exercise, or rest 
should be carried out. 

It was not long before the system I have briefly sketched 
recommended itself to the authorities of other hospitals and 
after two or three years Westminster and St. George’s 


Hospitals created similar posts and to-day there are no 
lees than nine well-known hospitals where almoners are 
working. The system leads to economy both in the time of 
the staff and the expenses of the hospital and its satis¬ 
factory results may be attested by the fact that no hospital 
that has appointed an almoner hat ever teen reason to recall 
its decision. The system must of necessity appeal to any 
hospital with a medical school in that it protects the 
interests of the general practitioners who have been, or are 
being, tra'ned within its walls. As no patient is dismissed 
without the consent of the physician or surgeon who has 
examined the patient it will be easily seen that the interests 
of the medical school as to clinical material are guarded. 

The daily letters of thanks and approval from outside 
doctors show that the general practitioners realise that a 
very potent method has at last been set on foot to safeguard 
their interests. The work of an almoner is both difficult and 
arduous and calls for a very special training and careful 
selection of candidates. A hospital almoners' council has 
lately been formed for the purpose of arranging the training 
and selection of almoners and for providing suitable candi¬ 
dates for London and the provinces. 

It is in the hope that this letter may explain briefly the 
work of an almoner and thereby prove that the out-patients' 
departments need no longer be a cause of apprehension to the 
outside doctors or a centre of pauperisation and abuse that 
I have ventured to encroach upon your valuable space. May 
I add that 1 shall be pleased to give any further information 
on the subject either by letter or by appointment to any of 
your readers who may be interested in the question. 

I am, Sir, yours faithfully, 

A. S. Morse, Oapt. and Sec. 

Hospital Almoners’ Council, Denison House, V&uxh&U 
Bridge road, S.W., Feb. 11th. 1908. 


PLEURAL EFFUSION AND ITS 
TREATMENT. 

Jo the Editor of The Lancet. 

Sin,—Dr. Harry Campbell tries, but in vain, to make the 
worse appear the better cause, and I should think he would 
make a very obstinate juryman whom the other 11 might have 
some difficulty in convincing. 1 can therefore scarcely hope to 
convert him from the error of his ways, so I shall not trouble 
much about this lost sheep, but I shall try and show the 
ninety and nine, who have not gone astray, the utter worth¬ 
lessness of his facile pen. 1 shall now analyse his letter 
paragraph by paragraph. 

Firtt .—His little pleasantries do not trouble me mnch and 
do not cover his retrtst from an untenable position in citing 
a condition which d >es not exist. He knows as well 
as I do that Dr. Harry Campbell U not the man to 
make “concessions for the purpose of humouring Sir 
James Barr,” or anyone else. There is a very considerable 
difference between an adherent and a non adherent plenra 
which cannot be glossed over bv sayiDg that "they did not 
affect one way or the other the main issue between us.” The 
elasticity and tautness of the long aie thus readily affected, 
and I cannot allow Dr. Campbell to shift his position at 
his own convenience without exposing his retreat to my 
merciless flank fire. In my first letter I agreed that the 
elasticity and tautness of a substance are two qnite different 
things, but the continuous tautness of the lungs depends 
on their elasticity and the pressure of air within them. I 
say so still. 

Second —In the first 12 lines he gives his whole show away 
and practically accepts my contention, bnt his illustrations 
are not very happy. “It is not the elasticity of the traces 
attached to a wagon which causes the wagon to be 
pulled along.” Neither is it the tantnesi of the traces, nor 
the tantnest of the lungs which exerts the traction, but the 
force that causes and maintains the tautneu. If the stress 
or force applied to a series of loosely connected wagons be 
intermittent they bmlap against one another, but if they be 
braced up and have an elastic connexion through their buffers 
all this bumpingdisappears. The elastic lungs are held against 
the thoracic parietes by the atmospheric pressure within 
the lungs, a pressure amounting to about 760 millimetres of 
mercury, less, under ordinary circumstances, a few millimetres 
of mercury due to the elasticity of the lungs and the varia¬ 
tions in the intrapulmonary pressure during the different 
phases of respiration. The greatest possible fall in the intra- 
pnlmonary pressure, as in Muller's experiment, could not 


The Lancet,] 


PLEURAL EFFUSION AND ITS TREATMENT. 


[Feb. 15, 1908. 521 


materially affect their pressure against the internal surface 
of the thoracic parietes, but if the lungs were not elastic and 
free to move with the thoracic parietes even this great 
pressure could not keep the lungs taut and there could 
be no intrapleural negative pressure. We are there¬ 
fore forcibly driven to the conclusion that at least healthy 
lungs can only be kept taut by their elasticity. If the 
lungs were non-elastic and braced up from root to 
parietes, then each time the intrapulmonary pressure 
exceeded the extrathoracic atmospheric pressure the lungs 
would cease to be taut, and this would occur with every 
expiration. In this case the lungs would be taut at the end 
of inspiration and during this fractional part of a second 
would render respiratory assistance to the circulation, but 
during the rest of the respiratory phase there would be a 
positive obstruction to the circulation. With an intermittent 
tension or stress the tautness of the lungs can only be con¬ 
tinuously maintained if they be elastic. 

Third. — He falls foul of his quondam friend, Dr. D. W. 
Samways, for failing to recognise his nice distinction between 
the tautness of the lungs and the elasticity which keeps them 
taut. “ Let us for argument’s sake suppose the lungs in the 
case in question suddenly to be rendered perfectly non¬ 
elastic, their tautne6s, however, remaining unaltered.’’ He 
really upsets my gravity, and I would suggest to him that a 
much neater way of putting it would be, suppose we suppose 
an impossibility. If a stretched piece of rubber suddenly 
lost its elasticity, would it remain taut ? I trow not. I have 
often seen rubber lose its elasticity but I have never after¬ 
wards seen it remain taut. With a constant weight attached 
to a piece of fibroid tissue it might remain tense, but with an 
intermittent stress such as occurs in respiration it could 
not continue taut. 

Fourth —He refers to the experiments of Valsalva and 
Muller which, I think, were much more fully explained in 
my paper on the Effects of Respiration on the Oirculation in 
the British Medical Journal, April 20th, 1907. In his state¬ 
ment of the Valsalva experiment there is nothing new but in 
Muller’s experiment he says what is not true: “If at the 
end of a deep expiration, when the pulmonary tissue is 
relaxed and the lungs cease to exercise traction, a powerful 
inspiratory effort be made with closed glottis, the greatly 
lowered intrapulmonary pressure thus effected will give rise 
to considerable traction." At the end of deep expiration 
the pulmonary tissue is not relaxed and the lungs do not 
cease to exercise traction. In this experiment a big chest, 
like Dr. Campbell’s, might produce a fall in the intra¬ 
pulmonary pressure of 80 millimetres of mercury, which 
would reduce the intrapulmonary pressure from 760 to 680 
millimetres of mercury. The elasticity of the lungs being a 
constant can be neglected, and, moreover, we are not at 
present considering the intrapleural or intrathoracic pressure. 
It is ridiculous to say that 680 millimetres of mercury can 
make the lungs more taut than 760 could. This great fall in 
the intrapulmonary, and consequently in the intrathoracic, 
pressure makes an enormous difference to the blood-vascular 
cavity within and without the thorax, so the blood is driven 
in, not sucked in, with a force of 80 millimetres of mercury 
plus the elasticity of the lungs. It is really painful to me to 
have to point out such palpable errors. 

Fifth .—“Hypertrophous emphysema’’ is a misnomer. 
Hypertrophy means increased nutrition and increased 
function, there is neither in emphysema. “The inspiratory 
muscles are throughout life ever on the watch to maintain 
pulmonary tautness at a certain mean level, with the object 
of maintaining a constant suction on the heart, and thus 
facilitating diastole,” &c. So far as the inspiratory muscles, 
which only act intermittently, are concerned they can only 
maintain tautness at the end of inspiration and apart from 
the elasticity of the lungs can maintain no constant suction. 
David Barry at the beginning of last century did not, and 
could not, fall into such egregious error. It would be a great 
waste of time and space to follow his suppositions about what 
happens, or should happen, in cases of “hypertrophous 
emphysema.” It is sufficient to say that as the elasticity of 
the lungs disappears so the intrapleural and intrathoracic 
negative pressures gradually lessen. 

Sixth .—Now for his fibroid phthisis. “ If the lungs are 
not taut, and if pulmonary traction is not increased, how are 
we to account for the sinking in of the upper part of the 
chest not infrequently met with in chronic phthisis, as well 
as in the more acute form of the disease ? ” Has he never 
Been the chest walls caved in by the atmospheric pressure in 
a child suffering from laryngeal diphtheria 1 This condition 


simply proves that the inspiratory muscles are quite in¬ 
capable of expanding the chest beyond the expansile power 
of the lungs. The infraclavicular spaces may get flattened 
whether there be many adhesions or not. The fibroid apices 
do not drag in the chest walls, but being non-elastic they 
take no part in filling up the thorax during inspiration ; the 
remaining elastic portions increase the negative pressure in 
the whole thorax daring inspiration, and consequently the 
portions of the chest over the non-expansile portions of the 
lungs are flattened in, not dragged in ; in the acute forms of 
the disease there are no adhesions to drag them in. 

Seventh .—This paragraph is entirely made up of supposi¬ 
tions without an attempt to prove any of them. 

Eighth .—There is here and elsewhere a little assump¬ 
tion at not understanding what I mean. I can assure 
him once for all that when I say intrapleural I mean intra¬ 
pleural, intrathoracic I mean intrathoracic, and intra¬ 
pulmonary I mean intrapulmonary, and I am not going to 
assume that there is any one of your readers who does not 
know as well as Dr. Campbell the difference in these 
expressions. The rest of the paragraph is chiefly made up 
of irrelevant remarks about Muller’s and Valsalva’s experi¬ 
ments. The conditions of these experiments are well known. 
I have previously shown that in Valsalva’s experiment the 
intrapulmonary pressure can be raised so high as not only to 
abolish the intrapleural negative pressure but raise the intra¬ 
thoracic pressure to such a positive height as to shut out the 
blood from the chest, reduce the heart to about half its size, 
and almost bring it to a standstill. In this experiment the 
lungs are made very taut under a pressure of about 860 milli¬ 
metres of mercury. What, then, is the use of talking about 
the suction of the chest depending on the tautness of the 
lungs? 

Ninth .—He is driven to very narrow straits when he says : 
“ I neglect to mention bronchiectasis and the enlargement 
of tubercular cavities as a means of filling up enlarged 
chests in cases of fibroid lungs.” Emphysema still remains 
the principal cause. 

Tenth .—Here he entirely begs the question when he says : 
“In so far as the bulbous condition of the fingers in fibroid 
phthisis is due to obstructed circulation it results from the 
widespread destruction of the pulmonary blood vessels.” It 
does not matter how many blood-vessels were destroyed, if 
his taut lungs constantly maintained a negative intrathoracic 
pressure there could be no obstruction to the systemic venous 
circulation and there should be no bulbous fingers. 

Eleventh .—He tries to wriggle out of this close comer by 
saying that 1 refer to “ non-elastic lungs ” and he to 
“comparatively non-elastic lungs.” This is a degree of 
comparison which in no way affects his bubble which I 
pricked. 

Twelfth .—He does me the credit of quoting a very long 
abstract from my letter which is sufficiently explicit and 
which he vainly tries to subvert. Now the inspiratory 
muscles are “just competent to expand the chest to its 
potential maximum, as may be observed in advanced cases 
of hypertrophous emphysema.” In these cases the lungs 
lose their elasticity, consequently they cease to be taut, 
and the intrapleural negative pressure diminishes or dis¬ 
appears. 

Thirteenth— In conclusion he hopes that “the energy 
expended may not be entirely lost on Sir James Barr.” 
Well, it all depends on how yon look at it; personally, I 
think he has wasted a lot of my valuable time over a trivial 
storm in a teapot. The only consolation I have is that I may 
have stimulated some of your readers to study the question 
of elasticity as applied to the lungs, and may have prevented 
them falling into the traps of error set for them by Dr. 
Harry Campbell. Consolation prizes are not, as a rule, very 
valuable, so if he wish my forgiveness he should send me a 
cheque for not less than 100 guineas. 

I must now deal with the letter of Dr. Samways in your 
issue of Jan. 25th. 

Dr. Samways intrudes as an uninvited guest to this feast 
of reason and flow of soul in order to set both Dr. Harry 
Campbell and myBelf right. I am always willing, nay, 
anxious, to learn, but in order that my knowledge may be 
based on a firm foundation I must inquire into the quality 
of the instruction and the capacity of the instructor. As my 
old friend, the late James Finlayson, said about examiners, 
that the first part of their work was to mark themselves up 
100 per cent., and then accordingly, as they thought that the 
examinee approached their ideal standard of perfection they 
gave him anywhere between 80 and 100 per cent., but Dr. 





522 TheLanobt,] 


MINISTRY OK PUBLIC HEALTH. 


[Fra. 15,1908. 


Finlay son wonld like to have bad the examiners examined 
and see if they were really worth 100 per cent. 

I shall now proceed to criticise my critic and see what 
percentage of stress and strain this elasticiam will stand 
before we come to the breaking point. I have no wish to 
snap him abruptly so I shall apply the stress gently. 

He lays down a very rigid definition of elasticity, to which 
I offer no objection, though it is not one to which pro¬ 
fessional physicists closely adhere, as it enables me to see 
what he intends to mean. Of coarse, your readers, like 
myself, expect that having settled the matter according to 
his own ideas, he at least would stick to the definition which 
he has adopted—I say adopted because after all the defini¬ 
tion is not his own. Let us see how Mb definition works out. 
He tells us that solid bodies like steel and ivory are much 
more elastic than even such perfectly elastic bodies as the 
various gases, but he forgets to say that the range of 
elasticity of those highly elastic bodies is very limited; 
if you exceed that extremely narrow limit you fracture or 
rupture or break the body, or yon may give it a 
permanent set, so that it does not return to its original 
form. If you attach a certain weight to a steel wire 
sufficient to stretch it one-twentieth of an inch, then 
double the weight will stretch it one-tenth of an inch, 
but if you go on doubling you quickly exceed the limit 
of its elasticity, and the wire either snaps or takes a 
permanent set and will not return to its original length on 
the removal of the weight—you have exceeded the very 
narrow limit of elasticity in this highly elastic body. If you 
take the blade of a sword made of finely tempered steel you 
will find it much more elastic than the iron or steel from 
which it was made, yet, according to Dr. Samways, I 
presume this should not be, because he says “ elasticity is 
a property fixed in amount for any substance.” Again, if 
you take the sword and convert it into a large tube of the 
same length it again becomes rigid, and if you attempt to 
bend the tube the force required quiokly breaks it. How is 
it that the great range of the sword’s elasticity has practi¬ 
cally disappeared 1 The molecules on the convex Bide of the 
attempted curve would now have a much longer way to move 
than previously, and when sufficient stress is put on to 
move them and manifest their elasticity those on the 
outer curve jump apart beyond the limitB of their 
elasticity and the tube breaks. The same thing happens 
with such a highly elastic body as glass. This is all very 
nice but it does not fit in very well with medical ideas 
of elasticity as found in the human body. According 
to Dr. Samways’ definition the ribs are much more 
elastic than the costal cartilages, the femur much more 
elastic than the ribs, and the more rigid the chest 
walls the more elastic do they become as it takes a greater 
force to produce any given deformation. An unyielding rope 
is more elastic than an extensile one ; it is true that it snaps 
more readily, but what does Dr. Samways care for that when 
it requires more force to produce a given amount of stretch. 
“Rubber yields considerably to a small force and is therefore 
comparatively inelastic. It possesses the quality of 
elasticity to a striking degree but in a low measure,” 
This last sentence is a distinct contradiction of terms; it 
is a misuse of the English language to say that anything that 
possesses a quality in a low measure lias it in a striking or 
high degree. It is not a question of small quantity and 
high tension like the high frequency current, because it is 
just in the tension that the rubber is deficient. 

Having some slight regard for your space I shall not 
diverge into a sidepath to discuss the unconscious cerebra¬ 
tion of Dr. Samways’ cat as she lay curled up and quietly 
asleep on the hearth dreaming of her far-off home, situated 
perhaps south-south-east by south from the hearth, and 
wondering when the potential energy of her limbs would 
become kinetic and enable her to speed her way through 
thick woods and devious paths unaided by a compass ; nor 
shall I soliloquise on the dormant moral qualities of his 
untried gentleman or saint who, unlike an elastic body, 
does not require a double force to resist a double tempta¬ 
tion. There may be some irreverent enough to suggest that 
this gentleman is an imbecile or a general paralytic. I know 
several men who would have no hesitation in writing a cheque 
for a sum much more than sufficient to pay off the National 
Debt; by such the temptation of a five-pound note is easily 
resisted. These may be, and no doubt are, very interesting 
psychological studies, but they have no more to do with 
elasticity than the moon has to do with green cheese. 

When Dr. Samways says that I am “certainly in error” 


he simply means that I do not agree with his definition of 
elasticity, and under the circumstances I am very pleased to 
be in error. “This property of a substance,” to whioh 
according to Dr. Samways you can neither add to nor take 
therefrom, “ is measured quantitatively by the amount of 
force required to produce a given distortion in a given volume 
or unit of the substance.” This is uncommonly like my 
statement, but perhaps not quite so well expressed, that the 
more taut or stretched the lung (of course, within the limits 
of its elasticity) the greater will be its elasticity or tendency 
to recover its form after being stretched. If a force of two 
pounds stretoh a piece of rubber one inch, four pounds will 
stretch it two inches, and it will resist further stretching by 
a force of four pounds, and when the weights are removed it 
will recover its former dimensions by a force gradually taper¬ 
ing down from four pounds to nothing. 

Now listen to what this critic says: “ Its elasticity 
and tendency to recover cannot be measured by stretch¬ 
ing ; it was inherent in it and fixed in quantity from 
the first.” Here he uses “elasticity” as an abstract quantity 
of the substance and he uses “ tendency to recover ” as abso¬ 
lutely synonymous, although I have just shown that it is a 
measureable force equal to the power to which it has been 
submitted. He might as well use potential and kinetic 
energy as synonymous terms, or mass and weight as one 
and the same thing. From experiments on tuning-forks it 
has been found that no matter how slightly or how closely 
the limbs are approached or how far they are separated it 
takes them the name time to recover their original position, 
and therefore it follows that the greater the force used the 
greater must be the tendency to recover. The vibrations of 
the tuning-fork from the greatest excursion down to silence 
all occupy the same time, so that with the diminution in the 


excursion the velocity is also diminished. i 

Here is another example of his way of reasoning: 

“ In this way the negative pressure in the pleural sacs 
is created by muscular effort and not by elastic recoil of the 
lungs.” He forgets that if the lungs were non-elastic and 
non-resistant but free to follow the movements of the chest- 
walls there would be no negative pressure in the pleural 
cavities. This is what practically happens in emphysema ( 

where the lungs have lost their elasticity and gradually 
expand until at last even the recoil of the chest walls is lost. 

“It would be even greater, as Dr. Campbell contends, if 

the lungs did not expand.” In this case the inspiratory i 


muscles would have to pull out unaided the thoracic wallB 
against the atmospheric pressure, and this I believe they 
cannot do. “ If the lungs be comparatively rigid the whole 
force of the inspiratory muscles can be expended on reducing 
the intrapleural pressure.” For how long? The fractional 
part of a second ; under such circumstances the lungs could 
only be taut at the end of inspiration, and relaxed during the 
rest of the respiratory phase. “One would have imagined 
that the elastic tissue would have arranged to be at rest when 
the thorax was at rest, but it strangely chooses, from birth 
onwards, never to assume the unstretched condition.” Well, 
nature does not seem to have taught him much when he 
cannot see such obvious utility, and all I feel inclined to say 
is, thank God there was no amateur physioist present at the 
Creation. 

If you allow this discussion to go on for about a couple of 
years I think we might settle the meaning of elasticity , if 
some new definition does not crop up in the meantime. Then 
I shall leave the rest of the English language to Dr. Campbell 
and Dr. Samways to settle, but I would take the liberty of 
suggesting to them that they might start with the distinc¬ 
tions between tweedledum and tweedledee which would serve 
as much practical utility as their contributions to elasticity. 

I am, Sir, yours faithfully, 

Liverpool, Feb. 8th, 1908. JAMES BARR. 


MINISTKY OF PUBLIC HEALTH. 

To the Editor of The Lancet. 

Sir, —The article in the current number of The Lancet on 
a Ministry of Public Health emphasises the crux of the pro¬ 
position. It is quite a necessity that such a Minister should, 
in general terms, have greater powers for public health than 
at present exist, and equally so his influence be real with 
the Treasury. This is clearly recognised by myself and 
others in this country who take an active interest in the 
matter, such as Sir T. Clifford Allbutt. It is shown in 
articles dealing with the subject since 1902, in which it is 



The Lancet,] 


THE QUESTION OF HOODS. 


[Feb. IS, 1908. 523 


reasoned that such a Minister should have Cabinet rank and, 
if possible, have had an expert training. 1 

Burgeon-General Fulton writes that thi6 question, which I 
propose to bring before the Congress on Tuberculosis at 
Washington, is engaging the attention of the American 
Public Health Association, which has appointed a standing 
committee, representing the United States, Canada, and 
Mexico, to promote such departments. Its next meeting 
will be at Winnipeg in the summer. That the various bodies 
in this country interested in public health will follow this 
lead I feel certain, and there is no time like the present for 
tbeir action. I am, Sir, yours faithfully, 

Brighton, Feb. 8th. 1908. • F. G. BlTSHNELL. 


THE QUESTION OF HOODS. 

To the Editor of Tub Lancet. 

Str,—I noticed in the report of the quarterly meeting of 
the Council of the Royal College of SurgeonB of England that 
the Council refused to accede to the fifth request of the meet¬ 
ing of Fellows and Members—viz., "That a hood should be 
added to the gown already worn by Fellows and Members." 
I consider the excuses very lame. 

Firstly, " as the hood was generally understood to be dis¬ 
tinctive of a degree, and in this sense it formed part of the 
academic costume of a university, it was considered that 
it would not be appropriate for a college.'' The College of 
Preceptors grants hoods to its Fellows and Licentiates ; 
King’s College, London, grants a hood to its Associates 
(A.K C.) ; the College of Organists grants a hood to its 
Fellows ; and all theological colleget grant hoods to their 
Licentiates who are not graduates of a university (vide 
‘‘Whitaker’s Almanack ”). 

Secondly, “ as hoods did not appear to be in general use 
among colleges of similar standing to the Royal College of 
Surgeons of England.” The Council forgets that it was the 
Jiret to gTant a cap and gown to its Fellows and Members 
and was followed by the Royal Colleges of Surgeons of 
Ireland and Edinburgh and the Society of Apothecaries. 
So as the Council of the Royal College of Surgeons of England 
was the leader in the gown, so it should be in the hood. 

I would suggest that the hoods be : for Fellows, the same 
shape as a Cambridge M.A. but made of crimson satin 
lined black ; for Members, the same shape but made of 
black stuff lined with crimson Batin. 

1 am, Sir, yonrs faithfully. 

Fob. 7th, 1908. _ J. M. CARYELL. 


To the Editor of THE LANCET. 

SiR,—The present Council of the Royal College of 
Surgeons has thought fit to reject the resolution of the 
annual general meeting of Fellows and Members to grant 
a hood to its alumni. No credit can attach to it for 
the temporary delay of this obvious and advantageous 
adjustment, and especially as it only bases the objection 
to it on the want of precedence. Graduates of the Royal 
College of Surgeons have quite as much right to claim, aud 
have often shown, their equality of attainments to those 
of many of the arts and professional degree holders, and 
with them equally to lay claim to possess the distinction of 
a hood. 

Although the medical colleges in London have not yet 
taken np teaching, they, as of old tradition, belong to a 
university standard, and which has been almost always an 
antecedent in the history of the part formation of all 
universities. They belonged to a heightened status, and, 
provisionally, on a level with a university. From that 
position the Newcastle College of Medicine, the old College 
of Physicians before the decadence, the Liverpool University 
College, Owens College, Firth College, and other Midland 
colleges have all been on a sufficient equality and superiority 
to bestow the right, or ad eundem right, to grant hoods to 
their diploma or degree holders. So, although we do not so 
foolishly set such store as the lawyers do on perpetual 
precedence, still there undoubtedly is precedence for this 
reasonable accomplishment of possetsing a hood by the Royal 
College of Surgeons, and in spite of whatever the Council 
chooses to say against me. 

When supporting my resolution for a hood at the annual 
meeting, I spoke on what I thought was the origin of the 


1 See The Evolution of our Sanitary Institutions: a Flea for a 
Minister of Public Ilealth, 1907, to be obtained from tile Sanitarv 
Publishing Co., 5, Fetter-lane, Loudon, E.C. J 


hood. I think masters or teachers were the first ones to wear 
them, as early as the middle ages, in colleges as well as in 
universities. Barely, then, the old surgeons were exactly in 
that Bame position. For they, even more than the physicians 
or the university men, were called upon as masters and 
teachers to fully instruct professionally tbeir students and 
their apprentices. But these masters of tbeir craft on being 
formed into a college aimed at, and took, by their con¬ 
stitution, a much higher position still. Likewise when the 
physicians formed themselves into the self-same higher 
collegiate position, they all wore hoods. Indeed, Charles II.'s 
mandate cf 1674, and onwards, foroed upon the members the 
university grade, and which thus constituted the collegiate 
position. So the pronouncement of the present Council of 
the Royal College of Surgeons cannot rest justly on Us 
negative argument. 

The surgeons, as separate from the ancient illegitimate 
practitioners, had always been at the head of the profession, 
above the grocers, above the apothecaries, above the harbour- 
surgeons, and above any of the universities in their own art 
and craft, though for convenience they have joined one or 
other of those bodies. Thus, from a business point of view, 
it is ill grace enough for the Council to indulge what seems a 
perpetual neglect discriminately against the body of the 
College; whilst benefits and privileges keep on accruing 
more and more to outside opponent bodies, and very mach 
to the detriment of its members. That is why I have 
traversed its s’atements, and wi-h it to acquiesce in the 
general needs of the situation. For it must be apparent 
if it acoepted fresh control, by both Fellows and Members 
together, there would be an end to any of the antiquated sub¬ 
servience amongst such an educated body of members where 
they remain unable to ratify tbeir own resolutions. Referenoe 
has been made above to the collegiate status of the physicians 
which justified the equivalent usage with the university of the 
hood. The only other medical body in London to search for 
any corresponding trace of conformity would be the Society 
of Apothecaries. And. by Mr. C. H. B. Barrett, it is 
recorded, in 1698. that the Livery of the Apothecaries, when 
the King (William III.) made a public procession, were in 
tbeir allotted place, and they wore both gowns and hoods. 

Again, quite outside the amply sufficient medical refer¬ 
ences, there do happen to be confirmatory precedents for 
granting a hood. Of oourse, the Royal College and Academy 
of Music are merely scholastic or training institutions and 
having certificates, and on that account they purposely 
remained unmentioned in my speech. But, besides music 
guilds containing graduates, both the College of Preceptors 
aud the Royal College of Organists have attempted, in 
London, to satisfy the university standards as colleges by 
giving a higher grade of diploma when such colleges have 
existed without a practical university. These bodies were 
consequently specially singled out by me and mentioned as 
precedents. And I have tbeir regulations actually by me and 
where they certainly do grant hoods. So, except for the 
consummate ease of criticism and opposition which is 
unworthy of attack, I hold that the Council of the Royal 
College of Surgeons had no justification whatever to issne 
its inappropriate dementi. At the time of the meeting, as 
now, I wished to suggest an improvement of the present 
incomplete academic dress of the College. If there are to be 
academicals at all they should have a hood attached, and not, 
as without the hood, liable to be mistaken by the public for 
the cloth garment of a verger or even that of the under¬ 
graduate status.—I am, Sir, yours faithfully. 

Boguur, Feb. 8th, 1908. H. ELUOT-BlAKB. 


REMOVAL OF AN OPEN SAFETY-PIN 
FROM THE (ESOPHAGUS OF AN 
INFANT. 

To the Editor of The Lancet. 

Snt,—Dr. D. R. Paterson's case and comments in your issue 
of Feb. 1st are interesting and instructive. Certainly the most 
rational plan in removing foreign bodies from the food- and 
air-passages is that which removes them through the month 
by a skilful grasp and help from the eye. This plan, how¬ 
ever, except in the most simple cases, must, in the nature of 
ordinary practice, be confined to specialists I was interested 
in Dr. Paterson’s article in the Eritish Medical Journal on 
cesophagoscopy, but did not practise it. there being no 
instruments available. I shall, however, take his advice and 
attempt the experiment at the first opportunity. I am 




524 ThbLanOET,] THE MEDICAL INSPECTION OF SCHOOL CHILDREN.—LIVERPOOL. 


[FBI!. 15 , 1908 . 


doubtful, however, whether the most skilful oesophagoscopist 
would have had success in the case quoted owing to the 
infant's size and age, but it is comforting to know that if he 
fails intestinal peristalsis with the patient in the recumbent 
posture may successfully remove the offending body without 
having recourse to a cutting operation. 

I am, Sir, yours faithfully, 

Oldham, Feb. 2nd, 1908. J. S. MANSON. 


IS THE DEATH-RATE THE BEST MEASURE 
OF SEVERITY IN DISEASE ? 

To the Editor of The Lancet. 

Sib,—M ay I ask you to insert the following correction in 
my article published in your last number under the above 
title? In Table II. the grand total Bhould be 1823 '8, not 
183 • 8. I am, Sir, yours faithfully, 

New Cross-road, S.E., Fob. 11th, 1908. F. M. TURNER. 


THE MEDICAL INSPECTION OF SCHOOL 
CHILDREN. 

To the Editor of The lancet. 

Sir,—T he Memorandum of the Education Board on the 
Medical Inspection of School Children recommends that it 
shall be carried out “ under the direct supervision of the 
medical officer of health,” and goes on to say that “some 
authorities will find that the teachers are able to under¬ 
take without undue strain a share of the work of 
furnishing data respecting each child and even perhaps to 
carry out some portion of the inspection.” As a matter 
of fact, the teachers, with the aid of a school nurse, could 
carry out the whole inspection after a fashion; the teacher 
could fill in the names, ages, addresses, heights, and 
weights of the children, and could test their sight and 
hearing ; the nurse could inspect their skins, teeth, and 
throats. Finally, to the children found defective the head 
master or mistress could give cards advising their parents to 
take the child to an oculist, dentist, aurist, or, if it is 
thought be could be trusted, to an ordinary doctor. 

But the Memorandum does not stop at inspection, but goes 
on to say that school nurses are “ to assist in carrying out 
medical advice concerning simple complaints ” ; similarly 
the medical officer (education) of the London County Council 
tells us in his report that "it is quite absurd to say a purse 
cannot recognise ringworm.” It is ; a nurse can do any¬ 
thing she is trained to ; woman doctors recognise and treat 
all diseases, and what makes the woman doctor is not the 
degree but the training before and after graduation. Nurses 
could therefore treat cases under the supervision of the 
medical officer of health. That they should do so is, I sub¬ 
mit, absolutely wrong ; it is as if in a hospital the surgeons 
and house surgeons were abolished and the surgical cases 
treated by the nurses under the supervision of the sanitary 
engineer. Local authorities themselves do not seem quite to 
approve of nurse treatment and are beginning to appoint 
junior members of the profession to hold office for a year or 
two as assistants to the medical officer of health, primarily 
to inspect school children, but also to discharge any other 
duty their chief may delegate to them. But this, too, is 
wrong ; the treatment of disease is not a minor matter, one 
to be safely left to medical underlings and “suitable 
persons ”; the treatment doctor must remain the equal of 
the more recently invented preventive dootor. To separate 
simple ailments from complex is impossible; the man who 
never sees a simple case will not understand a complex one ; 
the profession cannot survive the confiscation of Its 
experience. 

Whether or not there should be State treatment is a matter 
on which opinions will differ; it will be decided not by us 
but by education authorities ; we, however, can share in the 
decision by our votes and by becoming members of local 
councils and of health and education committees. If State 
treatment is to come it must be properly carried out; there 
will probably be no question between whole- and part-time 
appointments, for there will be no work left for doctors to do 
in their own time ; private practitioners may read their fate 
in that of private teachers; voluntary hospitals in that of 
voluntary schools. 

I am much obliged to “ A Lawyer ” for his answers 
to my former questions. 1 If his kindness is not ex- 


1 The Lijici't, Jan. 4th, 1908, p. 51. 


hausted I should like to ask one more. If a medical 
officer of health supervises the treatment of simple ailments 
by a school nurse is he liable to actions for malpraxis ; and 
can the General Medical Council remove his name from the 
Register for covering ? If this is done can he continue to 
hold his office? I am, Sir,yours faithfully, 

Feb. 8th, 1908. J. S. 

THE DESTINY OF CASE-BOOKS. 

To the Editor of The Lancet. 

Sir, —I had an experience quite as unpleasant as that 
related by your correspondent “M.R.C.S.” concerning the 
destiny of case-books. Some years ago I consulted a West- 
End specialist. I knew him pretty well and he Bhowed me 
his case-book then in use, and for my comfort explained that 
it was written in a shorthand invented by himself. A few 
months later this physician died and I received an envelope 
which contained a letter from his widow stating that she bad 
disposed of the practice to Dr. X. There was another letter 
from Dr. X explaining that he had purchased the practice 
and had all the case-books of the deceased consultant. 
Remembering that the case-books were in cypher I hoped 
they would be useless; their proper destination was certainly 
the fire. The first doctor was a gy n m lologist. 

I am, Sir, yours faithfully, 

Feb. 8th, 1908._DoMINA. 


LIVERPOOL. 

(From our own Correspondent.) 


Liverpool Royal Infirmary: Annual Meeting; The 
Position of the Abattoirs. 

The annual meeting of the subscribers to the Royal 
Infirmary was held on Jan. 29th. Allusion was made by the 
treasurer in flattering terms to the retirement of Mr. Rushton 
Parker from the active staff. Mr. Parker had had a con¬ 
nexion of 30 years with the Royal Infirmary. For 12 years 
as assistant surgeon and 18 years as honorary surgeon he 
concentrated his care and attention on the hospital to which 
he unsparingly devoted his best ability and time. Beds 
had been endowed during the year by Miss A. W. Hignett, 
Mr. James Lister, and Mr. Bruce Ismay in memory 
of their parents. The contribution from the Hospital 
Sunday and Saturday Funds had been £3378. Legacies, 
always a varying source of income, amounted to £1246. The 
total expenditure was £16,208 and the ordinary income was 
£14,034. On balance, £2600 having been transferred from 
the long-lived but now nearly exhausted maintenance fund, 
the charity was still in debt to the amount of £2335, and 
the convalescent fund was in debt to the extent of £164. 
3875 patients had been treated in the wards, 20,434 as out¬ 
patients, and for redressing of wounds, &c., 52,082 had 
attended. The Lord Mayor (Dr. Richard Caton), in proposing 
the adoption of the report and accounts, said that he trusted 
that such charities as the Royal Infirmary would not, as some 
people thought, be placed upon the rates. The present method 
of hospital governance was infinitely better than anything 
that could take its place in the form of Skate-aided hospitals. 
He trusted that they would do everything in their power to 
carry on that and other hospitals on their present basis. He 
regretted to find that the committee was in debt as regarded 
the convalescent fund, as that was such an important matter 
which led to the relief of their bed accommodation. Mr. 
T. H. Bickerton alluded to the question of the possibility of 
the renewal of the lease of the abattoirs in their present 
position near the infirmary. He expressed the hope that 
the corporation would not on any account consent to 
the renewal of the lease. The Liverpool Medical In¬ 
stitution had prepared a resolution to which some 200 
to 250 medical men had attached their signatures, which 
would be sent to the Lord Mayor for presentation to the 
city council. He hoped that the city would confirm the 
opinion of the medical profession that abattoirs should not be 
allowed to remain in densely populated centres. Mr. G. G. 
Hamilton said that his operating theatre in the infirmary 
was only at a Bhort distance from the abattoirs, and he 
joined in the hope that the lease would not be renewed. 
Several times he bad had to stop surgical operations to get 
rid of flies which were now recognised as such a medium for 
spreading disease. If it were proved that the flies had a 




The Lancet,] 


WALKS AND WESTERN COUNTIES NOTES.—SCOTLAND. 


[Feb. 15, 1908. 525 


breeding-place near the abattoirs it was a very serious thing 
to consider whether the abattoirs should be allowed to exist 
in their present situation. 

The Preservation of Infant Life. 

The large number of inquests held in a year by the city 
coroner on children fatally burned has stimulated interest in 
the preservation of infant life in the city. The matter waB 
brought before the health committee at its recent meeting by 
Mr. W. B. Stoddart, one of the city councillors (the well- 
known Cambridge cricketer). In response to the repre¬ 
sentations made by Mr. Stoddart for the better care of 
the children generous aid has been offered to the infant life 
preservation sub-committee of the health committee by two 
ladies—Mrs. Clayton of Wavertree and Miss Gladys C. 
Whitley of Sefton Park. The former has promised £200 and 
the latter £50 for the purpose of purchasing fire-guards for 
distribution amongst the poorest classes. The gifts were 
thankfully accepted by the health committee. 

Death-rate of Liverpool. 

Owing to the ravages of influenza and the rate of mortality 
among aged people the death-rate of the city for the past 
week was 33 7 per 1000, compared with 19 8 a year ago. 
The medical officer of health informed the health committee 
on Jan. 30th that the present outbreak of influenza was the 
most severe since 1895. 

Medical Appointments at Birhenhead. 

Dr. R. Owen Morris has been appointed medical officer of 
council schools and Mr. R. S. Marsden (medical officer of 
health of the borough) has been appointed superintendent 
medical officer of schools. 

Toxteth Park Vaccination Statistics. 

The vaccination officer of the Toxteth board of guardians 
has presented the board with the vaccination statistics for the 
year 1906 There were in the township 4140 births ; 3142 of the 
infants were successfully vaccinated, 17 were “ insusceptible,” 
6 were exempted on the conscience clause, 448 died before 
being vaccinated, 71 cases of vaccination were postponed by 
medical certificate, 441 could not be traced, and 15 infants 
were removed to other districts. 

Presentations to a Medical Officer of Health. 

During an interval in the proceedings of the Bootle council 
at a recent meeting Mr. T. W. N. Barlow, who was for six 
years medical officer of health of Bootle and who left last 
month to fill a similar post under the Wallasey district 
council, was the recipient of two handsome presentations. 
The mayor, on behalf of last year’s health committee, 
presented him with an illuminated address expressing its 
appreciation of his efficient services and the town clerk 
handed him a gold watch from his late fellow officials. Mr. 
Barlow feelingly acknowledged both presentations in appro¬ 
priate terms. 

Feb. Uth. 


WALES AND WESTERN COUNTIES NOTES. 

(From our own Correspondents.) 

Housing in Swansea. 

The success of the proposed cottage exhibition to be held 
in Swansea in 1909 has been assured by the election of a 
representative committee to carry out the necessary details. 
Delegates from all the sanitary authorities in South Wales 
have been placed upon the committee together with the 
local Members of Parliament and others. A site owned by 
the Swansea corporation will probably be made use of and 
in other ways the corporation is assisting the enterprise. 
For many years past the question of providing suitable 
houses for the working-classes has been under serious con¬ 
sideration not only by the Swansea town council but by 
most of the local authorities in the neighbourhood. Private 
enterprise has to a certain extent been able to meet the 
demand for cottages in the borough of Swansea where plans 
for as many as 458 houses were approved by the corporation 
in 1906. 

Medical Inspection of Schools. 

The Newport (Mon.) education authority has decided to 
appoint an assistant medical officer for the purpose of carry¬ 
ing out the medical inspection of the children attending the 
public elementary schools. The salary proposed is £225 per 
annum with periodical increases to £275. A suggestion that 


the work might be done by the general practitioners of the 
town did not meet with the approval of the authority.—The 
Barry education authority has decided to appoint a medical 
officer at a salary of £250 per annum. He will work in con¬ 
junction with the medical officer of health. The question of 
appointing a whole time medical officer of health for Barry 
has been under discussion but the arrangement indicated has 
been finally decided upon —At a meeting of the Torquay 
town council held on Feb. 6th it was decided to appoint a 
medical officer to carry out the medical examination of 
school children at a salary of £150 per annum, increasing 
to £210. 

Isolation Hospitals in North Wales. 

Mr. J. O. Williams, medical officer of health of Barmouth, 
Notth Wales, has received an offer from Mrs. Talbot, 
Tynyffynon, to contribute £100 towards the cost of erecting 
an isolation hospital provided that five other similar sums 
are promised. The committee which is making arrange¬ 
ments for the provision of an isolation hospital has 
appointed deputations to wait on those who are likely to 
support the movement. The question of providing an 
isolation hospital in the adjoining town of Dolgelly has been 
again discussed by the urban council without coming to a 
definite issue. The council has already decided to build a 
small hospital which would be easy of extension if occasion 
arose, but the members are not unanimous as to the necessity 
for the expenditure. 

Infant Mortality in Bristol. 

In common with the rest of England and Wales there has 
been a considerable fall in the rate of infant mortality 
during the past few years in Bristol. In a report which the 
medical officer of health (Dr. D. S. Davies) has recently 
presented to the city health committee he expresses the hope 
that by the appointment of health visitors a still further 
reduction may be made. Dr. Davies very properly warns the 
committee that too much must not be expected of special 
work in this direction. In justification of this warning he 
gives a comparative chart and comparative table for Bristol 
and Huddersfield, from which, he says, it is evident that the 
wholesale improvement in the Huddersfield infant mortality 
returns claimed as due to the special mea-ures taken there is 
not proved by the figures adduced to be due either entirely or 
in any large degree to these measures, for a practically identi¬ 
cal improvement has taken place during the same years in 
Bristol without any special methods to this end having been 
taken. In the three years 1905-06-07 during which special 
work against infant mortality has been in progress in 
Huddersfield, the infant mortality rate in that town has 
been reduced 18 per cent., when compared with the rate of 
the preceding ten years. In Bristol the reduction has been 
15 per cent In Huddersfield during 1907 the rate was 97 
per 1000 births, in Bristol 101, and in the whole country 118. 

Milk-supply in Monmouthshire. 

At a recent meeting of the Monmouthshire Chamber of 
Agriculture a resolution was passed asking that any legis¬ 
lation concerning the milk-supply should provide for 
uniform regulations throughout the country ; that no 
vexatious restrictions calculated to render the pro¬ 
duction of milk more expensive should be adopted ; and 
that the working of any new Act should be entrusted 
to the Board of Agriculture and Fisheries rather than to 
the Local Government Hoard. One of the speakers 
at the meeting deprecated what he called the milk 
scare, for which he said there were not sufficient grounds. 
A commentary upon these remarks is to be found in the 
report of the medical officer of health of the Llanelly rural 
district in which he stated that he could not recommend the 
registration of certain dairies and cowsheds, and with regard 
to other cowsheds in the district they were most of them left 
in such a filthy condition that it was not possible to enter 
them for inspection purposes. 

Feb. 10th. 


SCOTLAND. 

(From our own Correspondents.) 


Bdinburgh Iloyal Infirmary. 

At a meeting of the board of managers of this institution 
on Feb. 3rd Dr. Alexander Bruce and Mr. F. M. Caird were 
reappointed (the former as pathologist and resident physician 
and the latter as surgeon) for a further period of five years ; 



526 The Lancet,] 


SCOTLAND. 


[Feb. 15,1908. 


and Dr. W. T. Ritchie, Mr. Henry Wade, and Dr. W. E. 
Carnegie Dickson were reappointed to the pathological 
department for one year. These latter appointments are 
carried on from year to year. 

Edinburgh Royal Medical Society. 

The annual dinner of this society was held on Feb. 5th, 
the chair being occupied by the senior president, Dr. 
A. C. B. McMurtrie. Mr. Jonathan Hutchinson was the 
guest of the evening. The toast of the guest was proposed 
by the chairman and in his reply the former advised the 
members to keep the dreams of youth before them and to 
increase their zeal in medical pursuits as life advanced. In 
proposing the toast of the society Mr. Hutchinson spoke of 
the unsatisfactory character of examinations and threw out 
some novel ideas as to how they might be improved. A 
number of invited guests had been unable to accept the 
invitation to be present owing to other engagements. In 
fact, this dinner clashed, unfortunately, with at least three 
other medical meetings. 

Edinburgh Indian Students Association. 

The annual dinner of this association was held on Feb. 6th. 
Lord Salvesen was the chief guest and in his hands was 
placed the toast of “ India and the Edinburgh Indian 
Association." Several of the University professors were also 
present. The proceedings passed off most creditably to the 
student organisers. 

Honour to Dr. J. O. A ffleck. 

Many of the old students of clinical medicine in the 
Edinburgh Royal Infirmary will be pleased to know that the 
University of Edinburgh is to confer on Dr. J. O. AtUeck the 
honorary degree of LL.D. 

The Vacant Regius Chairs in Edinburgh and Glasgow. 

The filling of both the chair of clinical surgery in Edin¬ 
burgh and of that of practice of medicine in Glasgow is in 
the bands of the Secretary for Scotland. With regard to the 
first of these there are several local applicants; indeed, all 
the members of the senior surgical stafi in the infirmary and 
two or three outside surgeons are spoken of. With regard to 
the Glasgow chair it is understood that in addition to 
applicants from Glasgow there will probably be at least two 
or three from Edinburgh. There are, of course, many 
surmises but there is no trustworthy information. 

The Royal Hospital for Sick Children, Glasgow. 

The twenty-fifth annual report of this hospital has 
just been issued and forms very interesting reading. 
Three years after the hospital was opened the number 
of cases treated per annum was 300, now it is 11,000. 
Three years after the dispensary was opened the attend¬ 
ance there was 5000 per annum, now it is 11,000 per 
annum. The average daily number under treatment in 
the wards of the hospital during the past year was 67'1 and 
the average duration of residence was 23'83 days. The 
country branch at Drumchapel has proved a most valuable 
extension of the hospital. The wards there have always 
been full and many more than the regulation number of 26 
cots could easily have been utilised. In connexion with the 
work at the dispensary, also, it is noted that the resident 
sisters and nurses visited at their own homes 431 cases which 
could not be taken to the dispensary. The ordinary income for 
the year was £6819, as compared with £6469 in the previous 
year. The ordinary expenditure was: hospital, £4995; 
country branch, £1497 ; and dispensary, £1369. This 
leaves a deficit of £1042. The report refers to the 
movement that has been inaugurated for the raising of 
money for the rebuilding of the hospital on a more suitable 
site, as, apart from the lack of accommodation in the 
hospital itself, the present site is now crowded with build¬ 
ings, surrounded by high tenements, and is next door to a 
veterinary college where diseased animals are treated. The 
directors last year drew up a statement of the needs of the 
hospital and issued an appeal for £100,000 to enable them in 
the first place to build a hospital to contain from 200 to 250 
cots on a site in Glasgow where the children will get the 
maximum of fresh air and sunshine, and secondly, to extend 
materially the hospital accommodation in the country. As a 
result of this appeal at the close of the year the subscriptions 
totalled £60,000, of which sum £4500 were raised by a 
“shilling fund ” started by the proprietors of the Glasgow 
Evening Hems. At the present time the directors are nego¬ 
tiating for a suitable site. 


Interesting “ Milk " Prosecutions. 

In view of the present outbreak of enteric fever in Glasgow 
and Partick two interesting prosecutions took place in 
Partick police-court recently. The accused were both 
dairymen in the burgh and the charge against them was that 
of allowing the message boys on their respective milk carts 
to sit upon vessels used for the purpose of carrying milk. 
This constitutes a contravention of a section of the burgh 
regulations, which is to the effect that no person should rest 
his body on vessels used for holding milk. The defence in both 
cases was that the vessels were empty at the time and,would 
have been scalded before being used again. In both cases it 
was held that the by-law had been contravened, but the 
defendants were dismissed with an admonition. 

Dumfries and Galloway Infirmary. 

The report for the past year states that 788 in-patients 
were dealt with, which constituted a record for the hospital. 
The ordinary Income amounted to £3419 and the ordinary 
expenditure to £4216, showing a deficiency of £967, but, on 
the other hand, legacies were received during the year to the 
extent of £3000. At the annual meeting a protracted 
discussion took place with regard to a complaint that a 
patient had been sent into the hospital and carried from the 
ambulance to the operating theatre where he was operated on 
without any diagnosis and that he died in consequence. It 
was decided that there was no ground for complaint. 

The Epidemic of Enteric Fever at Peterhead : Professor 
M. Hay's Report. 

On Feb. 3rd, at a meeting of the Peterhead town council. 
Professor Hay's report on the epidemic of enteric fever was 
considered. The report is of considerable length and deals 
largely with the rise and spread of the epidemic. He notes 
at the outset that the situation of Peterhead, built on a head¬ 
land with a considerable slope seaward, is favourable to a 
good system of drainage ; but some of the drains are of the 
old-fashioned rubble-built type, and some of them are 
carried along streets parallel to the shore, thus losing the 
necessary slope that would render them self-cleansing. Also, 
while the newer buildings are provided with modern and 
efficient sanitary arrangements, many of the older houses 
have antiquated and even dangerous drainage arrangements 
and prove the need of the more strenuous enforcement of the 
Public Health Act. As regards the outlet of the town’s 
sewage, the principal sewer south of the harbour does not 
seem to be carried sufficiently far out to sea, as there is 
a strong and nauseating odour in its vicinity. With 
regard to the water-supply Professor Hay remarks that,, 
both from the inspection of the wells or springs 
and from chemical and bacteriological examination, the 
water was largely of the order of ordinary field-drain 
or subsoil water; also that at the beginning of the 
epidemic the water was open at many points to pollu¬ 
tion. Much of the water was surface water from 
cultivated fields liable to manuring and there was no 
provision for filtering it. This danger was increased by the 
use of the town’s refuse as manure. On Professor Hay’s 
recommendation the sale of all refuse for manure was 
stopped to farms within the water-gathering areas and to 
dairy farms. With regard to the origin of the epidemic Pro¬ 
fessor Hay is of opinion that it was started by milk infection 
which planted a laige number of cases throughout the town 
and that it was kept going mainly, if not wholly, through 
contact infection. The cases occurring in spots or patches 
favour this view, in contra-distinction to cases occurring in 
diffused areas, as would have been the case had the epidemic 
been started by water infection. He then proceeds to show 
that the further progress of the epidemic and the distribution 
of the cases were against the supposition that the water 
became infected, at least to any degree. He does not, 
however, defend the state of the water-supply which he 
thinks bad and in pressing need of reform. He afterwards 
goes on to specify what ought to be done to prevent a recru¬ 
descence, such as promptly notifying suspicious cases, having 
recourse to the Widal and other blood tests in obscure cases, 
examining any old cases with any suspicion of infectivity, 
getting rid of all obsolete and insanitary arrangements such 
as ashpits, and the stoppage of supplying domestic or ashpit 
refuse to dairy farms or farms within the gathering grounds 
of the water-supply for a year or two until enteric fever 
shall be stamped out. 

Feb.11th. 


The Lancet,] 


IRELAND.—PARIS.—BERLIN. 


[Feb. 15, 1908. 527 


IRELAND. 

(From our own Correspondents.) 


Emigration from Ireland. 

It is deplorable to record that during the fir6t month of 
this year 641 people (378 males and 263 females) emigrated 
from Ireland. Of the total, 360 were from Ulster (showing 
a decrease of 32 as compared with the same month last 

S ear), 131 from Leinster (a decrease of 38), 117 from 
funster (an increase of 16), and 33 from Connaught (an 
increase of 2). The destinations of these emigrants were as 
follows: 256 went to the United States, 272 to Great 
Britain, 48 to Canada, 37 to Australia, 11 to South Africa, 
6 to New Zealand, and 11 to other countries. The steerage 
passengers to the United States numbered 219, of whom 44 
had their passages paid in America. The public health con¬ 
ditions of Ireland certainly play their part in this progressive 
depopulation of the country, a fact which should be borne in 
mind by those who too readily attribute every ill in Ireland 
to political troubles. 

Opening of the Tuberculosis Exhibition at Banbridge. 

On Saturday, Feb. 8th, the Countess of Aberdeen journeyed 
from Dublin to Banbridge, county Down, to open the 
Tuberculosis Exhibition which is being held there. In the 
Temperance Hall, where the exhibition is located, lectures were 
given by Her Excellency, by Mr. R. Martin (medical officer of 
health of Banbridge), Dr. W. Chancellor, and others. In 
the evening Sir John Byers gave the opening lecture on 
*' What We May Ooserve in the Tuberculosis Exhibition." The 
subsequent lecturers were the Registrar-General (Sir Robert 
Matheson). Professor E. J. McWeeney, Dr. W. Calwell, Dr. 
H. L. McKisack, and Dr. It. T. Herron. 

The Lady Superintendent of the Belfast It 'orhhouse. 

The Local Government Board has refused to approve of 
the appointment of a lady elected by the Belfast board of 
guardians as lady superintendent of the workhouse and 
training school for nurses, having regard to the deliberate 
statements of the visiting medical officers and to the fact 
that, in the opinion of the Local Government Board, she 
does not possess the necessary personal qualifications for the 
office. Accordingly it recommended the guardians to pro¬ 
ceed to another election. In reply, the guardians have 
requested the Local Government Board to sanction the 
appointment for a probationary period of six months. The 
Local Government Board has written refusing to sanction 
such an appointment on probation and advised the Belfast 
guardians again to proceed to a new appointment, but at 
their weekly meeting on Jan. 28th the guardians, by 17 votes 
to 15, decided that the letter of the Local Government Board 
should be sent to a committee (which was subsequently 
appointed) with instructions to reply to it and to advance 
reasons in favour of the appointment. 

Feb. 11th. 


PARIS. 

(From our own Correspondent.) 


The Bisks of Arsenic in Agriculture. 

At a meeting of the Academy of Medicine held on 
Jan. 28th M. Cazeneuve called the attention of his audience 
to a situation which haB become extremely alarming. Within 
the last two or three years enormous quantities of arsenic 
have been used in agricultural operations. The employment 
of this poison by the vine-growers is no new thing in France, 
for it was suggested some 13 years ago as a means of com¬ 
bating insect pests, but its use has greatly increased in recent 
years. By far the greater part of the arsenic employed 
comes from a Spanish mining district. In 1901 this district 
supplied 120 tons of arsenical ores, while in 1905 the 
quantity necessary for agricultural needs had risen to 4810 
tons. Arsenic is not only employed in viticulture but also 
used for diseases of olives, and various instances of fatal 
poisoning have occurred in animals that have fed under the 
olive trees. At the conclusion of his address M. Cazeneuve 
asked the Academy to point out the dangers which might 
arise from the indiscriminate use of arsenic. 


Immediate Operation in Gunshot Wounds of the Auditory 
Beg ion. 

At a meeting of the Paris Hospitals Internes’ Society 
held on Jan. 23rd M. Wioart insisted on the necessity for 
immediate operation in gunshot wounds of the auditory 
region. He based his remarks upon many cases which he 
had seen and on one iD particular where radiography had not 
revealed the site of the ball which in consequence had not 
been extracted. Chronic suppuration set in, facial paralysis 
became incurable, and labyrinthine trouble persisted. The 
best route to follow for extractions was the retro-auricular, 
and the clearing out of the petro-mastoid cavity would be 
found to be of great assistance. 1 

The Treatment of Old-standing Injuries of the Wrist by Total 
Bisection of the Carpus. 

At a meeting of the Surgical Society held on Jan. 29th 
M. Valas read a paper on this subject. He said that trau¬ 
matic lesions of the wrist in which efforts at reduction have 
failed are often capable of being greatly improved by imme¬ 
diate operation and sometimes even by massage alone ; when, 
however, the lesions are of old standing, whether on account 
of having been overlooked or because immediate treatment 
has failed, they cause such inconvenience that the patient is 
always anxious that something should be done to help him. 
The majority of surgeons content themselves with removing 
the dislocated or fractured bones, but this method of ope¬ 
rating generally means that successive operations have to be 
performed until all the carpal bones have been taken away. 
M. Valas therefore considers it better to remove the whole 
carpus at one sitting. In six cases which he has treated in 
this way he has obtained excellent results ; in all these cases 
the carpal lesion was at least four months old and all the 
patients recovered complete movement of the hand. M. 
Valas concluded by saying that he thought that complete 
resection of the wrist was an excellent plan to adopt in such 
cases as he had described. 

Feb. 11th. 


BERLIN. 

(From our own Correspondent.) 

The Surgical Treatment of Bronchiectasis. 

Professor Koerte recently read a paper before the Berlin 
Medical Society on Operations for Bronchiectasis. He 
pointed out the difficulty of surgical intervention because in 
bronchiectasis a great number of cavitieB without a direct 
communication are usually present. The diagnosis was also 
very difficult, especially as regards the difference between 
bronchiectasis and gangrene of the lung. The operations 
for pulmonary gangrene gave, as a rule, better results than 
operations for bronchiectasis, for Professor Koerte has lost 
only eight out of 28 patients operated on for gangrene, as 
compared with 11 deaths in 15 operations for bronchiectasis. 
The only cases suitable for operation were those in which 
the bronchiectasis was limited to one lobe of a lung. 
A resection of at least two ribs was essential to make the 
lung accessible. After the lnng was incised each bronchi¬ 
ectasis must individually be opened, tied, and plugged. If 
the cavity did not collapse after the operation an extensive 
resection must be carried out. The dangers of the operation 
consisted in the profuse haemorrhage and in the shock which 
might occur at the moment of the incision. He did not nse 
Sauerbruch's chamber for the operation but he avoided 
pneumothorax by drawing the lung quickly into the wound. 
The early cases gave the best results but they, of course, 
very seldom presented themselves for surgical treatment. 

Diabetes Conjugalis. 

At a recent meeting of the Berlin Medical Society Pro¬ 
fessor Senator discussed the question whether diabetes might 
be communicated from husband to wife and vice versd. He 
said that some writers, believing that the disease can be so 
communicated, have proposed the name of “diabeteB con- 
jagalis”for this condition. Dr. Schmitz of Neuenahr bad 
found 26 married couples among 2320 diabetic patients, 
being 1 ■ I per cent, of the total number. The computation 
ought, however, to be made not by comparing the diabetic 
couples with the total diabetics, but by comparing the 
diabetic couples with the diabetic patients who were either 
married or lived connubially. The proportion of diabetic 


1 See The Lancet of Nov. 3rd, 1907, p. 1577, for an account of a 
paper on the same subject by M. Sebileau. 





528 The Lancet,] 


BERLIN.—ITALY. 


[Feb. 15,1906. 


couples then becomes higher. Professor Senator has observed 
516 married conples of whom either the husband or the 
wife, or both, were diabetic. The latter event happened 
in 18 instances (i.e., 3 5 per cent.), and taking only 
those couples who had been married from six months to 
one year the proportion rose to 4 ■ 1 per cent. Some of 
the cases were hereditary, but even 4 • 1 per cent, was not a 
proportion sufficiently high to make a communication likely. 
Some rather striking instances of communication have, how¬ 
ever, been recorded, such as that of a washerwoman who had 
washed the linen of diabetic patients and that of a surgeon 
who had performed an amputation on a diabetic patient. 
Some pathologists have produced diabetes in animals by the 
inoculation of diabetic urine ; experiments of this kind which 
Professor Senator had made were unsuccessful, but he never¬ 
theless was of opinion that a communication of the disease 
might happen in certain favourable circumstances. In 
the discussion Dr. Neumann said that among 108 diabetic 
patients whom he had observed there was only one married 
couple. Dr. Albu said that he had found diabetes in two 
married couples, but in one of them the disease was 
hereditary and in the other it was caused by cancer of the 
pancreas. Professor Ewald said that in 120 cases he had 
not seen a single instance of diabetes conjugalis. 

The Congress of Internal Medicine. 

The Twenty-eighth Congress of Internal Medicine will 
meet this year in Vienna from April 6th to 9th, Professor 
Miiller of Munich being in the chair. The official subjects of 
discussion will be as follows : (1) the Relations between the 
Genital Organs of Women and Internal Diseases, to be intro¬ 
duced by Professor von Rosthorn of Heidelberg and Dr. 
Lenhartz of Hamburg ; and (2) New Methods of Examining 
the Function of the Intestines, to be introduced by Professor 
Schmidt of Halle. The other addresses the titles of which 
have been announced include one on the Present State of the 
Pathology and Treatment of Syphilis by Professor Neisser of 
Breslau and one on the Quantity and the Distribution of the 
Blood in Anaemia by Dr. Morawitz of Heidelberg. Visitors 
wishing to take part in the proceedings should make applica¬ 
tion to the general secretary, Dr. Pfeiffer of Wiesbaden. 

Precooiout Menstruation. 

Professor Stoeltzner of Halle has described in the 
Medicinuohe Klinik the case of a child who began to 
menstruate when in her second year. She was two years 
and ten months old and had menstruated several times, the 
intervals being at first eight weeks and afterwards five weeks. 
She had well-developed mammtc and a large vulva. Her 
height was 102 centimetres and her weight was 19" 5 kilo¬ 
grammes, which corresponded to the weight of a child aged 
from five to six years. She was originally quite normal and 
at birth weighed 3 • 2 kilogrammes. She had her first tooth 
when six months old and could walk at the age of one year 
and two months. Precocious puberty has been described by 
some writers as a symptom of a morbid condition of other 
organs, such as malignant adenoma of a suprarenal gland or 
intracranial disease. In cases where precocious puberty was 
associated with menstruation a pathological condition of 
the ovaries was very likely to exist. Ovules were discharged 
as in normal menstruation and such children have been 
known to become pregnant. Children who presented this 
abnormality ought to be kept under observation, as malignant 
growths might develop in the ovaries. 

The Serum Treatment of Scarlet Fever. 

Dr. Pulawski of Radzlejov, writing in the Deutsche 
Medizinische Wochenschrift, reports the results obtained in 
scarlet fever by the subcutaneous injection of serum which 
was produced by the inoculation of horses with streptococci 
cultivated from the blood of severe cases of scarlet fever. 
Of 35 severe cases treated with this serum 28 per cent, died, 
whereas of 28 severe cases treated without the serum 71 pr r 
cent. died. The serum proved to be quite innocuous and did 
not cause any undesirable symptom beyond a slight 
urticaria. Among the patients treated with serum there 
were ten deaths ; these cases had, however, from the first 
been regarded as hopeless. In the remaining cases favour¬ 
able action of the serum was shown by the rapid develop¬ 
ment and shortened duration of the exanthem, by mitigation 
of the grave symptoms, and by a quicker convalescence. It 
is probable that the serum protects the patients against com¬ 
plications such as otitis, lymphadenitis, and nephritis. In two 
cases complicated by diphtheria the joint administration of 
scarlet fever serum and diphtheria serum was useful. 

Feb.10th. 


ITALY. 

(From our own Correspondent.) 


"La Ginecologia Moderna." 

Italians, according to Italy’s greatest composer Rossini, 
owe a debt of gratitude to Spain, “which saves them from 
being ranked as the most back ward of European nationalities. ” 
True in the main, the remark is specially true in medical 
literature, particularly medical journalism, in which all that 
can be said of Italy is that she is rather better than her 
Iberian sister. It is pro tanto the more gratifying, therefore, 
when a new accession to Italian periodicals is announced with 
the programme and the promise of La Ginecologia Moderna 
(Modern Gynacology), the monthly review just started 
at Genoa under the competent editorship of Dr. Luigi Maria 
Bossi, professor of obstetrics and the propaedeutics of gynae¬ 
cology in that school. Not only does the new periodical 
deal with the medico-chirurgical questions to which the 
ailments of the female sex give birth, but it takes cognisance 
of the more general problems arising out of the psycho¬ 
logical, the sociological, and the forensic aspects of that 
group of diseases. A novel feature of the journal will be the 
attention given to “female criminology,” in which the 
phenomena of hysteria play a part becoming steadily more 
conspicuous from what a sociologist has called ‘ ‘ the hyper- 
aestbesia of our over wrought civilisation.” Among the con¬ 
tributors to the subject appear Dr. Cesare Lombroso of 
Turin and Professor Enrico Ferri of Rome. No reader of 
contemporary causes cilrbres can fail to recognise in this 
department of La Ginecologia Moderna a most interesting 
field of observation and discussion. 

Pharmaceutical Misadventure. 

I had occasion recently to note the tragic consequences of 
the irregular prescription and administration of cod-liver oil 
with solution of phosphorus. Another case of misadventure 
is just reported from Codogno in the neighbourhood of 
Cremona, where a peasant woman was “ treated ” by a local 
pharmacist and died a few hours afterwards—a white powder 
(the nature of which has yet to be specified) having been 
given by mistake for magnesia. The pharmacist is now in 
prison and the matter, of course, sub justice. Meanwhile the 
case reinforces the warning addressed to all Italians (and 
others outside Italy) that, unless professionally prescribed and 
exhibited, medicines are fraught with danger—often death— 
to the consumer. I may add that Italian pharmacists are 
memorialising the Minister of Public Instruction (His Excel¬ 
lency Signor Rava), while maintaining the stringency of the 
gateway to the profession, to vouchsafe in consideration of 
the severe ordeal thus exacted the title of Doctor to the 
successful examinee. Certainly the claim is not an extra¬ 
vagant one, when the veterinary surgeon and the graduate 
in “ zooiatria ” can, after due examination, call himself 
“Doctor.” The memorialists, however, do not strengthen their 
cause by the threat—all too common in Italian Universities 
—to refuse to attend the classes till their petition is granted. 
While at that end of the pharmaceutical ladder the aspirant 
is agitating for fuller rights, at the opposite end there is 
another movement much less to be encouraged—that is, to 
recognise as fully qualified for the practice of pharmacy 
those “ assistants” who, without having passed an examina¬ 
tion, have completed a certain number of years of apprentice¬ 
ship. No doubt there are among these petitioners not a few 
highly expert and capable pharmacists, but to make all of 
them eligible for the rights which only the State diploma 
can confer would be to establish a dangerous precedent. 

The National Institute of Physical Education. 

True to the watchword of Cavour’s successor, Massimo 
d’Azeglio, given forth just 40 years ago—“We have made 
Italy. Let us now make Italians ”—the promoters of the phy¬ 
sical rehabilitation of the “pubes Italica” are sparing no 
effort to diffuse and to intensify their salutary propaganda. At 
Rome in May next they will hold their first “ Rinnione,” and 
the occasion will be signalised by the carrying out of a pro¬ 
gramme of gymnastic exercises, games, and other tests of 
physical development, agility, and strength, in which all the 
clubs of Italy, organised with that object, will be fully 
represented. Every facility will be offered to the public, 
domestic and foreign, to intervene at the “spettacolo”— 
railway transit being, for one thing, reduced 75 per cent, in 
cost to all who send in their names as intending visitors to 
the president, Signor Lucchini, Member of the Chamber of 



The Lancet,] 


CONSTANTINOPLE.—NOTES FROM PEKING. 


[Fbb. 15, 1908 . 529 


Deputies. Those of the profession in the British Isles who 
can take their holiday during the month of May—always 
delightful in Italy—might do worse than hononr the 
“Riunione ” with their presence. 

Feb. 10th. 


CONSTANTINOPLE. 

(From odr own Correspondent.) 

The Water-supply of Medina. 

On previous occasions 1 I have given some accounts of the 
recent measures undertaken to supply Mecca with drinkable 
water. The sister city Medina, quite or nearly as sacred 
to Islam as Mecca, on the good water-supply of which 
many thousands of Moslem pilgrims so much depend, is 
also soon to receive proper canalisation works and every 
other requisite for a large and satisfactory provision of 
pure water. The Sultan has already given the necessary 
orders to proceed, with as little delay as possible, 
with the construction of these canalisation works. 
There is, I understand, a copious supply of water 
conducted from a tepid source at the village of Kuba, 
two miles south of Medina, and distributed in under¬ 
ground cisterns in each quarter. Besides, a number of 
torrent courses (of which the Kanat to the north, at the foot 
of Mount Ohod, and Akik, some miles to the south, are the 
most important) descend from the mountains, forming 
considerable streams and pools after rain. These torrent 
courses, which converge in the neighbourhood of the city 
at a place called Zaghaba, make the whole district 
for many miles around one of the best watered spots 
in Northern Arabia. There is also underground water which 
can be reached by sinking deep wells, but many of these 
wells are brackish and quite useless for drinking purposes. 
Through the suburbs of Medina, which are the quarters of 
the peasants, runs the watercourse of the Batan, a tributary 
of the Kanat. All these water sources have been used for 
many centuries for drinking and cooking purposes. As some 
of the wells are of considerable depth the so-called “sakkas” 
(water carriers) descend into them with the help of ladders 
and after filling their “ courbas ” (leather bags) with water 
distribute it to the various houses. Seeing that these wells 
and other sources are quite open to all sorts of pollution and 
contamination, this mode of supplying water to the inhabi¬ 
tants of Medina left much to be wished for. The popula¬ 
tion continually suffered from different gastric troubles 
and infectious diseases, such as enteric fever, which 
have naturally been attributed to the contamination of 
the water. The water to be canalised is that of 
Zerka, or Aini Zerka. It will be conducted into two 
great reservoirs of 2000 cubic metres capacity. From 
these reservoirs the water will be conveyed into smaller 
reservoirs and fountains to be erected at different places in 
the city. All the works of canalisation will be constructed 
under the direction of a special commission. The way in 
which wells are dug at Medina is interesting. First a well is 
opened at a high elevation, then another lower down, a third 
still lower, and so on. Afterwards all these wells, from the 
highest to the lowest, are connected by subterranean 
channels. In this manner the water is brought to a plane 
whence it is conveyed to different points of the city and its 
suburbs. Often the inhabitants united of their own accord to 
execute these workB. The two above-mentioned great 
reservoirs will be constructed upon the place called Menahe 
situated in the north of Medina. 

Feb. 7th. 


NOTES FROM PEKING. 

(From our own Correspondent.) 


The Opium Question. 

In spite of all that has passed on the subject of opium in 
China, from Imperial edicts against the trade down to 
missionary and lay protests, the question still remains in 
a most unsettled and unsatisfactory condition. A new 
phase has recently been entered upon by the action of the 
Viceroy of Nanking who proposes to establish a Government 
monopoly in the opium business in his capital, a step that 

1 The Lancet, August 4th and Nov. 3rd, 1906. 


would no doubt be extended to other parts of the province 
if successful in Nanking. This has caused a strong protest 
from the British firms concerned in the foreign opium trade 
who feel their business would be injured unjustly, as it is not 
a matter concerning the use of opium but merely of diverting 
it into Chinese hands, thus infringing established treaty 
rights. The Hong-Kong Chamber of Commerce has taken 
the matter in hand and is upholding the merchants’ appeal 
to the Governor to see that the monopoly is not allowed. 
There is evidence to prove that the sale of anti-opium pills 
(containing a percentage of opium) and morphine is in¬ 
creasing. While the foreign importation of opium is de¬ 
creasing the area under poppy cultivation is beiDg extended 
and the native article is also improving in quality. Those of 
us who have an opportunity of judging can see little if any 
diminution in the number of Chinese addicted to the habit, 
though certain high officials have found themselves com¬ 
pelled to give it up. In the meantime one may rest content 
that the British and Chinese Governments are taking a right 
view of the whole matter, especially in the light of the recent 
agreements that there is to be a gradual diminution of the 
Indian opium trade pari passu with the decrease in the pro¬ 
duction of the native drug. This will not content the 
extremists among the anti-opium advocates but the 
moderates will realise that a sound incentive is given to 
China to make serious efforts to diminish her own output. 

Climate and Health. 

During the winter months (October to February inclusive) 
there is a great diminution of bacterial diseases. In the 
absence of sanitary regulations the public health may be 
looked upon as very good. With the exception of sporadic 
cases of small-pox all zymotic diseases die down and the 
chief complaints among hospital patients are rheumatism, 
neuralgia, bronchitis, and conjunctivitis, the two lust being 
mostly due to noxious fumes of anthracite stoves in houses 
which have no chimneys. Not infrequently one meets with 
cases of gangrene of the toes in the old and poor and a 
curious feature is the large number of workmen out-patients 
who suffer from septic inflammation of the hands due to 
cracks and fissures in callosities through which dirt enters. 
A good many Europeans also suffer from fissures at the 
points of the fingers due to the extreme dryness of 
the atmosphere and low temperature which at present 
ranges from 10° F. at night to 32° by day. The prevailing 
wind is north and north-west and as it comes from over the 
steppes of Siberia and Mongolia it is bitterly cold and 
sometimes accompanied by clouds of fine dust. The sky is, 
as a rule, cloudless and the sun often genially warm, so that 
one may look upon the winter climate of North China as 
being on the whole a very healthy one. With the excep¬ 
tion of occasional visits of influenza (from one of which we 
are now suffering) the European population enjoys good 
health. Children thrive well and there is no need here for 
that separation from their parents which has been found 
necessary in South China and India ; indeed, there are a 
good many European adults in North China who have never 
been home and yet are sound healthy specimens of manhood. 
Fog or mist is unknown. Notwithstanding the healthi¬ 
ness of the climate the tuberculous rate suffers little diminu¬ 
tion and still awaits the time when Chinese “ enlighten¬ 
ment,” which is so much talked about at present, reaches 
that stage when public health regulations will be found 
necessary to deal with the high mortality rate in this 
disease. 

Small pox. 

The beginning of every winter sees a recrudescence of 
this disease and it is generally supposed that the removal by 
the Chinese of their winter clothes from the pawnshops has 
much to do with the annual visitation. These garments 
consist of two layers of cotton between which is a thick 
layer of cotton-wool. Though in North China inoculation 
is still practised to some extent it has been of late years 
supplemented by calf lymph, a good supply of which has 
been imported from Japan. Here and there throughout 
Peking are Government vaccination stations where those who 
care to submit themselves can be vaccinated without any 
regard to asepsis. An increasing number are availing them¬ 
selves of the facilities offered. It is not an uncommon sight 
to see blind men with deeply pock-marked faces feeling their 
way through the streets. 

Adulteration of Milk. 

In the absence of any legislation against adulteration 
(except in a foreign settlement such as Shanghai where there 




530 '"The Lancet,] 


OBITUARY. 


[Feb, 15, 1908. 


are municipal health regulations on a par with those of any 
town in England) it can be carried to a fine art. Milk- 
sellers, for example, are as a rule unable to refrain from 
watering their milk and this is accepted by the foreign 
community (as they and not the Chinese are milk-drinkers) 
as so inevitable that the chief growl is about the quality of 
the water more than the quantity of it. Some Chinese dairy¬ 
men, however, carry the adulteration to a high pitch of 
excellence and add a yellow-coloured emulsion of beef tallow 
to liberally watered milk. When this emulsion dissolves 
out it rises as a rich thick cream, out of which butter can be 
made. If some of this cream be added to boiling water the 
tallow congeals on cooling—a rough-and-ready test which is 
but rarely employed. 

Jan. 8th. 



WILLIAM ALLINGHAM, I H.C.S. Eng., 

CONSULTING (StJBCEOlf 10 THE GREAT NORTHMEN CENTRAL HOS1-ITAL. 

The death of Mr. William Allingham, which we have 
already announced as having taken place at Worthing on 
Feb. 4th, was not unexpected, for his health had been very 
unsatisfactory for some time, while he had reached the 
advanced age of 78 years. 

William Allingham was born in 1829 and received his early 
education with architecture as its object, He studied his art 
at University College, London, took several students’ prizes 
in the subject, and later, while practising his first profession, 
exhibited studies at the exhibitions of the Royal Academy 
and obtained an honourable mention for a design which he 
submitted for a building to house the Great Exhibition 
of 1851. In this same year, however, he decided to 
abandon his profession and turned to medicine, which 
had always attracted him. He entered as a student at 
St. Thomas’s Hospital and had a successful career, taking 
prizes in anatomy, systematic and clinical medicine, and 
the Treasurer’s prize—in fact, he secured most of the 
rewards that fall to the lot of the able and energetic student. 
In 1855 he became a Member of the Royal College of 
Surgeons, proceeding to the Fellowship two years later, 
while between the taking of his pass and honour diploma 
he had the valuable and honourable experience of serving 
as surgeon in the Crimean war. He volunteered as soon as 
he was qualified and reached the seat of war, which was 
then in progress, in time to be present at the siege of 
Sebastopol and to see a vast amount of practical surgery 
in the most arduous circumstances at the hospitals at 
Scutari. During a large part of his war services he was 
attached to the French army, which was extremely badly 
provided with surgical aid, and there is no doubt that under 
the strenuous nature of the duties which devolved upon him 
Allingham gained the courage and sense of responsibility which 
marked him out as a successful operating surgeon from the 
beginning of his career. On his return he was for a time 
surgical tutor and demonstrator of anatomy and later 
surgical registrar at St. Thomas’s Hospital, and in 1863 he 
commenced practice as a consulting surgeon in Finsbury- 
square, then a very favourite centre for consulting practice. 
In a very short time he became known as a specialist in 
diseases of the rectum, and in 1873 he published his well- 
known book on that subject. This book went through five 
editions, the last one appearing in 1888; it was translated 
into several foreign languages and was accepted generally as 
an authoritative and inclusive work, though several surgeons 
differed from the author on points of operative procedure and 
technique. The work took final shape in 1901 when Herbert 
Allingham, William Allingham’s eldest son, collaborated 
with his father in an edition so thoroughly revised as to be 
practically rewritten. 

As he became more successful Allingham, following the 
example of other well-known consultants, transferred his 
practice from Finsbury-square to Grosvenor-street, and 
during the whole of the later period of his professional 
career he enjoyed a large practice as a consulting surgeon 
in cases of diseases of the rectum. He came to be regarded 
as one of the first authorities on the subject as well as one 
of the most skilful operators where surgical measures had to 
be taken. Although he was never on the honorary staff of 
one of the great metropolitan hospitals possessing a medical 
school, he was for many years surgeon to the Great Northern 


Central Hospital and to St. Mark's Hospital for Fistula and 
Diseases of the Rectum, while he was also consulting surgeon 
to the Farringdon General Dispensary and to the Surgical Aid 
Society, with the founding of which society in 1862 he was 
intimately connected. In 1884 he was elected on the Council 
of the Royal College of Surgeons of England. He retired 
from practice in 1894. 

Allingham, who was widely known in private life as a 
most kindly, generous man, an excellent host, and a sym¬ 
pathetic friend, was twice married. His first wife was Miss 
Christiana Hooke, by whom he had six children, the eldest 
son being Herbert Allingham, the brilliant young surgeon 
whose untimely death will be fresh in the memory of our 
readers ; while both his daughters married medical men, the 
elder, now Mrs. Chevallier Tayler, the wife of the well-known 
artist, having married first Mr. Charles Cotes whose memory 
as a surgical tutor is still preserved among St. George’s men ; 
while the younger is the wife of Mr. Claud E. Woakes. 
Allingham married secondly Miss D. H. Hayles who pre¬ 
deceased him last year and by whom he had no children. 


HERMANN SNELLEN, M.D., 

PROFESSOR OF OPHTHALMOLOGY, UNIVERSITY OF UTRECHT. 

The death of Professor Snellen of Utrecht removes another 
of the few remaining links with the founders of modern 
ophthalmology. The seed sown by Donders, von Graefe, and 
von Helmholtz fell upon fertile soil and was worthily tended 
by illustrious disciples. The mantle of Donders fell upon 
Snellen who has borne it nobly through a long and strenuous 
career. 

Hermann Snellen was born in 1834, the son of 
Dr. F. ’A. Snellen, a well known physician. He Btudied 
at Utrecht, where he remained as student and professor 
throughout his life. His graduation thesis presented in 1857 
gave ample evidence of his perseverance and skill in original 
research and of that scientific imagination which can alone 
guide research into fruitful paths. It was published in 
Virchow’s Arohiv in 1858 and dealt with neuroparalytic 
keratitis. In attacking this subject Snellen was entering the 
lists with those whose names were most famous in 
physiology, such as Magendie, Ciaude Bernard, Kiihne, 
Gaule, Schiff, and others. He was led by his experiments to 
bring forward the simplest theory which could be held 
to explain the condition. He regarded neuroparalytic 
keratitis as a purely traumatic condition, the severity of 
which was due to the anaesthesia of the cornea, whereby 
slight injuries, such as those caused by foreign bodies, 
failed to set in motion those reflex acts which are nature's 
method of relief. The theory brought into prominence 
factors which had been overlooked or under estimated by his 
predecessors and if it cannot be credited as a complete 
solution of the problem it was a stride towards that solution 
which after 50 years’ interval we still await. In 1862 
Snellen was appointed lecturer in ophthalmology and sur¬ 
geon to the Dutch Hospital for Diseases of the Eye at 
Utrecht. In the same year he published those test types 
which have since been employed universally. Test types 
had already been devised by Kiiohler (1843), Jaeger (1854), 
Stellwag von Oarion (1855), and others, but it was not until 
1862 that they were devised upon a scientific baBis simul¬ 
taneously and independently by Snellen and Giraud-Teulon 
at an ophthalmic congress in Paris. The basis was a visual 
angle of one minute and Snellen’s types are constructed on 
the principle that each letter subtends a visual angle of five 
minutes at the nodal point of the eye when placed at the 
given distance from the eye, whilst the breadth of the 
individual lines which compose the letter subtends an angle 
of one minute at the nodal point. Innumerable varieties of 
test types have since been brought forward, but the funda¬ 
mental principle, being founded upon accurate physiological 
data, is universally maintained. Snellen’s test types for 
near vision, constructed upon the same lines, have not found 
the same favour as bis distant types, for in the circumstances 
in which they are employed other factors which tend to 
vitiate their accuracy come into play. 

Though doubtless influenced greatly by his master Donders 
and by that mathematical instinct which is strongly de¬ 
veloped in so many Dutch men of science, Snellen did not 
confine his attention to optics. He devoted much time and 
thought to the relief of deformities of the lids, and “ Snellen’s 
sutures” are familiar to every ophthalmologist to-day. 
Indeed, he made his mark in every department of ophthal¬ 
mology. For many years he was associated with Leber, who 




The Lancet,] 


OBITUARY.—MEDICAL NEWS. 


[Feb. 15, 1908 . 531 


occupies a similar position with regard to Ton Graefe that 
Snellen does to Donders, and others in editing the chief 
German ophthalmic journal, von Graefe’s Archiv fur Oph¬ 
thalmologic. Many of his original communications are con¬ 
tained in that journal. With Professor Landolt be is re¬ 
sponsible for the article upon Ophtbalmometrology in the first 
edition of the “ Graefe-Saemisch HaDdbuch der gesammten 
Augenheilkunde.” He wrote the chapter on the Methods of 
Determining the Acuity of Vision in “ Norris and Oliver’s 
System of Diseases of the Eye,” an essay on the Development 
of our Knowledge of Glaucoma in the Ophthalmic Rex-ien 
(1881), &c. Snellen was appointed to the chair of ophthal¬ 
mology in the University of Utrecht in 1877 ; he resigned in 
1899, when he was succeeded by his son Hermann Snellen, 
junior. 

We are indebted to Mr. E. Nettleship for the following 
remarks : “ I first saw Snellen about 1872 or 1873 when he 
was in London; I was curator of the Moorfields Museum, 
only just commencing ophthalmic work, and beyond a general 
impression that he was a learned but very accessible man 
nothing remains. In the early ‘ eighties ’ I went to Holland 
for a short time, taking Utrecht first, and well remember the 
warmth and cordiality with which my wife and I were 
received at his house and that of Professor Donders, to 
whom he introduced us. Snellen paid frequent visits to 
Great Britain ; he spoke English fluently and was a genuine 
admirer of many things English. He was intensely national 
in spirit and expressed the strongest dislike to the possi¬ 
bility of his country being absorbed into the German Empire. 
Snellen was a most genial, kindly, warm-hearted maD, of the 
simplest habits, and intensely fond of his large family. He 
was a striking personality—large-framed, tall, with handsome 
features, and especially fine eyes, which though usually mild 
in expression could show animation and intense fire on 
occasion. Of placid temper, he had the gift of never 
fussing or seeming hurried, but of never being too late, and 
he carried his quiet energy and methodical thoroughness into 
his professional work. His operative manner and method 
were, I thought, equal to the best, although I remember 
thinking his desire for improvement sometimes led him to 
try new modes, especially of dressing after operation, rather 
readily, and always to think the newest plan the best.” 


ROBERT BIRCH, L.R.C.P. Lond., M.R.C.S. Eng., L.S.A. 

Mr. Robert Birch of Newbury, who died on Jan. 24th, was 
formerly one of the principal practitioners in the town, but 
the state of bis health unfortunately compelled him to 
relinquish active work some yearn ago and he had for a long 
time been a confirmed invalid. He was born in 1850 at 
Lichfield in Staffordshire, where his father was a solicitor. 
He studied medicine at King’s College and was admitted 
a Licentiate of the Society of Apothecaries in 1871 ; in 1873 
he took the diplomas of L.R.O P.Lond. and M.R C.S. Eng. He 
went to Newbury in 1876 and entered into partnership with 
the late Dr. Ryott. When the Newbury district hospital was 
established in 1885 he joined the medical staff, and on 
resigning his position in 1898 on the ground of ill-health he 
was elected one of the consulting medical officers. He was 
for a time a member of the Newbury town council and filled 
several other offices of local importance, having been a com¬ 
missioner of taxes and librarian of the literary and scientific 
institution. He was one of the founders of the Newbury 
and District Medical Society, of which he was afterwards 
honorary secretary and president. Mr. Birch was married in 
1882. and besides a widow he has left four sons and one 
daughter. The body was cremated at Woking on Jan. 25th. 


FREDERICK MORITZ SYKES, L.R.C.P. & S. EDIN., 
L.F.P.S. Glass. 

Thf. death of Mr. Frederick Moritz Sykes occurred after a 
short illness at his residence, the Manor House, Bridlington, 
on Feb. 7th. The deceased, who was a native of Clitheroe, 
studied at Edinburgh, and after qualifying there and also 
obtaining the Licence of the Glasgow Faculty made a 
voyage to the Amazon. In 1894 he went to Bridlington 
where he entered into partnership with Dr. T. Thompson, 
with whom he carried on a very extensive practice up to 
1900, when his partner left the town in consequence of 
failing health. Thereafter, Mr. Sykes undertook the entire 
conduct of the practice alone. He was a member of the 
honorary medical staff of the Lloyd Hospital. From the 


first he was exceedingly popular and was held in great esteem 
by all classes of the community. 


Deaths op Eminent Foreign Medical Men. —The 
deaths of the following eminent foreign medical men 
are announced :—Dr. G. Levy, formerly physician of the 
Civil Hospital of Strasburg.—Dr. T. Lemberger, privat- 
docent of pharmacology in the University of Cracow. 


Uttbiotl Jjttfos. 


Conjoint Examinations in Ireland by the 
Royal College of Physicians and the Royal College 
of Surgeons. —A.t examinations held in February for the 
Diploma in Public Health the following candidates were 
successful :— 

Martha Adams, M.B. Glasg.; Robert. Muscbamp, L.R.C.P. A S. Edin.; 

and John James Scanlau, L.R.C.P. & S. Edin. 

Apothecaries’ Hall of Ireland.— At a special 

meeting of the court held on Feb. 3rd the following 
candidates having passed the necessary examinations were 
admitted Licentiates in Medicine, Surgery, Midwifery, and 
Pharmacy of the Apothecaries’ Hall of Ireland :— 

Synott Valentine O'Connor and John Hargreaves Robinson. 

Foreign University Intelligence.— 

Bodapett: Dr. Frans Poor has been recognised as privat- 
docent of Dermatology and Dr. Kornel Scholtz as privat- 
docent of Ophthalmology.— Heidelberg: Dr. Carl Menge of 
Erlangen has been appointed Professor of Midwifery and 
Gynrecology in succession to Professor von Rosthorn. —Kief : 
Dr. F. Stefanis, Extraordinary Professor of Anatomy, has 
been appointed Ordinary Professor.— Philadelphia: Dr. B. F. 
Stahl has been appointed Professor of Medicine and Dr. 
M. B. Hartzell Professor of Dermatology in the Woman’s 
Medical College of Pennsylvania, and Dr. J. H. Gibbon Pro¬ 
fessor of Surgery in the Jefferson Medical College. —Pita : 
Dr. G. Gonella of Cagliari has been appointed to the chair 
of Ophthalmology.— Toronto: Dr. Charles K. Claike has 
been appointed to the chair of Psychiatry. 

Literary Intelligence.— The Oxford Uni¬ 
versity Press will publish immediately the Fitz Patrick 
lectures delivered before the Royal College of Physicians of 
London by I)r, Norman Moore, under the title “ The History 
of the Study of Medicine in the British Isles,” The volume 
contains numerous illustrations. 

Congress of the Royal Institute of Public 

Health at Buxton. —A congress of the Royal Institution 
of Public Health will take place at Buxton from July 18th 
to 24th under the presidency of the Right Honourable 
Victor Cavendish, M.P. An exhibition of medical and sani¬ 
tary equipments, appliances relating to school hygiene, and 
gas, water, and electrical apparatus will be held in the fine 
corridor of the Buxton Pavilion (852 feet long), and will 
be open to the public. The honorary secretaries of the 
exhibition are Mr. J. W. Souden and Mr. W. J. Leeming, 
Electricity Works, Buxton. 

Unregistered Dentists.— At a meeting 

recently held at Torquay of the registered dental prac¬ 
titioners of Torquay and Paignton the following motion was 
carried :— 

That in view of the rapidly increasing number of unregistered 
persona practising dentistry aud evading the Dental Act of 1878, we 
appeal to all registered dental surgeons throughout the country to use 
their utmost endeavour by local combination to Hssist the authorities in 
taking steps to amend the Act and whenever possible to bring forward 
cases to enable them to take action. 

The following resolution has been signed and sent to the 
General Medical Council 

We the undersigned registered dental surgeons in practice in 
Torquay and Paignton, S. Devon, desire to draw your attention to the 
urgent need for some action to be taken to check the increasing evil 
of unregistered persons practising dentist ry and evading the Dentists 
Act of 1878. During the past two years ten or more unregistered 
persons have started practice in these towns and the vicinity and we 
feel it is quite time that something should be done for our protection. 
(Signed)—Torquay: J. It. Andrews, F. N. Codrington Butler, Frank 
Briggs, J. Garnet Hernsted, Alfred Hunt, H. Helyar, T. S. Kendell, 
L. Strangways, J. Glanville Turle, and Rupert Wheatley. Paignton i 
C. B. Grenville, William Foot, James Petherbridge, and Vv. R. 
Whelock. 





532 The Lancet,] 


MEDICAL NEWS.—PARLIAMENTARY INTELLIGENCE. 


[Feb. 15, 1908. 


Royal College of Surgeons of England: 
Appointment of Conservator — Ac an ordinary monthly 
meeting of the Council of the Royal College of 
Surgeons held on Thursday last Dr. Arthur Keith, lecturer 
on anatomy and curator of the museum at the London 
Hospital, was appointed Conservator of the museum of the 
College. 

The Royal Waterloo Hospital for Children 

AND Women. —His Majesty the King has recently caused 
ten brace of pheasants and his annual subscription of 
£10 10s. to be forwarded to the Royal Waterloo Hospital, 
S.E. This institution was founded in 1816 by the late 
Queen Victoria's father, H R H. the Duke of Kent. 

Presentation to a Medical Practitioner.— 
On Feb. 6th the chief constable of Exeter, on behalf of the 
members of the Exeter police force, presented Mr. Joseph 
Anthony Wenceslaus Pereira, M.D Brux., L.R.C.P. Lond., 
M.K.C.S. Eng., with a portrait of himself as a mark of 
appreciation of his services to the force. 

Ashton Infirmary.— The District Infirmary, 
Ashton-under-Lyne, was founded in 1860 and since that time 
has been endowed with £64 478. The annual meeting of the 
subscribers was held on Feb. 1st and the familiar story 
told that more help was required, as the present income 
would not suffice for present wants, while the claims on the 
institution were always increasing. The deficit on general 
purposes was £1696 and the extension fund account was 
overdrawn by £1099, making a total of £2795. The 
chairman said that “ the hospital was almost exclusively 
carried on for the benefit of the working people 
and he appealed to that class for increased help.” 
An interesting part of the proceedings was an address 
by the Hon. Miss Brodrick who was a nurse at the 
infirmary two years ago. 

St. Petersburg Psycho-Neurological Insti¬ 
tute.—T he Novoe Vremya says that the Psycho-Neuro¬ 
logical Institute, organised by Professor Bechtereff and 
involving an expenditure of £80,000, is about to begin 
work. The governing idea of the promoter is the 
“scientific observation of psychic and nerve diseases un¬ 
interruptedly and over a long series of years, as far as 
possible in the same patient, so that an ideal patient for the 
institute would be a child whose growth, development, and 
life would furnish to the observer a complete biography in 
the form of a living picture. Specialists in many aspects of 
human life, besides medical men, will use the institute, so 
that patients may be studied from every point of view.” The 
institute is on ground belonging to the Military Medical 
Academy but is under the control of the Ministry of Public 
Education. 

Medico-Psychological Association of Great 
Britain and Ireland —The next quarterly meeting of 
this association will take place, by the courtesy of Dr. A. 
Miller, at the Warwick County Asylum, Hatton, on Thursday, 
Feb. 20th, at 3 o’clock, under the presidency of Dr. P. W. 
MacDonald. Dr. John Turner will give a lantern demonstra¬ 
tion and read a paper upon Some Further Observations 
bearing on the Supposed Thrombotic Origin of Epileptic Fits. 
Dr. R. Cunyngham Brown will read a paper entitled “The 
Boarding-out of the Insane in Private Dwellings,” which 
will be illustrated by lantern views. Dr. Miller invites 
members to luncheon at the Hatton Asylum at 1.30 p.m. and 
it is requested that an early reply may be sent to him 
Members will dine together at 7 o'clock at the Regent Hotel, 
Leamington, and will entertain some distinguished guests 
from the neighbourhood. It is hoped that as many members 
as possible will be present at the dinner. Evening dress 
is optional. 

British Medical Association : Award of 
the Middlemore Phize. —At the recent meeting of 
the Council of the British Medical Association the Middle- 
more Prize was awarded to Mr. Simeon Snell, F.R.C.S. 
Edin., for his contributions to the science of ophthalmology. 
This prize is of the value of £50, together with an 
illuminated scroll, and was founded by the late Richard 
Middlemore, ophthalmic surgeon of Birmingham, who be¬ 
queathed a sum of moDey for an award to be made every 
third year for the best essay on the scientific and practical 
value of improvements in ophthalmic medicine and surgery 
made or published during the previous three years. By a 
supplemental deed it was provided that the award might be 


made for the best essay or work on any subject in any 
department of ophthalmology. Mr. Simeon Snell iB Presi¬ 
dent-elect of the British Medical Association and the prize 
will be handed to him at the forthcoming annual meeting at 
Sheffield in July next. 

Death of a Centenarian.— Mrs. Mary Davies 

of Ystradmynach died recently at the age of 104 years. 

The State Registration of Nurses. — A 

public meeting in support of the State registration of trained- 
nurses will be held at the Caxton Hall, Westminster, S.W., 
on Friday, Feb. 21st, at 3 P.M. The chair will be taken by 
the Lady Helen Mnnro Ferguson. 

Donations and Bequests. — The late Mr. 

Thomas Hawley of Coventry by will bequeathed £500 to 
the Barnardo Homes, and a similar sum to the Leamington 
Hospital for Incurables.—By the will of Mrs. Mary Berrey of 
St. Leonards, Sussex, £1000 are bequeathed to the Beau Site 
Convalescent Home, Hastings, and a like sum to the Royal 
Society for Incurables, Putney.—During 1907 the employees 
of Messrs. J. S. Fry and Sons voluntarily collected £632 for 
the Bristol medical charities. 


IJarliaiwirtitrij Jntelligmt. 


NOTES ON CURRENT TOPICS. 

Industrial Poisoning. 

A copy of the preliminary tables of cases of industrial poisoning, 
fatal and non-fatal accidents, and dangerous occurrences in factories and 
workshops during the year 1907 has been presented to Parliament in 
pursuance of the Factory and Workshop Act, 1901, and the Notice of 
Accidents Act, 1906. 

National Physical laboratory. 

The report of the Committee appointed by the Treasury to inquire 
generally into the work now performed at the National Physical 
Laboratory has been laid on the table of the House of Commons. 

The Children Pill. 

Several of the provisions of the Children Bill which Mr. H. Samuel, 
the Under Secretary for the Home Department, introduced into the 
House of Commons on Monday are of special interest to the medical 
profession. The measure is of a consolidating as well as of an amend¬ 
ing nature. For example, it re-enacts the Infant Life Protection Bill 
of 1897, which was passed to stop the evils of baby-farming and to pro¬ 
tect the lives of infants sent out to nurse. That Act has been found 
ineffective and the Government proposes that a Select Committee should 
examine the subject and submit couclusions to the House so to 
enable them to be included in the Bill in its later stages. The Bill 
further proposes to deal with the evil of the overlying of infants. 
Mr. Samuel stated that over 1600 infants a year met their death by 
overlying and that this waste of life might be prevented. The Govern¬ 
ment proposes that a penalty should be imposed in such cases. The 
offence is not one of wilful cruelty but of negligence, and the penalty 
will be a light one except in cases where drunkenness can be proved. 
A penalty is also proposed in cases where children meet their death by 
scalds and burns received through having been left alone in a room 
with unguarded fires. 

The evil of smoking by juveniles is at last to be tackled, and no part of 
the Bill was received with more applause than that in which the Govern¬ 
ment proposes to put a stop to the practice, so far as is possible, by legis. 
lation. The Bill prohibits the sale of cigarettes', or of cigarette papers, to 
young persons under the age of 16. It further prohibits these young 
persons from smoking in streets and public places, and makes them 
liable to a reprimand for the first offence and to a light fine for sub¬ 
sequent infringements of the law’ in this respect. A still more 
effective provision of the Bill places in the hands of the police and of 
other authorised persons the powor to confiscate the tobacco which is 
being used by these youthful smokers in the streets. The Home Office 
has also under consideration a plan to deal with automatic machines 
for the Bale of cigarettes, but Mr. Samuel, whose remarks were circum¬ 
scribed by the operation of the “ ten minutes’ rule,*' did not mention the 
lines on w'hich the department proposed to proceed in this matter. The 
Bill, which is very comprehensive in its scope, contains clauses for the 
establishment of children’s courts and for the separation of the child 
offender from the ordinary adult criminal. The proposal further is to 
abolish the imprisonment of children and young persons up to the age 
of 16 years with a few carefully designed and necessary exemptions. A 
most favourable reception was 'given to the Bill which was read a first 
time. 

Infant Life Protection Bill . 

Mr. Stayelky Hill’s Bill to amend the Infant Life Protection Act of 
1897 has been published. The object of the Bil is to extend the pro¬ 
visions of the Act to cases where only one child is taken in to be 



The Lancet,] 


PARLIAMENTARY INTELLIGENCE. 


[Hub. 15,1908. 533 


nunod or maintained in consideration of a sum of money paid down. 
The Bill further enables the local authority to remove an infant kept 
by a person who is unfit by character or otherwise to have his or her 
care or maintenance or who is in a house unsuitable for the purpose. 
This subject is also dealt with in the Children Bill. 

Dairies ( Scotland) Bill. 

A Bill has been introduced into the House of Commons by Mr. 
Gulland for the purpose of regulating dairies in Scotland and 
insuring the purity oi milk-supplies. 


HOUSE OF LORDS. 

Tuksday, Feb. 11th. 

Milk Legislation. 

The Ear! of Northjirook asked the President of the Boani of Agri¬ 
culture whether it was the intention of the Government to introduce 
legislation with regard to the milk supply during the present session ; 
and. in the event of such legislation being introduced by the Local 
Government Board, what steps the Board of Agriculture proposed to 
take for the purpose of safeguarding the interests of agriculture. 

Earl Carrington said that, as bad been announced in the House 
of Commons, it was the intention of the Government to introduce 
legislation this session with regard to milk-supply. Ho admitted 
that the present control of the milk industry was not at all in as satis¬ 
factory condition as could bo wished. The Board of Agriculture was 
anxious to do everything it possibly could to put the industry on a 
6afer and more satisfactory basis. As regarded the second part of the 
question the Government could not be expected to make a definite 
announcement until the proposals were a little more developed. He 
would do all he could legitimately to protect farmers consistently with 
the public interest. _ 


HOUSE OF COMMONS. 
Wednesday, Feb. 5th. 


Moisture in Irish Butter. 

Mr. Richardson asked the honourable Member for South Somerset, as 
representing the President of the Board of Agriculture, what labelling 
would be necessary for Irish butter sold to the public which might 
contain more than 16 per cent, of moisture and up to 24 percent, of 
moisture.—Sir Edward Strachey replied: The Board has no 
authority to determine the manner in which Irish butter containing 
more than 16 per cent, of water should be sold so as to avoid giving rise 
to a complaint by the purchaser under the Sale of Food and Drugs Acts 
and it is not desirable that it should express au opinion on the 
question. 

A Case of Anthrax. 

Sir Francis Channing asked the Secretary of State for the Home 
Department whether an inquiry had been, or would be, made into the 
death by anthrax in the Royal Albert Hospital, Devonport, of John 
Tidds, a labourer, who had recently been employed in unloading a 
steamer which arrived from Karachi with a cargo of grain; and 
whether, having regard to occasional cases of infection from 
handling cargoes of hides, wool, and other articles from abroad, 
representations by circular, and in British possessions by regulations, 
had been, or would be, made and communicated to foreign 
shipper*. British consuls, and officials to secure better precau¬ 
tions against infection —Mr. Gladstone furnished the following 
written reply : Inquiries have been made by the factory inspector of 
the district and the certifying surgeon into this case. It appears that 
the man had been engaged in the hold of the vessel handling bags 
containing Karachi barley and it is suggested by the certifying sur¬ 
geon that the infection was conveyed by the sacks. A danger of this 
kind is obviously one that is very difficult to guard against. The 
Home Office has circulated cautionary notices for posting in promises 
where infected material is likely to be handled, and has also, through 
the Foreign Office, circulated widely to our consuls abroad copies of 
a series of lectures on anthrax which were delivered some little time 
ago by the medical inspector of factories. It is difficult to see what 
further steps ean be taken until the advance of scientific inquiry dis¬ 
closes new' methods of detecting the danger and new precautions that 
may be taken to meet it. 

Thursday, Feu. 6th. 


The Administration of the Vaccination Act, 1007. 

Mr. Lloyd Morgan asked the Secretary of State for the Home 
Department whether when declarations were made by conscientious 
objectors under the Vaccination Act, 1907, before a justice of the peace 
without going to petty sessions a fee of la. had to be paid by the person 
making the declaiation; and whether the justice of the pence before 
whom the declaration was made was obliged to demand the payment 
of the fee and pay it over to the county fund as a clerk’s fee.—Mr. 
Gladstone replied : A fee authorised bv a table of justices' clerk's 
fees can be demanded only when a clerk has rendered the service in 
respect of which the fee is authorised. I am advised that when a 
declaration is made before a justice in the absence of a clerk no fee 
should be demanded. 

Mr. Black asked the President of the Local Government Board 
whether he was aware that vaccination officers in some parts of the 
country were not sending the parents of unvaccinated and un¬ 
exempted children the notice ** Q ” before those children reached the 
age of four months ; and whether he would issue a special circular to 
all vaccination officers reminding them of their duty in this respect, 
so that those parents who were still unaware of the provisions of the 
Act of 1907 might have time to acquaint themselves with the present 
state of the law before it was too late for them to make a declaration 
of conscientious objection when they wished to do so, but were unaware 
of the time limit.—Mr. Burns replied : I have not received the com- 

f rtaint that vaccination officers in any part of the country are not send- 
ng the notice referred to. Their duty in the matter was pointed out in 
a circular issued to the guardians last year, a copy of which I requested 
might be given to each vaccination officer. It does not seem necessary 
to issue another circular; but if my honourable friend is aware of any 
case in which the vaccination officer has omitted to serve the notice, and 


if he will give me the particulars of it, I will make inquiry with regard 
to it. I may add that in consequence of orders which I have caused to be 
issued the parent is made acquainted with the provisions of the new 
Vaccination Act at the time when the birt h of the child is registered. 
These orders have been in force Bince September last. 

Mr. Crooks asked the President of the Local Government Board 
whether his attention had been called to difficulties that had arisen in 
obtaining the benefits of the Vaccination Act. 1907, in cases where the 
father of a child had been personally precluded from making a 
statutory declaration in consequence of absence from England on 
business as a sailor or otherwise at the time of the birth of his child 
and for the four months afterwards allowed by the Act in which the 
statutory declaration was to be made; and whether he would consider 
the advisability of taking steps, by legislation or otherwise, to enable 
iu such circumstances the wife to make the necessary statutory 
declaration under the provisions of Section 35 of the Vaccination 
Act, 1867, in the absence of her husband —Mr. Burns replied 
by written answer : My attention has been called to difficulties of the 
kind mentioned since the passing of the Act of last session. The law 
officers advised in 1898 that, in ordinary circumstances, the father was 
the only person who could obtain a certificate of conscientious objection, 
and a similar view would no doubt apply to the making of a declara¬ 
tion under the recent Act. I am not empowered to decide whether, in 
circumstances such as those mentioned in the question, the mother 
would lie the person comnetent to make the declaration, but it 
seems to me that, if she did so, proceedings ought not to be taken 
against the father. 

Friday. Feb. 7th. 

Medical Appointments in the Territorial Force. 

Mr. Crooks asked the Secretary of State for War whether it was 
proposed to appoint Surgeon Lieutenant Colonel (Honorary Surgeon- 
Colonel) P. B. Giles, one of tho medical officers of the First Hereford¬ 
shire Rille Volunteers, to the office of principal medical officer of one 
of the London divisions of the Territorial Army, who did not reside in 
London ; and, if any question of seniority of commission was concerned 
in the appointment, whether Buch a principle of selection had been 
adopted in connexion with similar appointments to other divisions of 
the Territorial Army. —Mr. Haldane furnished the following written 
reply: It is proposed to appoint this officer as stated in the question. 
He is commandant of the Volunteer Ambulance School in London, an 
institution which has been most successful in training a large proportion 
of volunteer medical officers. He resides near London. Seniority was 
not the determining factor in selecing officers for the appointment 
mentioned in the question, but those officers best fitted to carry out the 
work were chosen, seniority being given its due weight. 

Monday, Feb. 10th. 

The Medical Inspection of School Children. 

Mr. Wedgwood asked the President of the Board of Education 
whether his attention had been called to the speech of the chairman of 
tho Staffordshire education committee in which he stated that the 
efficiency or otherwise with which the local authorities put Into opera¬ 
tion the medical inspection of school children would be a determining 
factor in the annual grant given by the Board of Education ; whether 
this was generally known by all local education authorities; and 
whether the Board would circularise authorities, stating at the same 
time that it considered the appointment of whole-time medical men, as 
in Staffordshire, to lie the surest way of securing this efficiency.— 
Mr. McKenna replied : The Board has stated in section 10 of the 
Memorandum on Medical Inspection which has been issued to all local 
education authorities that the effectiveness of the minimum 
inspection required under the Act will in future be one of 
the elements to be considered in determining tho efficiency of 
each school as a grant-aided school. The appointment of whole-time 
medical officers will no doubt be advisable in larger and more populous 
districts, but In view of tho differences in area and population among 
the various local education authorities who are charged with the duties 
of inspection, I do not think an expression of opinion such as my 
honourable friend suggests could be made of universal or even of 
general application. Tho Board will always be happy to give advice 
to any authority which desires to consult it, but the detailed arrange¬ 
ments and personnel required will be matters in the first instance for 
the consideration of the authority in the light of local circumstances 
and existing public health organisation. 

Mr. Mackarnkss asked the President of the Board of Education 
whether he had considered the additional expense likely to be thrown 
upon the local authorities by carrying out the medical inspection of 
children under Section 13 of the Education Administrative Pro¬ 
visions) Act, 1907; and whether it was proposed to give them any 
relief from the Imperial Exchequer.—Mr McKenna answered : The 
financial arrangements in connexion with the forthcoming Education 
Bill will include an additional grant in aid of expenses of local 
education authorities under Part III. of the Act. 

Expenditure on Vaccination. 

Answering Mr. Lupton, 

Mr. Burns said that the total expenditure by boards of guardians on 
vaccination In 1905 was £275,828 and in 1906 £260,295. The total 
expenditure for 1907 was not yet completely ascertained. 

Tuesday, Feb. 11th. 

The Royal Commission on the Feeble-Minded. 

In answer to Mr. Wf.dgvvood, Sir Henry Campbell-Bannerman 
said that the chairman of the Royal Commission on the Feeble-Minded 
had informed him that the report of the Commission, which was in au 
advanced condition, had recently been delayed by unforeseen circum¬ 
stances. but it was confidently hoped that it would be completed 
before Easter. 

The Sale of Tuberculous Cattle. 

Mr. Cathcart Wason asked the honourable Member for South 
Somerset, as representing the President of the Board of Agriculture, 
whether he was aware that cattle in the last stages of tuberculosis were 
occasionally exposed for sale and food in the open market with conse¬ 
quent risk of spread of the disease and danger to human life; and 
whether he proposed to take any steps, by legislation or other¬ 
wise, in order that persons submitting dying diseased cattle for 
sale might be prosecuted.—Mr. Burns sent the following written 
reply: My honourable friend has asked me to reply to this question. 






534 Thb Lancet,] 


BOOKS, ETC., RECEIVED. 


[Feb. 15, 1908 


My attention has been called to the subject referred to in it and in 
September last I caused a circular to be issued to local authorities 
bringing the matter under their notice in order that they might, as 
far as possible, exercise supervision over the cattle in their districts 
with a view to anticipating and so averting possible or intended 
infringement of the law. I also suggested that suitable officers of the 
local authority should be instructed to watch closely the cattle 
markets, slaughter-houses, and knackers' yards in the district, with 
the view of satisfying themselves that no animal, the condition of 
which appears to render it unfit for human consumption, is disposed 
of in such a manner that it is likely to be used for this purpose. 

The Death-rate in Britain and Germany. 

Mr. Haddock asked the President of the Local Government Board 
what was the reduction in the death-rate in Germany and the United 
Kingdom between the years 1870 and 1906.—Mr. Burns furnished the 
following written reply: The Registrar-General's figures for England 
and Wales only give the death-rates for the German Empire from 1872 
onwards. I have thought it better, therefore, to compare the quin¬ 
quennia 1872-76 and 1901-05 and the single years 1872 and 1905 : — 


1 

Percentage reduction in death-rate j 
between— 

United 
Kingdom. | 

- 

German 

Empire. 


Per cent. 

Per cent. 

(1) 1872-76 and 1901-05 . 

23 

28 

(2) 1872 and 1905 . 

26 

1 

32 


It should be added that, although the German death-rate has de¬ 
clined to a greater extent than the English death-rate, it remains (tn 
1905) 19 8 per 1000 of population, as against 15 5 per 1000 in the United 
Kingdom. In other words, the death-rate of Gerraanj’ in 1905 was 
28 per cent, higher than that of the United Kingdom. 

Wednesday, Feu. 12th. 

The Mid wives Act. 

Mr. Rogers asked the President of the Local Government Board 
whether he had considered the provisions of the Midwives Act, 1902, 
which forbids the practice, habitually and for gain, of midwifery after 
Jan. 1st, 1910, by any woman not certified under the Act; whether he 
was aware that much doubt existed whether it would be found 
possible then and in future for trained certified midwives to 
earn an adequate livelihood by the practice of their profession 
in rural districts where population and births were few in 
number; and whether, in view' of the importance of proper 
care for mother and child and the close proximity of the 
date after which unskilled attendance was forbidden, he was 
prepared to introduce further legislation charging the supervising 
authorities, as created by the Act of 1902, with the duty and the power 
of securing for all cases of childbirth within their area such efficient 
nursing as the Act requires, but for which no provision was made.— 
Mr. Burns replied : The attention of the Government has been called 
to this matter, which is primarily one for the Lord President of the 
Council. I understand that the whole subject is receiving his considera¬ 
tion and that he is in communication with the Central Midwives Board 
with regard to it. 


BOOKS, ETC., RECEIVED. 


American Ophthalmological Society, Hartford. (Secretary, Dr. 
S. B. St.John, 26, Pratt-street. Hartford, Conn., U.S.A.). 

Transactions of the American Ophthalmological Society. Forty- 
third Annual Meeting, Washington, D.C., 1907. Vol. XI., 
Part II. 

Appleton, Sidney, London. 

A Text-book of Minor Surgery. By Edward Milton Foote, A M.. 
M.D., Instructor in Surgery, College of Physicians and Surgeons 
(Columbia Uni vend ty); Lecturer on Surgery, New York Poly¬ 
clinic Medical School. Price 21« net. 

A King in ltag6. By Cleveland Moffett. Price 6s. 

Bailliere, J. B. f et Fils, 19, Rue Hautefenille, Paris. 

Nouveau Traite de Chirurgie. Public en Fascicules sous la 
Direction de A. Le Dentil et Pierre Delbet. V. Maladies des Ob, 
LosionB Infectieuses, Parasitaires, Trophiques, Nt^oplasiques. 
Par Pl.Mauclaire, Professeur Agrege it la Faculte de Medecine de 
Paris. Chirurgien de la Maisou Aluuicipale de Sant^. Price, 
paper, Fr.6.; cloth, Fr. 7 50. 

BAiLLiftRK, Tindall and Cox, 8, Henrietta-street, Covent Garden, 
London, W.C. 

Protozoa and Disease, Comprising Sections on the Causation of 
Small pox, Syphilis, and Ca icer. By J. Jackson Clarke, M.B. 
Lond , F.R.C.S. formerly Pathologist to St. Mary's Hospital and 
Curator of the Museum,’ Demonstrator of Bacteriology, and Pro¬ 
visional Teacher of Biology in the Medical School. Part 11. 
Price Is. 6d. net. 

Ballantyne and Co., Limited, Tavistock-street, Covent Garden, 
London, W.C. 

The Principles of the Treatment of Gout. By Alfred W. Sikes. 
M.D., D Sc. Lond., F.R.C.S., M.U.C.P., late Medical Registrar. 
Demonstrator of Physiology and Demonstrator of Practical 
Medicine to St. Thomas’s Hospital, and Pathologist to Queen 
Cnarlotte’s Hospital. Pathologist to the Samaritan Hospital, 
Demonstrator of Physiology to King’s College. Price not 

Egvpt*and How to See It. Illustrated by A. O. Lamplough. 
Price 2s. 6 d. 

Bell, George, and Sons, London. 

The Black Death of 1348 and 1349. By Francis Aidan Gifquet, 
D.D , Abbot President of the English Benedictines. Sucoud 
edition. Price ts. net. 


Butterworth and Co 11 and 12, Bell Y'ard, Temple Bar, London. 

A Treatise on the Law relating to the Devolution of Real Estate on 
Death, under Part I. of the Land Transfer Act. 1897, and the 
Administration of Assets, Real and Personal. By the late Leopold 
George Gordon Robbins (Late Reader in Equity to the Inns of 
Court), and Frederick Trentbam Maw, both of Lincoln's Inn, 
Barristers-at-Law. Fourth edition. By Frederick Trentbam 
Maw. Price not stated. 

Churchill, J. and A., 7, Great Marlborough-street, London, W. 

The Functional Inertia of Living Matter: A Contribution to the 
Physiological Theory of Life. By David FraBer Harris, M.B., 
C.M., M D., B.Sc. Lond.. F.R.S.K., Lecturer on Physiology and 
Normal Histology in the University of St. Andrews; Examiner 
to the University of St. Andrews LL.A. Scheme; Vice-president 
of the Scottish Microscopical Society; Member of the Physio¬ 
logical Society and Royal Society of Medicine. Price 5s. net. 

Lectures on Medical Jurisprudence and Toxicology, as delivered at 
the London Hospital by Fred. J. Smith, M.A., M.D. Oxon., 
F.R.C.P. Lond., F.lt.C S.'Eng., Physician to, and Lecturer on, 
Forensic Medicine at the London Hospital; Medical Referee to 
the Horae Office. Second edition. Price 8*. 6 d net. 

Repons of the Society for the Study of Disease in Children. 
Vol. VII. Session of 1906-1907. Editor : George Carpenter, M.D. 
Price 12s. 6 d. net. 

Constable, Archibald, and Co., Limited, 10, Orange-street, 
Lelcestcr-square, London, W.C. 

Detection of the Common Food Adulterants. By Edwin M. Bruce, 
Instructor in Chemistry, Indiana State Normal School. Price 

Dairy* Laboratory Guide. By Charles W. Melick, B.S.A., M.S., 
Professor of Dairy Husbandry, Maryland Agricultural Experi¬ 
mental Station. Price bs. net. 


Edited 


Deuticke, Franz, Leipzig und Wien. 

Die Augenheilkunde in der Rbmerzeit. Von Dr. Rodolfo del 
Castillo y Quartiellers in Madrid. Autorisierte Ubersetzung aus 
dera Spanischen. Von Dr. Max Neuburger, Professor an der 
K.K. Universitfit in Wien. Price not stated. 

Doin, Octave, 8, Place de l’Od^on, Paris. 

Maladies do la Moelle et du Bulbe (Non Systematisees): Polio 
myelites, Sclerose en,Plaques, Syringomyelie. Par le Dr. C. 
Oddo, Professeur A l’Ecole de Modecine de Marseille, Medecin 
des HOpitaux de Marseille. Price not stated. 

Goose and Son, Norwich (Simpkin, Marshall, and Co., London). 

The Ritual of Temperance and Bodily Cleanliness. By Dr. H. C. 
Pattin, M.A., D.P.H., Medical Officer of Health for the City of 
Norwich. Price Is. net. 

Health Resorts Bureau, The, 27, Chancery-lane, London, W.C. 

The Lake ol Garda. By J. Greble Leech. The Official Guide to 
Lake Garda. Price la. net. 

Keoah Paul, Trench, TrOuxer and Co., Limited, Drydcn Home, 
Gerrard-street, London, W. 

A Proposal (or a Simplified Calendar. By Alexander Philip, LL.B. 
Price 6 d. net. 

Lewis. H. K., 136, Gower-street, London, W.C. 

Diseases of the Nose and Throat. By Herbert Tilley, B.S. Lond., 
F U C S ling Surgeon to the Ear and Throat Department, Uni¬ 
versity College Hospital, Loudon ; Teacher of Laryngology and 
Otology, University of London; formerly Surgeon to the Uolden- 
snuare Throat Hospital, London. Price 14a. net. 

Tumours of the CereDellum. By John Wyllie, M.D. Price 4a. net. 

Lloyd, Edward, Limited, Salisbury -square, Londou. 

The Municipal Tear-book of the United Kingdom for 1908. 
by liobert Donald. Price 7a. 6d. net. 

Longmans, Green, and Co., London, New York, Calcutta, and 
Bombay. 

Proceedings of the lloyai Society of Medicine. Vol. I., No. 2. 
December, 1907. Price 7s. 6d. 

Stoichiometry. By Sydney Young. D.Sc.. F.K.S., Professor of 
t’hemlatrv in the Uuiverslty of Dublin. Together with an Intro¬ 
duction to the Study of Physical Chemistry by Sir William 
ltamsay, K.C.B., F.R.8., Editor of the Series. Price 7a. 6 d. 

Macmillan and Co., Limited, St. Martin's street, London. 

Comparative Anatomy ol Vertebrates. Adapted irom the German 
of Dr Hubert Wiedershelm, Professor of Anatomy, and Director 
of the Institute oi Human and Comparative Anatomy in the 
University of Freiburg iu-Baden. By W. N. Parker, Ph.D., Pro¬ 
fessor of Zoology at tue University College of Soutb Wales and 
Monmouthshire in the University of Wales Third edition 
(founded on the sixth German edition). Price 16s. net. 

New Stdenham Society, The, London. (Agent; H. K. Lewis, 136, 
Gower-street, London, W.C.)| 

An Allas of Illustrations of Clinical Medicine, Surgery, and 
Pathology. Compiled ior the New Sydenham Society (A Con¬ 
tinuation of the "Atlaa oi Pathology") chiefly from Original 
Sources Fasciculus XXVII. (Double Number) being XXV. of 
the Clinical Atlas. Diseases of Fallopian Tube, Ovary, Uterus, 
Ac. Price to non-subscriberB 1 guinea. 

Stevens, B. F., and Brown, 4, Trafalgar-square, Charing Cross, 
Loudon. 

Optimism r Real Remedy. By Horace Fletcher. With a Foreword 
by William Dana Orcutt. Price 2*. 6d. net. 

“The Local Government Journal” Office, 27a, Farringdon-street, 
London, E.C. 

Tue Local Government Annual and Official Directory, 1908. 
Officially corrected. Edited by S. Edgecumbe Rogers. Seventeenth 
Year of Publication. Price 1«. 6 d. 




Thh Lancet.! APPOINTMENTS.—VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS. [Feb. 15, 19C8. 535 


Wilson, Effingham, 51, Threadneedle-stree f , London, E.C. 

A Handy Book on the Law of Private Trading Partnership. By 
JaraeB Walter Smith, Esq., K.C., LL.D.,ofthe Inner Temple, 
Barrisfcer-at-Law. Thirtieth thousand. New and revised edition. 
Price Is. 6d. net. 

Wright, Johx, and Co., Bristol. (Simpkin, Marshall, Hamilton, 
Kent, and Co., Limited, London.) 

“First Aid” to the Injured and Sick. An Advanced Ambulance 
Handbook. By F. J. Warwick, B.A., M.B. Cantab., M.R.C.S., 
L.S.A.. and A. C. Tunstall, M.D., F.R.C.S. Ed. Filth edition. 
Revised and enlarged. 30th thousand. Price, paper, Is. net., 
cloth, 2*. 6(1. net. 




Successful applicants for Vacancies, Secretaries of Public Institutions, 
and others possessing information suitable for this column, are 
invited to forward to The Lancet Office, directed to the Sub- 
Editor, not later than 9 o'clock on the Thursday morning of each 
week, such information for gratuitous publication. 


Alexander, G. H., has been appointed Clinical Assistant to the 
Samaritan Free Hospital. 

Chisolm, R. A., M.B., B.S. Oxon., has been appointed Assistant Phy¬ 
sician to the North-Eastern Hospital for Children, Hackney-road, 
Bethnal Green. 

Creswell, A. H., L.S.A., has been appointed Certifying Surgeon 
under the Factory and Workshop Act for the Cinderford District 
of the county of Gloucester. 

IIall, George, M.D. Lond., B.Sc. Durh., M.R.C.P. Lond., has been 
appointed Honorary Pathologist to the Royal Victoria Infirmary, 
Newcastle-on-Tyne. 

IIawes. Ivon Henry Skipwith, M.B., B.S. Durh., has been appointed 
Medical Officer and Public Vaccinator for the No. 4 District by the 
Chipping Sodbury (Gloucestershire) Board of Guardians. 

Hughes, Robert, M.B. Lond., has been appointed Medical Officer to 
the School Management Committee, Fenton, Staffordshire. 

Morgan, David James, M.D., B.C. Cantab., D.P.II. R C.P.S., has 
been appointed Medical Officer of Health of the County Borough 
of Swansea. 

Race, John Percy, L.R.C.P.Lond., M.R.C.S., L.S.A., has been 
appointed Assistant Medical Officer at the Joint Counties Asylum, 
Carmarthen. 

Revie, A., M B., C.M. Glasg., has been appointed Certifying Surgeon 
under the Factory and Workshop Act for the works of Messrs. 
Grant, Ritchie, and Co., Limited, at Kilmarnock, in the county of 
Ayr. 

Webb, Gilbert L., M.B., B.C. Cantab., has been appointed Resident 
Medical Officer at the British Lying-in Hospital. 

Wilson, William Robert, L.R.O.P. & 8. Irel., L.S.A., has been 
appointed Medical Officer to the Penzance Port Sanitary 
Authority. 


trades. 


For further information regarding each vacancy reference should be 
made to the advertisement (see Index). 


Bath, Rotal Mineral Water Hospital.— Resident Medical Officer. 
Salary £100 per annum, with lodging, board, and laundry. 

Bath, Royal United Hospital. —House Physician, also House 
Surgeon. Salaries £80 per annum, with board, lodging, and 
waebing. 

Bedfordshire County Council.— Assistant County Medical Officer of 
Health Salary £250 per annum, rising to £300, with expenses. 

Benenden Sanatorium for Tuberculosis.— Medical Superintendent. 
Salary £250 per annum, with board, lodging, and attendance. 

Birkenhead Borough Hospital.— Senior Resident Houne Surgeon. 
Salary £100 and fees. Also Junior Resident House Surgeon. Salary 
£80 and fees. 

Bolinobboke Hospital Wandsworth Common, S.W.—House Surgeon. 
Salary £75 per annum. 

Bolton Infirmary and Dispensary.— Senior and Junior House 
Surgeons. Salary for Senior £130 and for Junior £100 per annum, 
with apartments, board, and attendance. 

Bradford Education Committee.—T wo Assistants (one male, one 
female) to the Medical Superintendent. Salary £350 per annum 
each. 

Brighton, County Borough of.— Medical Officer of Health. Salary 
£600 per annum. 

Brighton, Sussex County Hospital.— House Physician, unmarried. 
Salary £70 per annum, with board, residence, arid laundry. 

Bristol Royal Infirmary.- Obstetric Officer. Salary £75 per annum. 
Also Junior House Surgeon for six months. Salary at rate of £o0 
per annum. Also Casualty Officer for six months Salary at rate 
of £50 per annum. All with board, lodging, and washing. 

Cardiff Education Committef..— Two Assistant Medical Officers. 
Salaries in each case £220 per annum, rising by £10 yearly to £250 
per amum. 

Carmarthen, Joint Counties Lunatic Asylum.— Second Assistant 
Medical Officer. Salary £160, increasing to £180 per annum, with 
board, lodging, washing, and attendance. 

Dudley, Guest Hospital.— Assistant House Surgeon. Salary £60 
per annum, with residence, board, and washing, 

Great Northern Central Hospital— Casualty Officer. Salary 
£100 per annum. 


Hammersmith Infirmary and Workhouse, Ducane-road, Worm¬ 
wood beruba, W.—Assistant Medical Superintendent of Infirmary 
and Assistant Medical Officer of Workhouse. Salary £120 per 
annum, with board, lodging, and washing. —— ^ 

Hampstead General Hospital, with which is Amalgamated the 
North-West London Hospital—Two Physicians and one 
Surgeon. 

Ingham Infirmary and South Shields and Westoe Dispensary.— 
Junior House Surgeon. Salary £90 per annum, with residence, 
board, and washing. 

Inverness District Asylum.— Assistant Medical Officer. Salary £1C0 
per annum, with board, lodging, and laundry. 

Kidderminster Infirmary and Children's Hospital.— House 
Surgeon. Salary £100 per annum and board. 

King Edward VII. Sanatorium, Midhurst, Sussex.—Junior 
Assistant Medical Officer, unmarried. Salary £100 per annum, 
with board, lodging, and attendance. 

Leicester Infirmary.— Assistant Houio Physician, for six months. 
Salary at rate of £50 per annum, with board, lodging, and 
washing. 

Lindsey' County' Council, Lincolnshire.—Medical Officer of Health 
and Medical Inspector of School Children. Salary £400 per annum, 
rising to £500, with expenses. 

Liverpool, David Lewis Northern Hospital.— House Surgeon, also 
House Physician. Salary £60 each per annum, with residence and 
maintenance. 

London Temperance Hospital.— Medical Registrar and Surgical 
Registrar. Salaries 40 guineas per aunum. Also Pathologist and 
Bacteriologist. Salary 50 guineas per annum. Also Anesthetist. 
Salary 20 guineas per annum. Also Radiographer. Salary 
10 guineas per annum. 

Maidstone, Kent County Asylum.— Fourth Assistant Medical 
Officer, unmarried. Salary £175 per annum, with quarters, attend¬ 
ance, See. 

Metropolitan Hospital, Klngsland-road, N.E.—Resident Anres- 
thetist. Salary at rate of £40 per annum. Also Casualty Officer. 
Salary at rate of £150 per annum. 

Middlesex Hospital, W.—Registrar to the Cancer Wards, also 
Scholar in the Cancer Research Laboratories. Salary of the 
Registrar £40 per annum and of the Research Scholar £60 per 
aunum. 

National Hospital for the Paralysed and Epileptic, Albany 
Memorial, Queen-square, Bloomsbury.—Assistant Pathologist. 
Salary 50 guineas per annum. 

New Hospital for Women.— Senior Assistant, Out-patient Children's 
Department; Two House Surgeons; Pathologist; also Medical 
Woman to take Charge of the Mechano Therapeutic Department. 

Norfolk County Council. —Medical Officer of Health. Salary £500 
per annum, rising to £650. 

North-Eastern Hospital for Children, Hackney-road, Bethnal 
Greeu, E.—Resident Medical Officer. Salary £100 perannum, with 
board, residence, and washing. 

Norwich, Norfolk and Norwich Hospital.— Assistant House 
Surgeon tor six months. Salary £20, with apartments, board, and 
laundry. 

Nottingham City Asy'I.um.— Second Assistant Medical Officer. Salary 
£150 per annum, with board, apartments, &c, 

Nottinghamshire Education Committf.f..— School Medical Officer. 
Salary £300 perannum, and travelling expenses. 

Plymouth Royal Ey*e Infirmary.— Honorary Surgeon. 

Royal College of Surgeons of England.—E xaminer in Denial 
Surgery. 

Roy’ai. Navy, Medical Department.—E xamination for not less than 
15 Commissions. 

St. George-in-the-East Infirmary and Workhouse and Casual 
Wards.— Assistant Medical Officer. Salary £120 per annum, with 
rations and apartments. 

St. Mary’ S Hospital for Women and Children, Plaistow, London, B. 
—Assistant Resident Medical Officer, unmarried, for six months. 
Salary at rate of £80 per annum, all found. 

St. Petf.r's Hospital for 8tone, &c., Henrietta-street, Covent 
Garden, W.C.—Junior House Surgeon for six months. Salary at 
rate of £50 a year, with board, lodging, and washing. 

Warrington Infirmary and Dispensary*.— Third House Surgeon, un¬ 
married. Salary £80 per annum, with residence and board. 

Worcestershire, Barnsley Hall Asylum, Bromsgrove.—Second 
Assistant Medical Officer. Salary £150 per annum, with quarters, 
board, washing, and attendance. 


®arrives, aitit $eafjjs. 

BIRTH. 

Iaxnfr.— On Feb. 4th, at Farnham, Surrey, the wife of Charles B, 
Tanner, M.D., F.R.C.S., of a aon. 


MARRIAGE. 

Beaman—Cooper.- On Feb. 1st, at St. Barnabas Church. Addison- 
road, Kensington, W., Wintrid Kelsey Beaman, Lieutenant, Royal 
Army Medical Corps, to Mary Hingland Cooper, of 1, Kensington 
Hall-gardens, W., only daughter of the late Mrs. W. A. Cooper. 


DEATHS. 

Galton.— On Feb. 7th, at Chunam, Svlvan-road, Upper Norwood. John 
Henry Galton. M. D. Lond. 

Bean.— On Feb. 6th. at Ox ford-gardens, W„ Surgeon-General william 
Henry Rean, M.D., retired, Indian Army, in his 81st year. 


N,B. —A fee of 5s. is charged for the insertion of Notices of Births, 
Marriages, and Deaths. 





53S Thb Lancet,] NOTES, SHORT COMMENTS, AND ANSWERS TO CORRESPONDENTS. [Fed. 15, 1908. 


States, Sjwri Comments, anb Jnsfoers 
to Correspondents. 

MISAPPLIED INGENUITY. 

Two men are said to have purchased 38 pound packages of margarine 
with a quarter of a pound of butter at lOd. The police Btated that 
the quarter of a pound of butter had been cut into small pieces, 
one of which had been put on the end of the pound packages of 
margarine, so that intending customers could then taste the genuine 
lOd. butter without coming to the margarine. One of the men went 
into a small shop in Blackburn, posing as a farmer whose milk 
float had broken dow’n, and asked the shopkeeper if she would take 
a pound of butter at 1#. She took it, but as it was a little short of 
weight she received Id. back. The men pleaded guilty and were sent 
to prison for three months. This will give them time to think over, 
and perhaps to improve on, their plans. It is a pity that so much 
ingenuity should take such an abnormal twist. 


George’s (1 p.m.), London (2 P.M.), King’s College (2 p.m.), Middlesex 
(1.30 p.m.), St. Mary’s (2.30 p.m.). Soho-square (2 p.m.), North-West 
London (2 p.m.), Gt. Northern Central (Gyna?cological, 2.30 p.m.), 
Metropolitan (2 30 p.m.), London Throat (9.30 a.m.), Samaritan 
(9.30 a.m. and 2.30 p.m.). Throat, Golden-square (9.30 a.m.), Guy's 
(1.30 p.m.), Royal Orthopaedic (9 a.m.). Royal Ear (2 p.m.), Children, 
Gt. Ormond-street (2.30 p.m ), Tottenham (Gynaecological, 2.30 p.m.) 
FRIDAY (21st).— London (2 p.m.), St. Bartholomew's (1.30 p.m.), St- 
Thomas’s (3.30 p.m.), Guy’s (1.30 p.m.), Middlesex (1.30 p.m.), Charing 
Cross (3 p.m. ), St. George’s (1 p.m.), King's College (2 p.m.), St. Mary’s 
(2 p.m.). Ophthalmic (10 a.m.). Cancer (2 p.m.), Chelsea (2 P.M.), Gt. 
Northern Central (2.30 p.m.), West London (2.30 p.m.), London 
Throat (9.30 a.m.), Samaritan (9 30 A.M. and 2.30 p.m.), Throat, 
Golden-square (9.30 a.m.), City Orthopaedic (2.30 P.M.). Soho-square 
(2 P.M.), Central London Throat and Ear (2 p.m.), Children, Gt. 
Ormond-street (9 a.m., Aural, 2 p.m.), Tottenham (2 30 p.m ), St. 
Peter's (2 p m ). 

SATURDAY (22nd).— Royal Free (9 a.m.), London (2 p.m.), Middlesex 
(1.30 p.m.), 8t. Thomas's (2 p.m.). University College (9.15 a.m.), 
Charing Cross (2 p.m.), St. George’s (1 p.m ), St. Mary's (10 a.m.), 
Throat, Golden-square (9.30 a.m.), Guy’s (1.30 p.m.). Children, Gt. 
Ormond-street (9.3) a m.). _ , _ _ _ . , 

At the Royal Bye Hospital (2 p.m.), the Royal London Ophthalmic 
(10 a.m.), the Royal Westminster Ophthalmic (1.30 p.m.), and the 
Central London Ophthalmic Hospitals operations are performed daily. 


PRECAUTIONS IN DISPENSING POISONOUS LINIMENTS AND 
APPLICATIONS TO HOSPITAL PATIENTS. 

To the Editor of The Lancet. 

Sir,—A distressing case of poisoning by misadventure has recently 
come under my observation in which a hospital patient, 76 years of 
age, took Borne aconite, belladonna, and chloroform liniment in 
mistake for a dose of medicine with fatal results, in spite of the fact 
that the liniment was dispensed in a fluted poison bottle, distinctly 
labelled poison , for external use only. This very forcibly impresses 
upon me the necessity of safeguarding the public as far as possible 
against such mishaps by a further precaution—that is, using a metal 
sprinkler instead of an ordinary cork for such bottles, which method 
would serve two useful purposes. In the first place it cannot, be 
removed from the bottlo without attracting the attention of children 
or persons who cannot read or in the case of a person under the 
influence of drink or distracted with pain. And in the second place 
It would insure economy in using the liniment which is a distinct 
consideration for those engaged in hospital dispensing, and although 
many suggestions have been made from time to time to make poison 
bottles more distinctive none appears to me bo practical as ming 
a sprinkler instead of an ordinary cork. Some years ago a similar 
fatality occurred with an out-patient of a Loudon hospital, but in that 
instance the belladonna liniment was dispensed in an ordinary eight- 
ounce medicine bottle. I am, Sir, yours faithfully, 

J. A. Thomas, M.P.S. 

General Hospital, Cheltenham, Feb. 8th, 1907. 

H. R. T .—We cannot give our correspondent an answer without 
knowing the circumstances of the case more definitely. There might 
be no harm in " Upsilon’s” request. 

Erratum.— In our analytical notice of Irish whisky on p. 433 in our 
issue last week, in the sentence “Analysis readily discriminated the 
tw’O, the former being a blend of pot-still and patent-still Bpirit and 
the latter a pure pot-still spirit," the word “principally” was inad¬ 
vertently omitted between the words “ latter ” and “a.” 
Communications not noticed in our present issue will receive attention 
In our next. 


Scbitiil Jliarjj for fjjc ensuing UM. 


OPERATIONS. 

METROPOLITAN HOSPITALS. 

MONDAY (17th). — London (2 p.m.), St. Bartholomew’s (1.30 p.m.), St. 
Thomas’s (3.30 p.m.), St. George’s (2 p.m.), St. Mary's (2.30 p.m.), 
Middlesex (1.30 p.m.), Westminster (2 p.m.), Chelsea (2 p.m.), 
Samaritan (Gynecological, by Physicians, 2 p.m.), Soho-square 
(2 p.m.), City Orthopedic (4 p.m.), Gt. Northern Central (2.30 P.M.), 
West London (2.30 p.m.), London Throat (9.30 a.m.). Royal Free 
(2 p.m.), Guy’s (1.30 p.m.), Children, Gt. Ormond-street (3 p.m.), 
St. Mark's (2.30 p.m.). 

TUESDAY (18th).— London (2 p.m.), St. Bartholomew’s (1.30 p.m.), St. 
Thomas’s (3 30 p.m.), Guy’s (1.30 p.m.), Middlesex (1.30 p.m.), West¬ 
minster (2 p.m.). West London (2.30 p.m.), University College 
(2 p.m.), St. George's (1 p.m.), St. Marv’s (1 p.m.), St. Mark’s 
(2.30 p.m.). Cancer (2 p.m.), Metropolitan (2.30 p.m.), Loudon Throat 
(9.30 a.m.), Samaritan (9.30 a.m. and 2.30 p.m.), Throat, Golden- 
square (9.30 a.m.), Soho-square (2 p.m.), Chelsea (2 p.m.), Central 
London Throat and Ear (2 p.m.), Children. Gt. Ormond-street 
(2 pm. Ophthalmic, 2.15 p.m.). Tottenham (2.30 p.m.). 

WEDNESDAY (19th).— St. Bartholomew’s (1.30 p.m.), University College 
(2 p.m.). Royal Free (2 p.m.), Middlesex (1.30 p.m.), Charing Cross 
(3 p.m.), St. Thomas's (2 p.m.), London (2 p.m.), King's College 
(2 p.m.), St. George’s (Ophthalmic, 1 p.m.), St. Marys (2 p.m.). 
National Orthopedic (10 a.m.), St. Peter's (2 p.m.), Samaritan 
(9.30 a.m. and 2.30 p.m.), Gt. Northern Central (2.30 p.m.), West¬ 
minster (2 p.m.), Metropolitan (2.30 p.m.), Loudon Throat (9.30a.m.), 
Cancer (2 p.m.), Throat, Golden-square (9.30 a.m.), Guv’s (1.30 p.m.), 
Royal Ear (2 P.M.), Royal Orthopedic (3 p.m.). Children, Qt. 
Ormond-street (9.30 a.m., Dental, 2 p.m.), Tottenham (Ophthalmic, 
2.30 p.m.). 

THURSDAY (20th).—St. Bartholomew’s (1.30 p.m.), St. Thomas’s 
(3.30 p.m.), University College (2 p.m.), Charing Cross (3 p.m.), St. 


SOCIETIES. 

ROYAL SOCIETY OF MEDICINE, 20. Hanover-square. W. 

Tuesday. ( Pathological Section). 8.30 p.m.. Discussion on Acidosis 
in Preguauev (opened by Dr. J. B. Leathes). Dr. Spriggs and 
Dr. Bainbridge will continue the discussion. The Obstetric 
Section of the Royal Society of Medicine is especially invited. 
MEDICAL SOCIETY OF LONDON, 11, Chandos-street, Cavendish- 
square, W. 

Monday.—9 p.m., Mr. C. J. Svmonds : Tuberculosis of the Kidney 
(illustrated by lantern slides, cases, and specimens). (Second 
Lettsomian Lecture.) 

SOCIETY OF TROPICAL MEDICINE AND HYGIENE, 20, Hanover- 
square, W. 

Friday.— 8.30 p.m., Fleet-Surgeon P. W. BaBsett-Smith: Kala 
Azar in the Iloval Navy (with illustrative cases). Sir Patrick 
Manson-. A Case of Kala Azar ending in Recovery. Dr. J. 
Cropper: Phenomenal Abundance of Malarial Parasites in the 
Peripheral Circulation from a Case of Pernicious Malaria in the 
Jordan Valley. 

SOCIETY FOR THE STUDY OF DISEASE IN CHILDREN, 11. 
Chandos street, Cavendish square, W. 

Friday.— 5 p.m.. Dr. G. Carpenter, Dr. E. Cautley, Dr. 
Whipham, Dr. P. Parkinson, Mr. G. Peraet. Mr. M. Ycarsley 
Mr. S. Stephenson, and others: Cases. Mr. H. S. Clogg: A 
Case of Intestinal Obstruction, Resection of a Foot of Gan 
grenous Intestine, Recovery. 

ROYAL MICROSCOPICAL SOCIETY, 20, Hanover-square, W. 

Wednesday.— 8 p.m., Mr. C. L. Curtles and Mr. J. E. Barnard 
Exhibitions of Slides and Lamp. Mr. E. M. Nelson : Eye-pieces 
for the Microscope. Rev. E. Tozer : The Life History of a New’ 
Protophyte. Mr. F. Chapman : On Dimorphism in the Recent 
Foraminifer, Alveolina Bondi. 

CHELSEA CLINICAL SOCIETY, Chelsea Dispensary, Manor-street, 
ChelBea, S.W. 

Tuesday.— 8.30 p.m., Mr. C. English. The Quiescent Appendix 
Dr. T. W. Parkinson: Contrast of Symptoms in Two Cases of 
Cancer of the PancreaB. 

LECTURES, ADDRESSES, DEMONSTRATIONS, &c. 

ROYAL COLLEGE OP SURGEONS OP ENGLAND. 

Monday, Wednesday, and Friday.— 5 p.m., Prof. V. Bonney: A 

Study of the Connective Tissues in Carcinoma and in certain 
Pathological Conditions preceding its Onset. 

(Hunterian Lectures.) 

MEDICAL GRADUATES' COLLEGE AND POLYCLINIC, 22, 
Cheniea-Btreet, W.C. 

Monday.—4 p.m., Dr. G. Little: Clinique (Skin). 5.15 p.m.. 
Lecture—Dr. J. M. H. MacLeod : Lupus ErythematosuB. 
Tuesday —4 p.m., Dr. W. Harris: Clinique (Medical). 5.15 P.M., 
Dr M. C. Hawkes: Swedish Medical Gymnastics, their Applica¬ 
tion in the Treatment of Diseases of the Nervous System. 
Wednesday— 4 p.m., Mr. J. Pardoe: Clinique (Surgical). 

5.15 P.M., Lecture Dr. J. Mackenzie: The Nature of the 
Symptoms in Heart Failure. . 

Thursday —4 p.m., Mr. Hutchinson : Clinique (Surgical). 

5.15 P.M., Lecture:—Dr. T. W. Eden: The Examination of 
Pregnant Women before Labour. 

Friday.—4 p.m., Mr. A. LawBon : Clinique (Bye). 
POST-GRADUATE COLLEGE, West London Hospital, Hammersmith, 
road, W. 

Monday. —12 noon, Lecture:—Dr. Low: Pathological. 2 p.m.. 
Medical and Surgical Clinics. X Kays. Mr. Dunn: Diseases 
of the Eye. 2.30 r.M., Operations. 5 p.m., Lecture:—Dr. 
Davis: Clinical. _ , . , .. 

Tuesday —10 a.m., Dr. Moullin: Gynaecological Operations. 
12 noon: Lecture Dr. Pritchard: Practical Medicine. 2 p.m.. 
Medical and Surgical Clinics. X Rays. Dr. Ball: Diseases of 
the Throat, Nose, and Ear. 2.30p.m., Operations. Dr. Abraham : 
Diseases of the Skin. 5 p..m., Lecture Dr. Moullin: Gynseco- 

WedmbSat^To a.m., Dr. Ball: Diseases of the Throat, Nose, and 
Ear. Dr. Saunders : Diseases of Children. 2 p.m., Medical and 
Surgical Clinics. X Rays. Dr. Scott: Diseases of the Lye. 
2.30 p.m. , Operations, b p.m.. Lecture :—Dr. Pritchard : On the 

Vaccination Treatment of Infective Diseases. 

Thursday.— 12 noon, Lecture:—Dr. Pritchard: Practical Medicine. 

2 p.m., Medical and Surgical Clinics. X Rays. Mr. Dunn: 
Diseases of the Eye. 2.30 p.m., Operations. 5 p.m., Lecture :— 
Mr. Edwards -. Clinical. 



The Lancet,] 


DIARY.—EDITORIAL NOTICES—MANAGER’S NOTICES. 


[Feb. 15, 1908. 537 


Friday.— 10. a.m.. Dr. M. Moullin : Gynecological Operations. 
2 P.M., Medical and Surgical Clinics. X Kays. l)r. Ball: 
Diseases of the Throat, Nose, and Ear. 2.30 p.m., Operations. 
Dr. Abraham: Diseases of the Skin. 5 p.m.. LectureDr. 
Abraham : Cases of Skin Disease. 

urday.— 10 a.m., Dr. Ball : Diseases of the Throat. Nose, and 
Ear. Dr. Saunders: Diseases of Children. 2 p.m.. Medical and 
Surgical Clinics X Kays. Dr. Scott: Diseases of the Eye. 
2.30 p.m., Operations. 

NORTH-EAST LONDON POST-GRADUATE COLLEGE, Prince of 
Wales's General Hospital, Tottenham. N. 

Monday.— Cliniques10 a.m.. Surgical Out-patient (Mr. H. 
Evans). 2.30 p.m.. Medical Out-patient (Dr. T. R. Whipham); 
Throat, Nose, and Ear (Mr. H. W. Carson); X Ray (Dr. A. H. 
Pirie). 4.30 p.m., Medical In-patient (Dr. A. J. Whiting). 
Tuesday. —Clinique:—10.30 a.m.. Medical Out-patient (Dr. A. G. 
Auld). 2.30 p.m., Surgical Operations (Mr. Carson). Cliniques-.— 
Surgical Out-patient (Mr. Edmunds); Gynecological (Dr. A. E. 
Giles). 

Wednesday.— Cliniques:— 2.30 p.m., Medical Out-patient (Dr. 
Whipham); Dermatological (Dr. G. N. Meachen); Ophthalmo- 
logical (Mr. R. P. Brooks). 

Thursday.—2.30 p.m., Gynaecological Operations. (Dr. Giles). 
Cliniques:—Medical Out-patient (Dr. Whiting); Surgical Out¬ 
patient (Mr. Carson); X Kay (Dr. Pirie). 3 p.m., Medical 
In-patient (Dr. G. P. Chappel). 4.30 p.m., Lecture:—Mr. W. 
Edmunds: Surgical Aneurysm. 

Friday. —10 a.m., Clinique:—Surgical Out-patient (Mr. H. Evans). 
2.30 P.M., Surgical Operations (Mr. Edmunds). Cliniques: — 
Medical Out-patient (Dr. Auld); Eye (Mr. Brooks). 3 p.m.. 
Medical In-patient (Dr. M. Leslie). 

LONDON SCHOOL OF CLINICAL MEDICINE. Dreadnought 
Hospital, Greenwich. 

Monday. — 2.15 p.m.. Sir Dyce Duckworth: Medicine. 2.30 p.m., 
Operations. 3.15 p.m., Mr. W. Turner : Surgery. 4 p.m., Dr. 
StClair Thomson : Ear and Throat. Out-patient Demonstra¬ 
tions .— 10 a.m., Surgical and Medical. 12 noon. Ear and Throat. 
Tuesday. — 2.15 p.m., Dr. R. T. Hewlett: Medicine. 2.30 p.m., 
Operations. 3.15 p.m., Mr. Carless : Surgery. 4 p.m., Mr. M. 
Morris: Diseases of the Skin. Out-patient Demonstrations:— 

10 a.m.. Surgical and Medical. 12 noon, Skin. 2.15 p.m., Special 
Lecture:—Dr. Hewlett: Some Bacteriological Methods of 
Diagnosis. 

Wednesday.—2.15 p.m., Dr. F. Taylor: Medicine. 2.30 p.m., 
Operations. 3.30 p.m., Mr. Cargill: Ophthalmology. Out¬ 
patient Demonstrations10 a.m., Surgical and Medical, 

11 a.m.. Eye. 

Thursday. —2.15 p.m., Dr. G. Rankin : Medicine. 2.30 p.m.. Opera¬ 
tions. 3.15 P.M., Sir W. Bennett : Surgery. 4 p.m., Mr. M. 
Davidson : Radiography. Out-patient Demonstrations:— 
10 a.m.. Surgical and Medical 12 noon, Ear and Throat. 
Friday.- 2.15 p.m., Dr. R. Bradford: Medicine. 2.30 p.m., 
Operations. 3.15 p.m., Mr. McG&vin: Surgery. Out-patient 
Demonstrations: — 10 a.m., Surgical and Medical. 12 noon. 
Skin. 3.15 p.m. | Special Lecture : —Mr. McGavin : Cancer of 
the (Esophagus. 

Saturday.— 2.30 p.m., Operations. Out-patient Demonstrations:— 
10 a.m., Surgical and Medical. 11 a.m., Eye. 

GREAT NORTHERN CENTRAL HOSPITAL, Holloway-road, N. 
Monday— 9 a.m., Operations (Mr. White). 2.30 p.m., In-patients— 
Medical (Dr. Beevor); Out-patients—Medical (Dr. Willcox), 
Surgical (Mr. Low), Eye (Mr. Morton and Mr. Coats). 

Tuesday. —2.30 p.m. , In-patients—Medical (Dr. Beale), Throat and 
Ear (Mr. Waggett); Out-patients—Surgical (Mr. Edmunds), 
Throat and Ear (Mr. French); Operations (Mr. Beale). 
Wednesday.— 2.30 p.m.. In-patients—Surgical (Mr. Stabb); Out¬ 
patients—Medical (Dr. Horder), Gynacological (Dr. Lockycr), 
Skin (Dr. Whitfield), Teeth (Mr. Baly); Operations (Mr. Stabb). 
Thursday.— 2.30 p.m., In patients—Medical (Dr. Morison). 
Friday.— 3.30 p.m.. Lecture:—Dr. G. French : Subjective Noises 
in the Head. 

NATIONAL HOSPITAL FOR THE PARALYSED AND EPILEPTIC, 
Queen-Bquare, Bloomsbury, W.C. 

Tuesday.—3.30 p.m.. Lecture :— Dr. Ormerod: Hysteria. 

Friday. —3.30 p.m., Lecture:—Dr. Collier : Myasthenia Gravis. 

ST. JOHN’S HOSPITAL FOR DISEASES OF THE SKIN, 
Leicest-er-square, W.C. 

Thursday.— 6 p.m., Lecture:—Dr. M. Dockrell: Syphilis as it 
Modifies other Eruptions of the Skin; Symptoms, Diagnosis, 
and Treatment. 

CHARING CROSS HOSPITAL. 

Thursday.—3 p.m., Demonstration -.—Dr. Galloway and Dr. 
MacLeod: Diseases of the Skin. 4 p.m., Demonstration:— 
Dr. I. Bruce: Electrical. (Post-Graduate Course). 

HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST, 
Brompton. 

Wednesday. — 4 p.m. Lecture:—Dr. Perkins: Cases from the 
Wards. 

HOSPITAL FOR SICK CHILDREN, Great Ormond-atreet. W.C. 

Thursday.— 4 p.m., Lecture:—Dr. Still: Dyspepsia in Children 
past the Period of Infancy. 


EDITORIAL NOTICES. 

It is most important that communications relating to the 
Editorial business of The Lancet should be addressed 
eaclvsively “To the Editor/' and not in any case to any 
gentleman who may be supposed to be connected with the 
Editorial staff. It is urgently necessary that attention should 
be given to this notice. _ 

It is especially requested that early intelligence of local events 


having a medical interest , or which it is desirable to bring 
under the notice of the profession, may be sent direct to 
this office. 

Lectures, original articles, and reports should be written on 
one side of the paper only, AND WHEN ACCOMPANIED 
BY BLOCKS IT IS REQUESTED THAT THE NAME OF THE 
AUTHOR, AND IF POSSIBLE OF THE ARTICLE, SHOULD 
BE WRITTEN ON THE BLOCKS TO FACILITATE IDENTI¬ 
FICATION. 

Letters , whether intended for insertion or for private informa¬ 
tion, 7iivst be authenticated by the names and addresses of 
their writers—not neoessarily for publication. 

We cannot prescribe or recommend practitioners. 

Local papers containing reports or news paragraphs should be 
marked and addressed “ To the Sub-Editor." 

Letters relating to the publication, sale and advertising 
departments of The Lancet should be addressed “ To the 
Manager .” 

We cannot undertake to return MSS. not used. 


MANAGER’S NOTICES. 

TO SUBSCRIBERS. 

Will Subscribers please note that only those subscriptions 
which are sent direct to the Proprietors of The Lancet at 
their Offices, 423, Strand, London, W.C., are dealt with by 
them 1 Subscriptions paid to London or to local newsagents 
(with none of whom have the Proprietors any connexion what¬ 
ever) do not reach The Lancet Offices, and consequently 
inquiries concerning missing copies, &c., should be sent to 
the Agent to whom the subscription is paid, and not to 
The Lancet Offices. 

Subscribers, by sending their subscriptions direct to 
The Lancet Offices, will insure regularity in the despatch 
of their Journals and an earlier delivery than the majority 
of Agents are able to effect. 

The Colonial and Foreign Edition (printed on thin 
paper) is published in time to catch the weekly Friday mails 
to all parts of the world. 

The rates of subscriptions, post free, either from 
The Lancet Offices or from Agents, are :— 


For the United Kingdom. 

Oue Year .£1 12 6 

Six Months. 0 16 3 

Three Months . 0 8 2 


To thk Colonies and Abroad. 

One Year .£1 14 8 

Six Months. 0 17 4 

Three Months . 0 8 8 


Subscriptions (which may commence at any time) are 
payable in advance. Cheques and Post Office Orders (crossed 
‘London and Westminster Bank, Westminster Branch”) 
should be made payable to the Manager, Mr. Charles Good, 
The Lancet Offices, 423, Strand, London, W.C. 


TO COLONIAL AND FOREIGN SUBSCRIBERS. 

Subscribers abroad are particularly requested 

TO NOTE THE RATES OF SUBSCRIPTIONS GIVEN ABOVE. It 
has come to the knowledge of the Manager that in some 
cases higher rates are being charged, on the plea that the 
heavy weight of The Lancet necessitates additional 
postage above the ordinary rate allowed for in the terms of 
subscriptions. Any demand for increased rates, on this or on 
any other ground, should be resisted. The Proprietors of 
The Lancet have for many years paid, and continue to pay, 
the whole of the heavy cost of postage on overweight foreign 
issues; and Agents are authorised to collect, and generally 
do so collect, from the Proprietors the cost of such extra 
postage. 


METEOROLOGICAL READINGS. 

(Taken daily at 8 JO a.m. by Steward's Instruments.) 

The Lancet Office, Feb. 13th, 1908. 


Date. 

Barometer 
reduced to 
Sea Level 
and 32° P. 

Direc¬ 

tion 

of 

Wind. 

Rain¬ 

fall. 

Solar 

Radio 

in 

Vacuo. 

Maxi 

mum 

Temp. 

Shade. 

Min. 

Temp. 

Wet 

Bulb. 

Bu&. 

Remarka. 

Feb. 7 

30-68 

S.W. 


62 

50 

40 

43 

43 

Foggy 

„ 8 

30-46 

W. 

... 

Vi 

47 

40 

39 

41 

Fine 

i, 9 

30-44 

w. 


57 

49 

40 

38 

40 

Cloudy 

.. io 

30 45 

S.W. 


62 

50 

40 

42 

44 

Overcast 

.. 11 

30 58 

w. 


65 

51 

40 

40 

41 

Overcast 

.. 12 

30 49 

S.W. 


75 

51 

41 

43 

45 

Cloudy 

„ 13 

30 23 

K. 


57 

43 

36 

36 

36 

Hazy 


During the week marked copies of the following newspapers 
have been received '.—Kensington News. Westminster Gazette, 
West Sussex Gazette. Daily Dispatch (Manchester), Montreal Gazette 
(Canada). Dublin Daily Express. Dublin Evening Telegraph, Dundee 
Advertiser, Liverpool Daily Post and Mercury, Daily Sews, Math 
Herald, Yorkshire Observer, Broad Arrow, Ac. 












538 The Lanobt,] 


ACKNOWLEDGMENTS OF LETTERS, ETO., RECEIVED, 


[Feb. 15, 1908. 


Gommnnications, Letters, &c., have been 
received from— 


A.— Mr. W. F. Allingham, Worth¬ 
ing ; Apothecaries’ Hall, Ire¬ 
land, Dublin, Secretary of; 
Messrs. Arthur and Co., Lond.; 
Mr. Thomas Allen. Lower Wick; 
Mr. G. Armnnd, Paris; Agence 
Franco-Anglaise de Publicity, 
Paris; Argyll Motors, Alex¬ 
andria. 

B — Mr. J. W. Benson, Lond.; 
Dr. J. Brena, Zacatecas, Mexico; 
Mr. R. Sidney Betts, Bourne¬ 
mouth; Bayer Co., Lond.; 
Bedfordshire County Council, 
Bedford, Clerk to the; Messrs. 

J. Beal and Son, Brighton; 
Messrs. G. Back and Co., Lond.; 
Bolton Infirmary, Secretary of ; 
British Pharmaceutical Codex, 
Lond., Publisher of; Dr. D. 
Bower, Bedford ; Mr. C. Buttar, 
Lond.; Bristol, Medical Officer of 
Health of; British Association 
for the Advancement of Science, 
Lond.; Dr. C. L. Birmingham, 
Westport; Bradford Education 
Committee, Secretary of; Messrs. 
T. B. Browne, Lond.; Benefited; 
Dr T. M. Bride, Manchester. 

C. —Mr. H. H. Ciutton, Lond.; 
The Cancer Hospital, Lond., 
President and Committee of; 
Mr. W. Carter, Watford; Mr. 

J. W. Astley Cooper, Cocker- 
mouth ; Canada, Department of 
Agriculture, Ottawa, Veterinary 
Director-General of; Chelsea 
Clinical Society, President and 
Council of; Dr. Edmund 
Cautley, Lond.; Cardiff Educa¬ 
tion Committee, Director of; 
Mr. F. W. Clarke, Cborltoncum- 
Ilardy; Dr. H. E. Corbin, Stock- 
port. 

D. —Mr. J. Scott Duckers, Lond.; 
Mr C. M. Dickinson. Crawshaw- 
booth; David Lewis Northern 
Hospital, Liverpool, Secretary 
of; Domiua; Messrs. Down 
Bros., Lond.; Daimler Motor 
Co., Coventry; Mr. Leonard S. 
Dudgeon, Lond.; Sir Dyce Duck¬ 
worth, Lond. 

E. —Dr. B. Emrys-Roberts, Liver¬ 
pool; Egyptian Government 
Inspector- General of Prisons, 
Cairo; Messrs. Evans, Sons, 
Lescher, and Webb, Lond. 

P.- Mr. A. Freer, Stourbridge; 
Mr. R. Ferner, Leipzig. 

G. —Messrs. R. W. Greeff and Co., 
Lond.; G. H. R. D. 

H. —Dr. A. J. Hall. Sheffield; 
Hospital Almoners’ Council, 
Lond., Secretary of; Holborn 
Surgical Instrument Co., Lond.; 
Dr. J. B. Hellier, Leeds; Messrs. 
Hankinson and Son, Bourne¬ 
mouth; Dr. L. Hamel, Havre; 
Dr. John B. Huber, New York; 
Hastings, Town Clerk of; Hamp¬ 
stead General Hospital, Lond., 
Secretary of. 

I. —India, Under Secretary of State 
for, Lond.; Ilford. Ltd., Ilford; 
Interstate Medical Journal , St. 
Louis. 

J. —Dr. Ernest Jones, Lond. 

K. —Dr. H. Kerr, Newcaatle-on- 
Tvne; Mr. S. Keir, Lancaster; 
Messrs. Knoll and Co., Lond.; 


Messrs. R. A. Knight and Co., 
Lond.; Dr. Charles Kerr, 
Dundee ; Messrs. Kemsley Lond. 

L. —Mr. fl. K. Lewis, ~ Lond.; 
Dr. T. Glover Lyon, Lond.; 
Mr. C. Lane, Mongbyr, India; 
Mr. C. Lillington, Lillehammer, 
Norway; Dr. Alexander Lundie, 
Dalmuir. 

M. -Mr. P. P. Murphy, Lond.; 
Mr. W. R. Meyer, Hurstpier- 

£ oInt; Mr. H. C. MacBryan, Box; 

>r. F. G. Miranda, Grenada; 
Mr. R. Mosse, Zurich ; Messrs. 
W. Marshall and Son, Lond.; 
The Moto-H6ve Co., Lond.; 
Mr. John D. Malcolm, Lond.; 
Dr. D. M. MacDonald, DuDkeld; 
Messrs. Merttens and Co., Man¬ 
chester ; Dr. H. MacCormac, 
Lond.; Messrs. Masson and Co., 
Paris; Messrs. C. Macintosh and 
Co., Manchester; Medical Society 
of London, President and Council 
of; Dr. C. E. Michael, Lond. 

N.-Dr. G. W. Nicholson, Lond.; 
Mr. J. C. Needes, Lond.; Mr. H. 
Needes, Lond. 

P.— Mr. Stephen Pagot, Lond.; 
Dr. M. S. Paterson, Frimlev; 
Dr. W. Pasteur, Lond.; The 
Prcscriber , Edinburgh; Ply¬ 
mouth Royal Eye Infirmary, 
Secretary of ; Dr. H. Pike, Paris; 
Miss K. Phillips, Liverpool; 
Messrs. Peacock and Hadley, 
Lond.,- Dr. L. Powell, Lond. 

Q.—Dr. L. C. Query, Paris. 

R.—Dr. S. J. Rosa, Bedford; 
Captain E. A. Roberts, I.M.S., 
Sanawar, India; Royal Society of 
Medicine, Lond., Secretary of; 
Mr. A. Pau, Frankfort: Major 

O. Robinson, R.A.M.C., Gib¬ 
raltar; Mr. C. Kyall, Lond.; 
Royal Victoria Infirmary, New- 
castle-on-Tyne, Secretary of; 
Royal Waterloo Hospital, Lond., 
Special Appeal Committee, Or¬ 
ganising Secretary of; Messrs. 
Reynolds and Branson, Leeds. 

B.—Dr. A. B. Slater, Lond.; 
Messrs. Savory and Moore, Lond.; 
Messrs. G. St reet and Co., Lend.; 
Messrs. Stonebridge and Foil, 
Woburn Sands; Dr. Frank 
Shufilebotham, Newcastle under- 
Lyne; Dr. E. I. Spriggs, Lond.; 
Mr. N. L. Usher Somers, West 
Bromwich; Seamen's Hospital, 
Society, Lond., Secretary of ; 
Messrs. Southall, Birmingham; 
Star Engineering Co., Wolver¬ 
hampton; Smith's Advertising 
Agency, Lond.; Dr. E. P. 
Sherman, Richmond, U.S.A.; 
SelaDgor State, Acting-Surgeon 
of; Dr. G. Arbour Stephens, 
Swansea; Scholastic, Clerical,&c., 
Association, Lond. 

T.—Dr. F. M. Turner, Lond.; 
Mr. H. Henry Thorp, Stafford; 
Mr. J. A. Thomas, Cheltenham ; 
Miss A. Taylor, Edinburgh; 
Dr. W. H. Maxwell Telling, 
Leeds. 

V,—Dr. G. Variot, Paris. 

W.— Dr. J. Sim Wallace, Lond.; 
Dr. W. H. Wright, Derby; Dr. 
O. C. Withrow, Fort William; 
Messrs. J. Wiley and Son, New 


York; Mr. C. Walker, Liverpool; County Council, Worcester, 
Wand Manufacturing Co., Lei- Clerk of; W. T. S.; Mr. J. 
cester; Mr. James R. Whitwell, Williams, Bradford; Messrs. 
Melton; Mr. A. G. Whiteliorne- Willing and Co.. Lond. 

Cole, Hove; Worcestershire Y.—Mr. Evan Yellon, Lond. 

Letters, each with enclosure, are also 
acknowledged from— 


A. — Mr. C. Allingham, Lond.; 
Dr. Allingham, Delabole; A. L., 
Gosport; Association of Certifi¬ 
cated Dispensers, Lond., Secre¬ 
tary of. 

B. —Dr. F. Bryan, Earls Colne; 
Dr. H. H. Baker, Qara. Egypt; 
Bury Hospital, Secretary of; 
Borough or Bootle, Cashier of; 
Dr. E. Bauer, Neuchatel: Dr. 

C. R. Box, Lond.; Mr. H. D. 
Bryce, Lond.; Messrs. J. H. 
Booty and Son, Lond.: Bethel 
Hospital, Norwich, Clerk of; 
Mr. A. K. Barnes, St. Ives; 
Mr. W. Bryce, Edinburgh ; Mr. 

K. S. Basa, Gujranwalla, India; 
Dr. J. H. Bletsne, Hornchurch ; 
Barnwood House, Gloucester, 
Medical Superintendent of; Dr. 
Duncan F. Brown, Greenock. 

G.- Dr. J. M. Cowan, Glasgow; 
Clayton Hospital, Wakefield, 
Hon. Secretary of; Messrs Col¬ 
gate and Farnell, Eastbourne; 
Messrs. Claye and Son, Stock- 
port; Mr. R. A. Caldwell, 
Bournemouth; Cheltenham Cor¬ 
poration, Accountant to the; 
Mr. C. N. Chadborn, Hovei 
Dr. S. G. Corner, Coggeshall; 
Dr. C. T. de Crespigny, Glen- 
thompson, Victoria. 

D.- Miss C. Dye,Clermont, U S. A.; 
Mr. G. Dodson, St. Leonanls-on- 
Sea; Dr. W. Daisb, Dubbo; 
Derby Corporation, Accountant 
to the; Paul E. Derrick, Adver¬ 
tising Agency, Lond.; Messrs. 
Davy, Hill, and Hodgkinsons, 
Lond.; Mr. R. Davy, Bow. 

B.—Dr. J. W. H. Byre, Lond.; 
Dr. R. Elphinstone, Silverstone; 
Mr. A. R. Elliott, New York; 
Eastbourne Borough, Clerk to 
the; Mr. F. G. Ernst, Lond.; 
Messrs. Elliott, Son, and Boy ton, 
Lond. 

P. Mr. G. M. Fraser, Aberdeen; 
Messrs. Flood and Sons, Lond.; 
Dr. F. J. Fehrsen, Somerset 
East, Cape Colony; Dr. R. H. 
Fox, Lond.; Fenstanton, Ltd., 
Lond.; Miss Francis, Croydon. 

G. —Mr. H. J. Glaisber, Lond.; 
Dr. W. G. Galletly, Northwold; 
Gloucester General Infirmary, 
Secretary of; G. K. G.; Mr. E. 
Gooch, Lond. 

H. —Dr. W. N. Heard, Swanage; 
Mr. A. J. Hutton, Lugar; Mr. 
P. Howe, Ashton under Lyne ; 
Halifax, County Borough of, 
Accountant to the; Dr. C. F. 
Hodgklnson, Gormanston, Tas¬ 
mania; II. D.; Messrs. Abel 
Hey wood and Son, Manchester; 
Mr. E. C Hort, Lond.; H. J. C ; 
H. F. W. 

J, —Dr. R. L. Joynt, Dublin; J. S.; 
J. R. 

JL Dr. C. G. Knight, Belfast; 
Dr. C. F. Knight, Portobello-, 
Kent County Asylum, Maid¬ 
stone, Clerk to the. 

L.—Mr. A. R. Lamport, Lond.; 
Dr. J. Lambie, Lond.; Mr. C. 


Lean, Lond.; Mr. A. Lowe, 
Bradley; Locum, Sunderland;. 
Mr. W. W. Llnnev, Croydon; 
London Throat Hospital, Dean 
of. 

M —Mr. M. A. Marett, Hastings; 
Mr. L. Mackay, Pitlochry; 
Messrs. Maple and Co., Lond.; 
Dr. L. Molloy, Blackpool; 
Mr. A. Moxon, Nuneaton; Rev. 
H. E. C. Keith Murray, Burley; 
Mr. M. W. Matthews, Edin¬ 
burgh; Dr. M. Martin, Glasgow; 
Messrs. J. Menzies and Co., 
Edinburgh; M. A. P.; Mr. 
A. H. McCandlish, New Ferry; 
Messrs. Maconochie Bros Lond.; 
Mr. Eustace Miles, Lond. 

N. —Dr. W. Nightingale, Leek; 
North Staffordshire Infirmary, 
Stoke-on-Trent, Secretary of; 
National Provident Institution, 
Lond., Secretary of. Dr. H. R. 
Nelson, Victoria, British Colum¬ 
bia; Norfolk News Co., Lond.; 
N. C. 

O. —Mr. C. A. P. Osburne, Old 
Catton ; Ontario Treasury, 
Toronto, Treasurer of; O. H. 

P. — Mr. R. W. Power, Oldham; 
Mr P. C. Peare, Leicester; 
Mr. J. S. Perkins, Aber Bargoed; 
Mr. A. K. Peacock. Lond.; 
Pudukottnh State, India, Chief 
Medical Officer of: Dr. Pellegrini, 
Turin; Mr. F. R. Peas lee Seaton ; 
P. D.; Mr. H. Powell-Itees. Lond.; 
P. S. H.; Mr. J Potter, Oldham. 

Q. —Queen's College, Cork, Bursar 
of. 

R. — Mr. H. M. Riley, Leicester 
Staff-Surgeon C. H? J. Kobi son, 
R.N., Port Said; Messrs. Rossi, 
Lond.; Mr. S. W. F. Richardson, 
Cape Town; Royal Derby 
Nursing Association, Secretary 
of; Rotherham Hospital, Secre¬ 
tary of. 

B.—Mr. G. L. St. George; Lisburn; 
Seltzogene Patent Charges Co., 
St. Helens; Sheffield Univer¬ 
sity, Registrar of; Sheffield 
Royal Hospital, Secretary of; 
Messrs. J. Smith and Co., Lond.; 
Messrs. Scott and Bowne, Lond.; 
Mr. P. Smith, Sirhowy; Messrs. 
Sykes, Josephine and Co., Lond.; 
Messrs. Spiers and Pond, Lond.; 
Mr. R. Simpson, Plymouth; 
Messrs. Siebe, Gorman and Co., 
Lond.; Mr S Stephenson Lond.; 
South Wales Argus, Newport; 
Dr. C. S. de Segundo. Lond.; 
Stockport Infirmary, Secretary 
of; S. J. R. 

T.— Dr. C. F. Tucker, Beeac, Vic¬ 
toria ; Messrs. Truelove and 
Hanson, Lond.; Mr. J. Thin* 
Edinburgh. 

W.— Mr. T. F. Wyse, Dalkey;. 
Dr. R. Prosser White, Wigan; 
Mr. C. F. Warren, Wagga-Wagga; 
Mr. J. Ward, Lond.; Messrs. 
Wright, Dyer, and Day kin, 
Kedditch; Miss White, Croydon; 
Mr. L. E. Watts, Bournemouth;. 
W B., Dr. W. J. Wilson, Belfast. 


EVERY FRIDAY. 


THE LANCET. PRICE SEVENPENCE. 


SUBSCRIPTION, 

For the United Kingdom. 

Ono Year ..£1 12 6 

Six Months. 0 16 3 

Three Months . 0 8 2 


POST FREE. 

To the Colonies and Abroad. 

One Year .£1 14 8 

Six Months. 0 17 4 

Three Months . 0 8 8 


Subscriptions (which may commence at any time) are payable in 
advance. 


ADVERTISING, 

Books and Publications ... Seven Lines and under £0 5 0 
Official and General Announcements Ditto 0 5 0 

Trade and Miscellaneous Advertisements 1 nSff _ n d c 

and Situations Vacant . S U q b 

Every additional Line 0 0 6 

Situations wanted : First 30 words, 2s. 6 d. ; per additional 8 words 6 d. 
Quarter Page, £1 10s. Half a Page, £2 15s. An Entire Page. £5 5s. 


An original and novel feature of “The Lancet General Advertiser” is a Special Index to Advertisements on pages 2 and 4. which not only 
affords a ready means of finding any notice but is in itself an additional advertisement. 

Cheques and Post Office Orders (crossed “London and Westminster Bank, Westminster Branch”) should be made payable to the Manager, 
Mr. Ciiaiit.fs Good, The Lancet Office, 423, Strand, London, to whom all letters relating to Advertisements or Subscriptions should be addressed. 

The Lancet can be obtained at all Messrs. W. H. Smith and Son’s and other Railway Bookstalls throughout the United Kingdom. Adver¬ 
tisements are also received by them and all other Advertising Agents. 

Agent for the Advertisement Department in France—J. ASTIEK, 31, Rue Bapst, Asnieres, Paris. 






THE LANCET, February 22, 1908, 


Erasmus Milsmt Jettart 

ON 

THE PYOGENETIC ACTIVITIES OF THE 
PNEUMOCOCCUS. 

Delivered before the Royal College of Surgeons of England on 
. Feb. 12th , 1908 , 

By J. W. H. EYRE, M.D., M.S. Durii., 
M.R.C.S. Eng., D.P.H. Cams., 

BACTERIOLOGIST TO GUY’S HOSPITAL ASP TO ST. MARY’S CHILIiREN’S 
HOSPITAL, PLAISTOW ; LECTURER 01? BACTERIOLOGY' AT THE 
MEDICAL AND DENTAL SCHOOLS OF GUY'S HOSPITAL. 


Introduction. 

Gentlemen, —In 1881 Ogston of Aberdeen published an 
account of his observations upon the microscopical con¬ 
stituents of surgical pus which enabled him to state that 
minute spherical bodies, “micrococci,” were usually present 
in this pathological product of infected wounds. Moreover, 
he differentiated these cocci into those occurring in irregular 
masses—‘‘grouped micrococci”—which were usually asso¬ 
ciated with circumscribed abscess formation, and those 
which occurred in rows like strings of beads—“chain 
micrococci”—which were usually found in connexion with 
the spreading “cellulitis ” type of suppuration. Three years 
later Rosenbach published the results of his investigations 
which fully confirmed the earlier observations of Ogston. 
This second worker succeeded In isolating staphylococci 
and streptococci, as they were now termed, cultivated 
them upon artificial media in the laboratory, and differ¬ 
entiated some of the several varieties included in this 
first general morphological classification. For the next 
decade, no matter in what situation or association it 
presented itself, pus was pretty generally regarded as the 
outcome of infection by members of the staphylococcus and 
streptococcus “pyogenes” groups—a result largely due to a 
too literal interpretation of Koch’s dicta, which laid it 
down that in order to establish a claim for the specificity 
of any newly discovered bacterium, that organism must be 
shown to be constantly present in some particular and 
definite lesion ; must be capable of isolation and cultivation 
outside the animal body ; and on its reintroduction into a 
suitable host must reproduce the original lesion. Hence as 
the specific etiological factors of the various bacterial infec¬ 
tions were recognised and isolated attention was invariably 
first directed to the reproduction of the original lesions in 
their entirety, and subsidiary phenomena such as the provo¬ 
cation of pus formation were entirely disregarded, or, again 
instancing the formation of pus, regarded merely as the 
result of accidental and preventable contamination with the 
so-called “ pyogenic ” cocci already referred to. And it is 
only within recent years, since, in fact, the inter-reactions 
of seed and soil, of bacterial irritant and tissue cell, have 
been the subjects of extended study that the principle has 
been generally recognised that practically any and every 
pathogenic bacterium possesses the power, under some cer¬ 
tain combination of factors, of initiating purely pyogenic 
processes in place of, or in addition to, its particular specific 
lesion. 

Perhaps the most striking illustration of the above state¬ 
ments that can be adduced iB afforded by a study of that 
organism which forms the subject for our present considera¬ 
tion. First studied in its association with one form of 
inflammatory reaction in pulmonary tissue—viz., acute 
croupous or lobar pneumonia—its specificity in this con¬ 
nexion was conclusively established before its potentialities 
in other directions received any but the scantiest considera¬ 
tion. Indeed, it is not so many years ago that the definite 
statement was made—in all sincerity and as representing the 
established conviction of a large body of observers—that 
the pneumococcus was of itself never responsible for the 
formation of pus, and despite the fact that the presence 
of the pneumococcus could so readily be demonstrated in 
those purulent collections within the pleural cavity that 
are frequently associated with pneumonia, such empyemata 
were invariably regarded as the direct result of secondary in¬ 
fection with some one or more of the ordinary pyogenic 
staphylococci or streptococci. The pyogenetic activities of 
the pneumococcus itself have, however, now been demon¬ 
strated experimentally in so complete a manner that the 

No, 4408. 


present seems a fitting opportunity to review our knowledge 
of the subject upon which present-day opinions are based. 

Historical Summary. 

The micro-organism I have chosen for the subject 
of my lecture was first discovered by Sternberg in 
September, 1880, in the course of some investigations on 
malarial fever. By means of inoculation experiments he 
found that his own saliva was pathogenic for rabbits and he 
isolated a definite diplococcus, which he considered the 
cause of such pathogenicity, and to it gave the name “ micro¬ 
coccus Pasteuri.” This he described in a report to the 
National Board of Health (U.S.A.), which, however, was 
not then published but to which he refers in the National 
Board of Health Bulletin of April, 1881. 

In January, 1881. during a discussion following the read¬ 
ing of a paper (“Recherches F.xperimentalea sur la Trans¬ 
mission du Virus Rabique de l’Homme au Lapin,” par MM. 
Raynaud et Lannelogue, Jan. 18th, 1881) before the Paris 
Academy of Medicine, Pasteur stated that in December, 1880, 
he inoculated two rabbits with saliva from a fatal case of 
hydrophobia, that of a boy, four hours after death. The 
rabbits (lied in 36 hours and a new bacterium was discovered 
in their blood shaped like the figure 8 and surrounded by a 
gelatinous capsule. It was virulent in broth cultures where 
it often formed chains. He expressed his ignorance of its 
relation to rabies but distinguished between the new organism 
and his “ vibrion septique”—i.e., the bacillus of malignant 
ccdema. For the next few months communications were 
made to the Academy in rapid succession confirming these 
observations, and a commission was appointed to investigate 
the subject. Pasteur reported to this commission in April, 
1881, that he had found the new organism in the saliva of 
one more fatal case of rabies and three fatal cases of 
broncho-pneumonia, and had failed to find it in the saliva 
of three persons dead from other diseases. 

Vulpian (1881) stated that he had found the micro-organism 
in a virulent condition in the saliva of healthy individuals. 

In 1881 also E bert and Koch and in the following year 
Friedliinder, Leyden, and Gunther demonstrated micro¬ 
scopically the constant presence of a diplococcus in the 
lungs in cases of lobar pneumonia. The two latter, more¬ 
over, described the surrounding capBule as being present in 
specimens made from the fluid drawn from the hepatised 
lung itself during life by means of a sterile syringe, but 
they were unsuccessful in obtaining pure cultures of the 
organism 

In 1883 Matray and Ziehl studied cases of pneumonia and 
fully confirmed these observations. 

In the meantime, and on the experimental side Grifflni and 
Carabray inoculated rabbits with pneumonic sputum and 
regularly produced a fatal septicsemia ; continuing their 
experiments they were equally successful in reproducing the 
septicaemia in other rabbits by using for the purpose of 
inoculation blood taken from the original rabbits after death. 

In November, 1883, Friedliinder described cultures upon 
solid media of what he considered to be the pneumococcus. 
He stated that his organism was an oval coccus, surrounded 
by a gelatinous capsule, which readily grew on gelatin at 
the ordinary room temperature. These observations gave a 
great impetus to the bacteriological study of croupous 
pneumonia by the modern methods, although we are now 
aware that Friedliinder’s “oval coccus” was in truth a 
bacillus and in no way concerned in the causation of the 
disease. 

Two months later (1884) before the Societfi Anatomique 
Talamon described cultivations in bouillon of the genuine 
diplococcus and showed cultures grown at the body tempera¬ 
ture from pneumonic exudates. Two of these cultivations 
were absolutely pure. Of 20 rabbits inoculated into the chest 
cavity with these cultures 16 died from septicaemia, often 
accompanied by fibrinous pleurisy and pericarditis, and some¬ 
times by a true lobar pneumonia. The blood and exudates 
of these fatal cases always oontained cocci, and yielded pure 
cultures capable of producing similar inoculation results. 
Guinea-pigs and dogs, he stated, were immune. He had also 
found the coccus in fluid drawn during life from the 
hepatised lung—in man—in eight cases. In one fatal case it 
occurred in the general circulation at the moment of death. 

As Friedliinder and Talamon were working with two 
distinct organisms a good deal of confusion resulted from 
their conflicting statements. As an example of this Sternberg 
in April, 1885, read a paper before the Pathological Society 
of Philadelphia, pointing out the identity of the coccus 
H 




540 The Lancet,] DR. J. W. H. EYRE : THE PYOGENETIO ACTIVITIES OF THE PNEUMOCOCCUS. [Feb. 22,1908. 


which he had discovered in 1880 in his own saliva with the 
coccus which he had more recently isolated in cases of lobar 
pneumonia, but fell into the error of supposing it to be 
identical also with Friedliinder's micro-organism. All this 
confusion and misunderstanding was, however, cleared up 
by the researches of Fraenkel, who in April (before the 
Congress fiir Innere Medicin, Berlin) and July, 1885, 
independently recognised the identity of Sternberg’s coccus 
of sputum septicaemia with the pneumococcus, and quoted 
three cases of lobar pneumonia from which he bad cultivated 
it on solid media. In communications during the course of 
the following year he published fuller accounts of his 
observations and gave differential descriptions of the 
pneumococcus and Friedliinder’s pneumobacillus. 

In May, 1886, Weichselbaum communicated to the Geaell" 
Bchaft fiir Aerzte (Vienna) a report to the effect that he had 
examined the exudate from 129 cases of pulmonary inflam¬ 
mation, of which 94 were undoubted lobar pneumonia and 
from which he cultivated the pneumococcus. In 21 of the 
same series he isolated a streptococcus and from nine cases 
only did he obtain Friedliinder’s pneumobacillus. 

Early observers, as I have previously remarked, adhered 
rigidly to the postulates of Koch and attempted to prove that 
the action of the pneumococcus was special and specific and 
that its pathogenic properties were always, and solely, 
directed to the production of a special form of pulmonary 
inflammation which resulted in the consolidation of consider¬ 
able areas of the lung tissue. When, however, they 
attempted to reproduce this lesion in laboratory animals it 
was found that the experimental animals rapidly succumbed 
to a general septicaemia, unaccompanied by lobar pneumonia, 
and it was necessary to continue the investigations until a 
combination of conditions sufficiently comparable to that 
obtaining in man was discovered, when the experimental 
infection resulted In the production of lobar pneumonia. This 
combination of conditions was finally obtained by Gamaleia 
(1888) working in the Pasteur Institute, for by employing 
sheep and dogs for his inoculation experiments he was 
successful in reproducing the typical pathological leBions of 
acute lobar pneumonia. 

During the early inquiries into the life-history of the 
pneumococcus each worker, almost, applied to the organism 
a different title. The chief of these were as follows 


1. Micrococcus Faateuri ... ... ... 

2. Micrococcus pneumonia? crouposa- 

3. Microbe septicemlque desalive ... 

4. Coccus lauceolatus . 

5. Coccus of sputum septicaemia ... 

6. Bacillus septlcus sputlgenus 

7. Bacillus salivarius septlcus . 

8. Dlplococcus pneumonia.* . 

9. Diplobacillus pneumonia . 

10. Pneumococcus. 

11. Pneumonia coccus . 


... Sternberg. 


... Pasteur. 
... Tal&mon. 
... Fraenkel. 




Flugge. 

Biondi. 

Weichselbaum. 

Fraenkel and Weichael- 
baum. 


12. Meningococcus ... 


-{ 


Fo & 


and Dordoni- 
Uffreduzzl. 


13. Micrococcus lanceolatus capsulatus. 

14. Dlplococcus lanceolatus capBulatus. 

15. Dlplococcus lanceolatus flbrlnogenicus ... 

16. Dlplococcus lanceolatuB cedematogenlcus 

17. Gloococcus of Fraenkel. Klebs. 

18. Streptococcus lanceolatus Pasteurl ... ... Gamaleia. 


Of this formidable list only three have obtained any vogue 
—viz., pneumococcus, diplococcus pneumonise, and strepto¬ 
coccus lanceolatus. The last named has the advantage of 
accurately describing the organism and is the title preferred 
by the purist. The first possesses the virtue of brevity, is 
the one in commonest colloquial use, and is the one that will 
be adhered to throughout the present paper. 

So far all the investigations had been directed to the 
association of the pneumococcus with lobar pneumonia, but 
now that the causal nature of the association of the organism 
with this disease had been firmly established clinical obser¬ 
vations concerning manifestations of the pathogenetic pro¬ 
perties of the pneumococcus other than, but frequently asso¬ 
ciated with or following, lobar pneumonia gradually 
accumulated. For instance, Fo4 and Carbone (1894) 
encountered lesions in the human subject which, although 
apparently all due to invasion of the tissues by the pneumo¬ 
coccus, varied so widely in their histological characters that 
they felt compelled to recognise two distinct varieties or 
strains of this organism, which they designated respectively 


“ oedematogenetic ” and “ fibrinogenetic ”—desoriptive ad¬ 
juncts which sufficiently indicate the main histological 
characters of the lesions produced. The first they named 
the meningococcus and the second the pneumococcus. 

As the numbers of workers increased, however, and animal 
experiments were multiplied it was found that—as in the 
case of other pathogenic bacteria—one and the same strain 
of pneumococcus could, by varying the conditions of experi¬ 
ments, be induced to produce widely varying lesions, while 
clinical observations showed the presence of the pneumo¬ 
coccus, obviously in a causal capacity, in very different 
pathological conditions. 

Some of the Lesions due to Pneumococcus Infection. 

Meningitis. —Foil and Bordoni-Uffreduzzi reported to the 
Royal Academy of Medicine, Turin, their observations on 
lanceolate diplococci which they had discovered in the 
exudation of cases of epidemic cerebro-spinal meningitis. 
They further identified this organism with Fraenkel’s pneu¬ 
mococcus and published a most valuable study of its 
biological properties and cultural varieties. Many cases of 
meningitis associated with or following upon pneumonia 
have since been recorded by Weichselbaum, Netter, and 
others, and the disease has been frequently reproduced in the 
laboratory by means of subdural inoculations of the pneumo¬ 
coccus. At the same time, instances of primary infection of 
the central nervous system by the pneumococcus have 
accumulated, and when Wolff in 1897 carefully analysed the 
literature dealing with meningitis he found that the pneumo¬ 
coccus was recorded as the causative factor in over 40 per 
cent, of the total number of cases. Osier records a series of 93 
cases of meningitis, of which over 22 per cent, were due to 
the pneumococcus. Brodie, Rogers, and Hamilton (1898), too, 
have described cerebro-spinal meningitis due to the pneumo¬ 
coccus oonsecutive to an epidemic form of rhinitis in African 
natives; and Turner, in a still more recent (1907) article 
notes the presence of 17 cases of pneumococcic meningitis 
(out of a series of 70 which were investigated bacterio- 
logically) in natives employed in the Rand mines. 

Ulcerative endocarditis. —Endocarditis usually affecting 
the aortic valve is frequently due to the pneumococcus. 
Both the vegetative and ulcerative varieties have been pro¬ 
duced experimentally by Kruse, Pansini, Vanni, Netter, 
and others who, however, noted that unless some injury of 
the valve already existed an endocarditis could rarely be set 
up. The method usually adopted, therefore, was to pass a 
sterile probe down the carotid artery into the left ventricle 
and injure the valve, then to inject virulent broth cnltnres of 
the pneumococcus either directly into the heart or sub¬ 
cutaneously. 

Suppurative pericarditis. —This is practically always con¬ 
secutive to lobar pneumonia and pleurisy. Sometimes the 
exudation is sero-pus or serum containing large flakes of 
fibrin rather than ordinary pus. At other times the heart is 
enveloped in a thick membranous layer of fibrin-entangled 
pus cells and the visceral layer of the pericardium lined 
with a similar exudation, the two surfaces being separated 
by a perfectly clear serous fluid. 

Pleurisy —An exudation of clear serous fluid into the 
pleural cavity resulting from the extension of the pneumo¬ 
coccus through the lung to the visceral layer of the pleura is- 
the commonest sequel of pneumonia, and at the same time, as 
it is usually readily reabsorbed and the pleura rarely requires 
opening, is the least important. Frequently, however, the 
pnenmococcns multiplies rapidly in this fluid which then has 
a sero-purnlent character and contains numerous large flakes 
of fibrin or may gradually merge into a fluid having all the 
appearance of ordinary pus. The pneumococcus, however, 
is often able to give rise to a serous or seropurulent pleurisy 
quite apart from any antecedent of pneumonia, and this 
observation is of frequent occurrence in experimental inocu¬ 
lations into the trachea of the rabbit (through a catheter 
passed through the larynx). Under these conditions the 
pneumococcus may actually enter the lung, pass through the 
pulmonary tissues without leaving behind it any trace of 
inflammatory reaction, pass through the pleura, and reaching 
the pleural cavity produce a marked pleurisy which often 
extends to the enveloping membrane of the heart and causes 
a large collection of serous exudation within that sac. The 
frequency of the pneumococcus as the exciting cause of 
serous pleurisy is well shown in the following table, which 
includes those cases investigated bacterio'ogically in Gny’s 
Hospital during the past five years—24 out of a total of 82, 
or a percentage of 29, being the result of the analysis. 






The Lancet,] DR. J. W. H. EYRE: THE PYOGENETIC ACTIVITIES OF THE PNEUMOCOCCUS. [Feb. 22,1908, 541 


Table I .—Clear Fluid from, the Pleural Cavity. 


- 

1903 

1904. 

1905. 

1906. 

— 

1907. 

Pneumococcus (pure). 

2 1 

5 

10 

3 

4 

Other organisms (excluding bacillus 
tuberculosis). 

10 

2 

4 

9 

8 

No growth (some certainly and some ' 
possibly due to bacillus tubercu¬ 
losis and others probably duo 
to pneumococcus). 

6 

2 

6 

15 ! 

20 

Empyema. — Pus due to the activities of the pneumococcus 
is perhaps most familiar to the surgeon in the shape of 
empyemata. An analysis of the cases of empyema in Guy’s 
Hospital investigated bacteriologically during the past five 
years shows that 77 per cent, are due to this organism alone. 

Table II. — Pus from the Pleural Cavity. 


- 

1903. 

j 1904. I 1905. ' 

1 1 

1906. 

1907. 

Pneumosoccus (pure). 

10 

20 

! 23 

16 

21 

Pneumococcus associated with 
other bacteria. 

3 

— 

1 

1 

1 

2 

-Other organisms (excludin bacillus 
tuberculosis). 

2 

4 

5 

3 

8 

No growth (some certainly and 
others probably due to bacillus 
tuberculosis). 

2 

1 

2 

1 1 

2 

3 


The naked-eye characters of the pnruleat Said are some¬ 
times practically diagnostic. While the pus from cases of 
pneumococcic empyema or pneumococcic peritonitis may 
present the greenish yellow colour and creamy consistence of 
what used to be called laudable pus, it is more often a 
yellowish fluid of somewhat thinner consistence, which, 
although quite homogeneous when removed from the body, if 
collected in a test tube and allowed to stand soon undergoes 
auto-sedimentation and separates into two layers of about 
equal bulk, the lower yellow layer consisting of pus cells and 
the upper a translucent, opalescent fluid quite clear except, 
perhaps, for the presence of a few flakes of fibrin. The 
microscopical examination of the fluid is often very character¬ 
istic, showing in addition to the pneumococcus itself many 
involution forms, empty capsules, dead cocci, and deeply 
staining particles. The contention of the clinician that a 
pneumococcic empyema is always primarily purulent and 
that the serous pleurisy due to this organism never becomes 
purulent obtains very little support either from direct observa¬ 
tion or from inoculation experiment. If in a series of intra¬ 
pleural or intraperitoneal inoculations of the rabbit the condi¬ 
tions are so arranged that the experimental animals shall die at 
varying periods it will be found at the post mortem inspec¬ 
tion that where death has rapidly followed on the injection 
the exudation is clear serum teeming with pneumococci. If 
death is delayed to three, four, five, or more days every 
gradation in the character of the exudation, from clear 
serum, sero-pus to creamy pus, will be met with. In the 
same way the gradual change in the character of the fluid 
can be noted clinically in many cases if exploration of the 
chest is repeated from day to day. 

Otitis media .—The pneumococcus has been frequently 
isolated from, and in many cases found in pure culture in, 
the pus of otitis media. Zufal (1888), who recorded many 
cases, was able to produce this disease experimentally by 
means of inoculations into the tympanic cavity. 

Arthritis .—The pneumococcus has also been isolated from 
the serous or pnrulent exudation in mono- and poly-arthritis 
occurring either as a primary manifestation of pneumococcic 
septicaemia or during the course of a lobar pneumonia, the 
earliest cases being those described by Vogelius (1897). The 
sterno-clavicular joint, shoulder, hip, and knee are those 
most commonly affected. Gabbi produced arthritis ex¬ 
perimentally by injuring joints, either by traumatism or 
the use of chemical irritants, and then inoculating virulent 
cultures of the pneumococcus subcutaneously. 

Pneumocoocio peritonitis .—Peritonitis due to the pneumo¬ 
coccus differs in character according to whether it occurs in 
adults or in children. In the former it is usually diffuse and 
observations are now accumulating which show that the 


appendix is not an uncommon point of departure. In 
children, on the other hand, the peritonitis is very fre¬ 
quently local in its distribution, being early shut off from 
the general cavity by fibrinous adhesions. Pneumococcic 
peritonitis was first noted (1890) by Sevestre. Dieulafoy 
collected a number of cases ; and Bryant (1901) contributed 
a further series. Marchaux (1899) recorded vaginitis and 
peritonitis as common complications of pneumonia amongst 
natives in Africa. 

Localised abscess formation .—Circumscribed collections of 
pus, subcutaneous, intramuscular or within some viscus, 
have often been described (e g.. Batten and Fonlarton, 
1901), and can readily be produced experimentally in 
laboratory animals. 

Conjunctivitis, Jfe .—On the continent the pneumococcus 
is said to infect frequently the conjunctival sac, producing 
an acute conjunctivitis—often in epidemic form—but is not 
so commonly found in this situation in England. Gasparini 
has also recorded the pneumococcus as giving rise to 
keratohypopion. 

I 'aria. —Finally, the pneumococcus has been recorded as 
causing, among other lesions, epiphysitis, osteomyelitis, 
periostitis and necrosis, thyreoidltis, parotitis, tonsillitis, 
follicular and membranous, gastritis, nephritis and peri¬ 
nephritis, endocervitis, &c. 

Enough has been said to show the protean character of the 
lesions for which the pneumococcus has been recorded as 
the responsible cause. In order to explain the presence of 
the pneumococcus in the widely separated situations indicated 
by the foregoing summary it is necessary to consider for a 
moment how the organism gains access to the body tissues in 
the first instance. 1 have already mentioned that the 
pneumococcus was first discovered as the result of the 
examination of the saliva of a healthy individual. Sternberg 
records the organism as present in the same situation in 
20 per cent, of the healthy persons examined ; Netter in 
15 per cent. ; Washbourn and myself, in a limited 
number of individuals (20), in 30 per cent. ; in a 
more extended series I have found it present in 18 
per cent. It is also commonly found in the normal 
nose, its presence being recorded by Netter, Kurth 
and von Besser, and others—its percentage Incidence being 
nearly 30 and the tonsillar crypts frequently harbouT the 
coccus. In many instances the pneumococci isolated 
from these situations are of low virulence; indeed, some¬ 
times they are avirulent, and at other times of a high degree 
of virulence. Washbourn and I carefully studied a number 
of them and found that even if the original virulence was 
low it could readily be exalted. A few varieties, however, 
were only exalted in virulence with great difficulty and then 
soon returned to their original condition. Hence the portal 
of entry is in the vast majority the respiratory tract and the 
cells of the upper air passages form the first line of defence. 
The pulmonary tissues constitute the second line of defence. 
Once arrived at the lung alveoli the pneumococcus readily 
enters the blood capillaries and so reaches the general 
circulation. In this situation if antibodies in sufficient 
quantity are available the invader is destroyed ; short of this 
the cocci become deposited in areas of lowered bacterio- 
scopic pressure and so give rise to localised infections, or 
multiplying in the blood stream produce a general 
septicremia. Thus pneumonia may be regarded as a 
defensive process designed to prevent metastases or septi¬ 
caemia. At its best, however, it is not absolutely 
efficient. Banti, Prochaska, and others maintain that 
pneumococci are invariably present in the blood in pneu¬ 
monia and although years ago both Washbourn and myself 
were of opinion that the cocci only arrived at the peripheral 
circulation immediately prior to the fatal termination im¬ 
proved methods for the examination of the blood for the 
presence of micro-organisms lead me to believe that the 
cocci are present during the first two or three days of the 
disease even in the least severe cases of pneumonia. Next to 
the respiratory system the alimentary tract is probably the 
most common channel of entrance. Foulerton’s case of 
gastritis and the numerous recorded cases of pneumococcic 
appendicitis place this method of infection beyond doubt. 
It is therefore easy to see how any organ or tissue may 
become the seat of pneumococcic infection. Finally, as 
affording a possible explanation of pneumococcic peritonitis 
occurring more commonly in the female than the male, 
Doyen records the presence of non-virulent pneumococci in 
the healthy vagina and cervix, and I have isolated the coccus 
from these situations in three instances -in two the organism 






542 The Lancet,] DK. J. W. H. EYRE: THE PYOGBNETIC ACTIVITIES OF THE PNEUMOCOCCUS. [Feb. 22,1908. 


being of considerable virulence and in the third of very low 
virulence. 

In order to gain some idea of the frequency with which 
the pneumococcus is met with in situations other than 
pulmonary tissue and of the frequency with which its 
presence provokes the formation of pus, I have examined 
the records of the bacteriological department of Guy’s Hos¬ 
pital for the past five years. Arranged in tabular form, the 
results conclusively demonstrate the validity of the claim of 
the pneumococcus to be considered, potentially at any rate, 
a pyogenic coccus, for after subtracting seven cases of septi¬ 
caemia, two of infective endocarditis, and 24 of pleurisy with 
clear fluid, we have no less than 168 instances—rather more 
than 1 per cent, of the total number of bacteriological speci¬ 
mens for the five-year period—where the presence of the 
pneumococcus had led to the formation of exudations 
possessing all the physical attributes of pus. 


Table III.— Pneumocoocio Lesions other than Pneumonia. 



1903 

1904 

1905 

1906 

1907 

Totals. 

Septicaemia . 

1 

2 

1 

1 

2 

7 

Infective endocarditis . 

— 

— 

1 

— 

1 

2 

Purulent pericarditis. 

3 

1 

4 

— 

1 

9 

Purulent peritonitis (pure) . 

1 

1 

2 

2 

4 

10 

„ ,, (mixed) . 

— 

1 

— 

— 

— 

1 

Appendicular abscess (pure) . 

— 

1 

— 

— 

— 

1 

,, ,, (mixed) . 

— 

1 

2 

1 

— 

4 

Purulent meningitis.. ... 

1 

2 

— 

3 

8 

14 

Empyema (pure).. .~ 

10 

20 

28 

16 

21 

95 

,, (mixed) . 

3 

— 

— 

1 

2 

6 

Pleurisy.- 

2 

5 

10 

3 

4 

24 

Osteomyelitis. 

— 

— 

— 

— 

1 

1 

Periostitis (femur) .. 

— 

1 

— 

— 


1 

Necrosis (rib). .. 

— 

— 

1 

— 

— 

1 

Purulent arthritis, knee. 

— 

— 

1 

— 

4 

5 

,, ,, shoulder. 

— 

— 

1 

— 

i 

2 

„ ,, hip . 

— 

— 

— 

— 

1 

1 

Abscess, cerebrum . 

— 

— 

1 

1 

— 

2 

„ cerebellum . .. 

— 

— 

i 

— 

— 

1 

„ mastoid. 

— 

— 

2 

— 

3 

5 

„ liver. 

— 

— 

— 

1 

— 

1 

,, pelviB ... ... .. 

- 

— 

— 

— 

1 

1 

,, lacrymal sac. 

— 

— 

— 

— 

1 

1 

,, (subcutaneous), thigh . 

— 

— 

1 

— 

1 

2 

„ back . 

— 

— 

— 

— 

1 

1 

„ „ K«lP . 

— 

1 

— 

- 

- 

1 

M „ sacrum. 

1 

— 

— 

— 

— 

1 

Conjunctivitis .. . 

— 

— 

1 

— 

— 

1 

Total. 

IQ 

Q 

D 

□ 

Q 

201 

Total specimens examined . 

L065 

1083 

1933 

4050 

6301 

14432 


I have carefully excluded from the above table all cases 
in which the identity of the pneumococcus isolated from the 
pus was not completely established by methods above 
criticism, and in this connexion I would deprecate the 
diagnosis of “ pneumococcic ” suppuration by microscopical 
examination of stained films alone. It is far from rare 
when inquiring as to the attributes of the strain of pneumo¬ 
coccus implicated to find that the diagnosis rests on the 
slender foundation of the observation of “diplococci ” in the 
pus, regardless of the fact that the pneumococcus is not by 
any means the only organism which assumes this morpho¬ 
logical character in morbid exudates. The streptococcus 
very frequently, and the staphylococcus aureus and also 
staphylococcus albus by no means rarely, assume this type 
of division under similar conditions. Nor is the term 
“capsulated" as applied by observers who are satisfied with 
such cursory examination any more convincing, for often the 
note that this anatomical peculiarity of the pneumococcus is 
present will be found to depend solely on the ‘ * negative ” 
evidence of an unstained halo—such as is so frequently 
due to the contraction of rapidly dried serum from the peri¬ 
phery of the paired coccus—around the organism, which halo, 


be it noted, will probably be found surrounding.nearly every 
particle of dirt on the same slide. 

Attributes op the Pneumococcus. 

Consequently it will be well to recapitulate briefly now 
those essential characteristics of the pneumococcus which 
are deemed necessary by the bacteriologist to establish its 
identity—although I may at once say I have no intention of 
entering minutely here into the laboratory habits of this 
micro-organism. Incidentally it must be mentioned that for 
convenience of reference the particular pneumococcus 
isolated from each individual is designated by a name, letter, 
or number prefixed by the word “race,” or better “strain,” 
and when a number of strains are found to possess similar 
characteristics they are grouped together under the heading 
of “ Type.” 

Characteristics of the Pneumococcus. 

Technically described the pneumococcus is an aerobic, 
facultative anaerobic, non-motile, highly parasitic coccus 
occurring in body fluids as pairs, of which the individual 
members are lanceolate or “ candle-flame shaped, with the 
rounded bases in apposition, and surrounded by a mucinous 
capsule which can be positively demonstrated by MacConkey’s, 
Muir's, or one of Hiss’s staining methods; or as short 
chains’, also capsulated; occurring in artificial cultiva¬ 
tions as more nearly spherical bodies in pairs or short 
or long chains ; staining with the ordinary aniline dyes and 
not decolourised by Gram’s method ; growing upon artificial 
nutrient media at the temperature of the body only, but not 
upon gelatin at 20° G. (Certain saprophytic forms devoid of 
virulence, or practically so, are capable of multiplication at 
temperatures approximating to what is spoken of as room 
temperature—i.e., 20° to 22° C.—but with these races we are 
not at present concerned.) Multiplying in broth of reaction 
varying from + 12 to + 6 with the production of a uniform 
turbidity; in litmus milk with the production of an acid 
reaction, occasionally accompanied by clotting ; upon agar 
and inspissated serum as translucent discrete circular, hemi¬ 
spherical or slightly flattened colonies; upon agar over the 
surface of which sterile rabbits’ or human blood has been 
smeared, in similar manner but more freely than upon 
ordinary agar, and accompanied by a discolouration of the 
blood due to the transformation of the oxybsemoglobin to 
methajmoglobin, which is an almost pathognomonic feature 
of the growth of this coccus; and in the serum of animals that 
have been immunised to the pneumococcus in the form of a 
flocculent deposit in an otherwise clear fluid, the flocculi 
being composed of felted masses of long and convoluted 
chains of pneumococci. 

Finally, and most important of all, is the fact that a 
pneumococcus isolated from a definite lesion in the human 
subject is markedly pathogenic for the rabbit. Speaking 
generally, if injected into the peritoneal cavity of this animal 
it will produce an acute septicaemia and cause the death of 
the animal in one, two, three, or four days, while the organism 
can be recovered from the blood of the general circulation and 
from all the organs in a state of purity. The dose usually 
employed for this purpose is the entire growth from the 
surface of one 24-hours-old blood agar tube cultivation 
emulsified in one cubic centimetre of broth. Usually a dose 
many thousand times smaller than this suffices, but I have 
never yet found it necessary to employ a larger one. 

Interesting but of minor importance from the point of view 
of identity is the power possessed by the pneumococcus of 
splitting up certain carbohydrate substances when these are 
dissolved in the medium in which the organism is growing. 
The substances generally used in these tests are dextrose, 
lievulose, galactose, lactose, saccharose, maltose, mannite, 
dextrin, and inulin. The first six of these are always acted 
upon by the pneumococcus, and if the medium, originally 
neutral in reaction, is tinted with litmus solution, the 
activity of the pneumococcus is indicated by the change in 
colour associated with the presence of an acid reaction. The 
remaining three compounds are sometimes but not invariably 
"fermented” by the organism under discussion, hence the 
contention of some American observers that the fermenta¬ 
tion of inulin by the pneumococcus is so constant a 
character as to be of the highest value in diagnosis is not 
borne out in every-day work. 

Having indicated the general characters of the cocci 
isolated from the varied materies morbi already tabulated 
the question that next arises is how to explain the varying 
pathogenetic properties exhibited by the pneumococcus. 
Before referring to the experimental work which has teen 











The Lancet,] DR. J. W. H. EYRE: THE PYOGENETIC ACTIVITIES OF THE PNEUMOCOCCUS. [Feb. 22,1908. 543 


carried ont in the attempts to answer satisfactorily this 
question I would remind you of the essential factors that 
are concerned in this question of infection, or of immunity 
if you prefer to regard it from the standpoint of the 
defenders rather than that of the invaders. Briefly, those 
factors which we shall now deal with here are : (1) the type 
of the organism ; (2) the virulence of the organism ; (3) the 
cambers of the infecting organism; and (4) the defensive 
powers of the invaded tissues, e.g., the resistance or the 
susceptibility of the animal cell or of the invaded individual. 

Typei of Coeoiu. 

Daring some of our observations upon the natural history 
of the pneumococcus Washbourn and I noted that although 
all strains of virulent pneumococci produced a rapidly fatal 
septicaemia when introduced into the peritoneal cavity of the 
rabbit, yet if the injection was made into the subcutaneous 
tissue the various strains frequently presented striking differ¬ 
ences in the histological characters of the local lesions they 
produced. Thus in the case of strains recovered from the 
hepatised lung in cases of pneumonia, fibrinous exudation 
formed the bulk of the material at the site of inoculation ; 
while when strains isolated from broncho-pneumonia and 
from suppurative lesions were injected the local reaction con¬ 
sisted mainly of accumulations of polymorphonuclear leuco¬ 
cytes. These two types of cocci which we referred to as the 
••fibrinous" and the “cellular'’ types respectively agreed 
in some measure with those previously described by Fod, and 
the hope was raised that the existence of two distinct and 
fixed varieties of pneumococci would afford an explanation 
of the differing clinical phenomena provoked by the invasion 
of human tissues by this organism in general, and in 
particular of the occurrence of acute septicaemia on the 
one hand and of pus formation on the other. Such, however, 
was not the case, for it was soon found when the experiments 
were carried further that by varying the conditions of the 
experiment either type was capable of giving rise to pus 
formation or to septicaemia. As an example of the different 
results obtained by varying one factor of the experiment— 
viz., the resistance of the tissue cell—I may instance the 
infection of the subcutaneous tissue of the abdomen of the 
rabbit. 

(a) If we select for the experiment a young rabbit we find 
that a small dose of either of these types of the pneumo¬ 
coccus will cause death within 48 hours from acute 
pneumococcic septicaemia. At the seat of inoculation the 
reaction, usually small in amount and limited in area, is 
practically always cedematous in character, and either of 
the serous, sero-hscmorrhagic, or more rarely the haemor¬ 
rhagic type. 

(4) If, however, we substitute a half grown rabbit and 
inject a similar dose of the same cultivation the animal 
survives for a much longer period, say three or four days, or 
even a week. Now the local reaction at the seat of infection 
is a much more extensive process and clearly indicates by 
both its macroscopical and microscopical characters the 
particular “ type ’’ of pneumococcns that has been employed 
to produce the infection. It may be either a firm gelatinous 
exudation consisting of fibrin and leucocytes, together with 
red blood discs, thrown out and occupying the subcutaneous 
cellular t sue for a considerable distance around the needle 
puncture frequently, indeed, extending down to the peri¬ 
toneum l low; or else a dense, opaque, yellowish exudation 
consisting almost entirely of small round cells, fibrin being 
almost entirely absent. 

(o) Finally, if a fully grown animal is infected with a 
similar dose of either type the local lesion at the seat of 
inoculation consists of a larger or smaller circumscribed 
oedema, usually noticed within 24 hours of infection, which 
enlarges slightly during the next few days, though remaining 
strictly localised, becomes soft, and in about ten days con¬ 
tains pus and can be made to fluctuate. If untreated the skin 
over the abscess undergoes necrosis, sloughs, and gives exit 
to a thick creamy yellowish pus literally teeming with 
pneumococci and the animal dies from exhaustion in a fort¬ 
night or so, or in some few instances completely recovers. 

Again by varying the site of inoculation and introducing 
the organism either into the peritoneal cavity or directly 
into the general circulation each type of pneumococcns 
would produce an acute septicaemic infection irrespectively 
of the age of the experimental rabbits. 

From the clinical aspect exceptions were numerous and it 
was found that the fibrinous type of pnenmococcuB was as 
often isolated from purulent collections unassociated with 
pneumonitis as the cellular type. 


Degress of Virulence, 

Then, too, in our early observations Washbourn and 
myself found that pneumococci isolated from patho¬ 
logical processes in man invariably possessed a certain 
amount of virulence for the rabbit and so constituted 
the virulent type of pneumococcus; on the other hand, 
some strains of pueumococci isolated from various situa¬ 
tions in the healthy body were devoid of virulence for 
that rodent and constituted the avirulent type ; whilst 
between these two extremes every grade of virulence could 
be recognised. Here again an obvious explanation for the 
various lesions produced in man as the result of infection by 
the pneumococcus seemed to be forthcoming and it was at 
once put to the test. Strains of pneumococci were isolated 
from various situations and from exudates of very different 
naked-eye characters and their virulence was tested. The 
usual rough-and-ready method of estimating virulence by 
observing the amount of a 24-hours-old broth culture of the 
organism under investigation needed to produce any given 
result did not appeal to us, as among other peculiarities of 
the highly parasitic pneumococcus it does not usually grow 
well in this medium and when it does it varies from time 
to time in its rate of growth and moreover rapidly loses 
its virulence. Cultivations upon blood agar which had 
previously been described by Washbourn and myself as 
particularly adapted for the purpose of maintaining 
the virulence were therefore employed and a more accurate 
method of estimating the size of the doses, in which 
a specially manufactured and calibrated loop was always 
used to remove the growth from the medium was devised. 
Briefly our method was as follows. One loopful of the 
24-hours-old growth at 37° C. was taken from the surface of 
the blood-agar and thoroughly emulsified in a known 
quantity (10 cubic centimetres) of sterile broth or saline 
solution, in a suitable vessel. It was then easy to prepare 
dilutions, in tenths, of the original loopful by measuring tne 
requisite fractions of this emulsion in sterile graduated 
pipettes, transferring them to other vessels and adding more 
saline solution to any desired volume. Thus a series of 
rabbits could be inoculated with decreasing amounts of the 
pneumococcus cultivation and the minimal lethal dose 
ascertained. 

The accompanying table shows such a series of inoculations 
of a strain known as strain “ Sudbury,” which was originally 
isolated from the rusty sputum of a case of lobar pneumonia. 


Table IV.— Determination of the Minimal Lethal Dose of 
the Pneumococcus (Strain “ Sudbury"). 


Rabbit. 

Dose of culture. 

Method of 
injection. 

Result. 

No. 1 

1 

loopful. 

I ntraperitoneally. 

Death in 18 hours. 

2 

01 

11 

M 

24 „ 

3 

0*01 


tt 

.. 48 ., 

.. 4 

0-001 



h 3 days. 

5 

0 0001 

•1 


.. 3 ., 

„ 6 

000001 

II 


»i 7 •• 

.. 7 

0 000001 

*• 


M 7 ,i 

„ 8 

0 0000001 

• 1 


Unaffected. 

.. 9 

o-oooooooi 

•I 


•• 


It was soon found that the different strains of pneumo¬ 
cocci differed markedly in their virulence. Of some when 
first isolaed it was necessary to inject an entire blood agar 
culture to kill the animal. Others, again, were fatal in 
doses corresponding to one-millionth part of a loop. Usually 
it was found that even those of comparatively slight virulence 
would after one or two passages through animals be so 
enhanced in virulence that the very minute dose just men¬ 
tioned—the one-millionth part of a loop—now proved to be 
the minimal lethal dose. Consequently such a degree of 
virulence came to be regarded as the standard, and a pneumo¬ 
coccus which was fatal in doses of 0 000001 of a loop was 
spoken of as possessing “standard virulence.” 

The method already described for estimating the virulence 
of any given strain of pneumococcus not only enables the 
bulk of the dose to be measured in terms of a loop with some 
degree of accuracy but also gives a fairly close approxima¬ 
tion to the actual number of cocci contained in at least the 
smaller doses. For example, working with a pneumococcus 
of standard virulence it was found that the minimal lethal 









044 The Lancet,] DR. J. W. H. EYRE : THE FYOGENETIC ACTIVITIES OF THE PNEUMOCOCCUS. [Feb. 22,1908. 


Table X.—Initial Virulence of Yarioui Strains of 
Pneimooocoi. 


No. Sex. 


1 

2 

3 

4 

5 

6 

7 

8 
9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 I 

20 

21 1 
22 | 
23 


M. 

F. 

M. 

M. 

F. 

M. 

F. 

F. 

F. 

F. 

M. 

F. 

F. 

F. 

M. 

M. 

M. 

F. 

F. 

M. 

F. 

M. 

M. 


Age. 


# Pneumococcus 
isolated from— 


24 | M. 

25 ' M. 

26 F. 
27. M. 
28 F. 


29 

30 

31 

32 


M. 

M. 

M. 

F. 


33 M. 


34 

35 

36 

37 

38 

39 

40 

41 

42 


M. 

M. 

M. 

F. 

M. 

M. 

F. 

M. 

F. 


30 

22 

26 

36 

18 

26 

20 

18 

42 

A 

3 

2 

8 

18 

15 ! 
24 
30 
26 
18 

6 

3 

Ik 

16 

36 I 
45 
22 
10 

10 I 

3 1 

1A 

27 

12 | 

30 ; 

22 | 
30 

18 i 

19 I 

7 

5 | 

9 

3 ! 

5 I 


Peripheral blood. 


Heart blood. 


Vegetations on 
valve. 

Peritoneal pus. 


Fluid from chest 


43 F. 


44 


F. 


15 

3 


Pus from knee. 

»i n shoulder. 

h it knee. 

•• „ hip. 

Pus from cerebral 
abscess. 

Pus from subcutaneous 
abscess. 

Pus from subcutaneous 
abscess. 


Minimal 
let hal 
dose. 


0'000001 loop. 
OC00001 
1*0 

0-000001 
0'01 
o-oi 
20 
o-ooi 
001 


Clinical 

result. 


Cerebro-spinal pus. 


Pus from cheat. 


0000001 
0 000001 
0 000001 
0 000001 
0001 
0*001 
01 
1-0 
20 

o-oooooi 
0001 
0 001 
l-o 
1 entire 
culture. 
0*000001 loop. 
| 0 000001 „ 
0*000001 ,, 
0-000001 M 
0 00001 „ 
0-00001 
01 

1-0 .. j 

1 entire 
culture. I 
1 entire , 
culture. 

0 000001 loop.; 
0-000001 , 
o-oooooi , 

10 

o-oooooi „ 

0 000001 „ 
o-ooooi „ 
o-oi 

0-00001 „ 
0-001 
2 loops. 


Death. 


Recovery. 

Death. 

Recovery. 

Death. 

Recovery. 


Death. 


Recovery. 


Death. 

Recovery. 


Death. 

Recovery. 

Death. 

Recovery. 


dose was either 0-000001 or 0-0000001 of a loopful and 
control plate cultivations made with that quantity of the 
emulsion corresponding to 0 000001 showed that sometimes 
it contained 200 cocci, sometimes 20. If it contained 200 
cocci the minimal lethal dose was 0 • 0000001 of a loop • if it 
only contained 20 the animal that received 0 ■ OOOOOOl’ of a 
loop was usually unaffected, and 0 ■ 000001 of a loop proved 
to be the minimal fatal dose. 

Now in the experiments already quoted the introduction of 
the pneumococcus into the subcutaneous tissues of an animal 
of but feeble resisting power—i.e., the young rabbit—was 
followed by acute and rapidly fatal septicaemia, while the 
same organism similarly used to infect an animal of greater 
resistance—i.e., the full-grown rabbit—led to the forma¬ 
tion of a localised collection of pus. Conversely it 
seemed possible that septicaemia in the adult—I purposely 
specify the adult in order to avoid touching upon the ques¬ 
tion of greater susceptibility in the infant and the aged— 
would be the result of infection by a pneumococcus of 
extremely high virulence, while pus formation would be due 
to the inroads of attenuated pneumococci. Sometimes this 
does obtain. For instance, a recent case of primary 
peritonitis yielded a pure culture of a pneumococcus the 
virulence of which was so low that two loopfuls of the 
optimum cultivation were required to produce fatal infection 
m the rabbit, whilst a morphologically identical pneumo¬ 
coccus from a fatal case of septicaemia was of standard 
virulence—that is to say, was two million times as powerful 
Now, supposing it were possible to apply the results of these 
observations without reservation to pneumococcic infections 
in man, it should be a simple matter, given the nature of the 
lesion produced, to forecast the approximate virulence of the 
strain of coccus isolated; or, given the virulence of the 
organism, to predict the characters of the lesion that would 
follow its introduction into human tissues. Thus the pneumo¬ 
coccus of high virulence should produce septiciemia and the 
pneumococcus of low virulence should induce the formation of 
pus. But, on the other hand, two strains of pneumococci of 
equal and standard virulence were isolated from two oases which 
differed widely in the clinical manifestations, the one being 
a chronic otitis media, the other being a fatal case of pneu¬ 
monia, suppurative pericarditis, and suppurative cerebro¬ 
spinal meningitis. However, the hypothesis I have sug¬ 
gested was put to the test and a large number of strains 
isolated and the virulence of each estimated, with the result 
that it proved untenable, for the simple reason that no 
constant relationship could be shown to exist between any 
given pathological manifestation of pneumococcic activity 
and either high, low, or medium virulence. The general 
results obtained will be readily appreciated from the 
accompanying details which are arranged in tabular form. 

Size of Dose. 

The next point to which my attention was directed was the 
relationship, if any, that existed between the size of the dose 
of infective material—or if you prefer it the number of 
pneumococci injected—and the character of the resulting 
lesion. Under certain conditions it was found that the size 
of the dose exercises a direct bearing upon the subsequent 
lesion—a result which was arrived at in a manner illustrated 
by the following example. In this experiment full-grown 
male rabbits were injected with cocci from one and the same 


45 

1 F - 

46 

Rusty sputum. 

0-000001 loop 


46 

F. 

50 

•• 

o-oooooi „ 

Death. 

47 

M. 

24 


o-ooi 

Recovery. 

48 

M. 

36 

*> .1 

1*0 


49 

M. 

45 

Lung juice. 

o-oooooi 


50 

F. 

45 

» .. o-oooooi .. 


61 

M. 

38 

I» J, 

2-0 


52 

F. 

28 

•t »■ 

1 entire 






culture. 


53 

M. 

f- 

• • II 

0 000001 loop. 


M 

M. 

l'i 

• • *1 

o-ooocoi „ 


55 

M. 

1,V 

»• It 

O-OOOCOl „ 


56 

M. 

i f. 

II II 

o-oooooi ,, 


57 

M. 

A 


o-cooooi „ 


68 

F. 

2 


0 001 


59 

F. 

V. 

•I II 

o-oi 


60 


i f. 

•I II 

1-0 


61 

M. 

J 

i a 

•I II 

1 

i-o 1 



Table VI .—Minimal Lethal Dote 0 • 000001 loop. Virulence 
Attenuated l»j Four Suooettive Suboultivatio-ns upon 
Ordinary Agar. (Fneumococcus Strain " Hunt.”) 



j !f„ p Dose of 

Method 



& 

& 

£ -SPc 5 pneumo- 
W g coccus. 

< “ 

of infec¬ 
tion. 

Lesion. 

Result. 

No. 31 

M. 1230 0 0000001 

Subcu- 

Transient local 




taneoualy. 

oedema. 

ted. 

.. 32 

M. 1250 0-000001 

1 

•» 

Localised ab- 




| | 

scess; necrosis of 
skin; raw. 

18 days. 




granulating sur- i 


.. 33 

34 

M. 1280 0 001 

M. 1300 1 loop. 


face. 

Death in 
12 days. 


Limited fibrinous 





exudation ; 

72 hours. 




pneumococcic 


| j 

| 

scptica-mia. 



Xote. —O’OOOCOl loop contained 200 pneumococci. 





The Lancet,] DR. J. W. H. EYRE : THE PYOGENETIC ACTIVITIES OF THE PNEUMOCOCCUS. [Feb. 22,1908. 545 


cultivation of a strain of pneumococcus (which had been 
isolated from the lung juice of a fatal case of lobar 
pneumonia). The factor that was wittingly varied was the 
tize of the dose. The first rabbit received approximately 
20 cocci, the next 200, the next ZOO,000, and the last 
200,000,000. 

Cell Resistance. 

Having investigated the various phases of pneumococcic 
infection with reference to (1) the biological type and (2) 
the virulence of the organism concerned, and, incidentally 
(3), the magnitude of the infective dose without obtaining 
any satisfactory explanation of the disease lesions produced in 
man by the invasion of his tissues by the one morphological 
entity, the pneumococcus, it still remains to inquire into 
the possibility of the resistance of the cell being the most 
important factor, and I may say at once that in this direc¬ 
tion undoubtedly lies the solution we are seeking. Experi¬ 
mental work had already pointed to the importance of this 
factor. Indeed, most of the instances which 1 have already 
adduced in illustration of the action of the other factors in 
the problem have also demonstrated to a greater or less 
degree the influence of this the most important factor. Thus 
we have seen how the pneumococcus which in the young 
and immature rabbit is able to produce a rapidly fatal 
septiciemia, in the adult and fully formed rabbit remains 
localised to the seat of inoculation, and is at most 
only able to give rise to a circumscribed collection of 
pus. 

The rabbit forms the subject of the bulk of the pneumo¬ 
coccus experiments, because it is certainly the most sus¬ 
ceptible of all the laboratory animals to infection by this 
organism. The young rabbit is infected with the greatest 
ease, half-grown animals are slightly more resistant, and 
fully grown and mature ones are more resistant still, but 
even in the normal adult rabbit the resistance offered to the 
pneumococcus is veiy slight, and that resistance varies to no 
appreciable degree in different individuals. Now in the pro¬ 
cess of immunisation the method that gives the most satis¬ 
factory results is the preliminary intravenous injection on 
two or three suitable occasions of “killed” broth cultiva¬ 
tions of the pneumococcus. This proceeding is fouifd to 
confer a certain slight degree of immunity upon the animal, 
which now survives the introduction of several times the 
minimal lethal dose of living cocci into its subcutaneous 
tissues, but, and this is the point I wish to emphasise, a 
small circumscribed abscess almost invariably forms at the 
seat of inoculation. If this is untreated it bursts, discharges 
its pus, and then the cavity closes by granulating up. When 
completely healed the animal is found to be highly resistant 
to subsequent injections of living cocci. 

Many experiments were undertaken in the attempt to 
devise some means of measuring the resistance offered by 
the living cell to the onslaughts of the pneumococcus, and 
in the course of these advantage was taken of the fact 
already referred to that the pneumococcus when grown in 
immune serum —that is to say, the serum of an immune 
animal—became agglomerated into masses of convoluted 
chains which formed fiocculi in an otherwise clear fluid, 
in short because agglutinated. In the course of these 
observations the serum from the healthy individual of 
several varieties of mammals was examined as well as that 
of highly immunised animals of various species, and also 
Berum from subjects suffering or convalescent from natural 
or experimental pneumococcic infections, and, speaking 
generally, the constancy of the phenomenon was established. 
Many other observers, particularly Issalf and Arkharow. also 
noted the peculiar features of growth in immune sera; 
indeed, Bezamjon and Griffon endeavoured to utilise the 
agglutinins present in the blood of infected individuals 
as a method of diagnosis. Pneumococcus agglutinins, 
however, are only formed in small quantities and for 
a limited period, and rapidly disappear from the serum, so 
that it is difficult not only to measure their amount but 
also, in many instances, to demonstrate their existence, so 
that for clinical purposes the agglutination reaction in 
pneumococcic infections has but a very restricted applica¬ 
tion. 

Next the bactericidal action of normal and of immune 
eerum was carefully investigated, and while the observations 
of Baring and Nissen and Kruse and Pansini relating to the 
absence of bactericidal substances from the serum of the 
normal rabbit were fully confirmed it was further found that 
the serum of immunised animals varied considerably in this 
respect in that sometimes bactericidal substances were 


present in considerable amount, although on the other hand 
they were frequently absent or present only in amounts too 
minute to be appreciated. Mennes, however, pursuing this 
line of investigation, found that while the serum of an 
immunised animal frequently failed to exercise any definite 
bactericidal action by itself, if white blood cells from either 
a normal or an immunised animal were added to the mixture 
of cocci and immune serum the serum so acted upon the 
cocei as to render them sensitive to the action of the leuco¬ 
cytes, and many of the pneumococci in the mixture were 
englobed and destroyed by the white cells. This property he 
stated was peculiar to immune serum. 

Then came the epoch-marking and now widely accepted 
researches of Wright and Douglas, which followed on 
Leishman’s work on phagocytosis, in the course of which the 
presence of certain bodies designated * ‘ opsonins ” was 
demonstrated in human serum substances which enabled 
the serum containing them to behave in a manner similar to 
that described by Mennes in connexion with his pneumo¬ 
coccus immune serum. These observers next devised a very 
ingenious method for measuring the amount of opsonin in a 
given serum, by means of which they were able to show 
that as compared with normal serum, the serum obtained 
from a recently infected individual or animal contained a 
diminished amount of an opsonin special and specific for the 
infecting bacterium. The serum of an immune animal on 
contrary contained as much as or more of that specific 
opsonin than the serum of the normal. Finally, by 
injecting small doses of “killed” cultivations of the 
bacterium into the subcutaneous tissues of the patient 
they were able so to stimulate the immunising machinery 
in the direction of the over-production of specific 
opsonin as beneficially to influence the course of the infec¬ 
tion. Such in bald outline are the experimental data around 
which Wright and his pupils have built up a complete and 
extensive system of pathology, diagnosis, and vaccine- 
therapy. It now remains to indicate its application to 
pneumococcic infections in particular. 

In the first place man, as compared to the adult rabbit, 
exhibits a very marked resistance to invasion by the pneumo¬ 
coccus, although this resistance varies considerably in 
different individuals and at different ages. These differences 
are, no doubt, due to many factors, of which hereditary 
selection may be one. Another which possibly has a bearing 
upon this aspect of the question is the situation of the 
pneumococcus in nature. Some 10 per cent, at least of the 
healthy population cultivate the pneumococcus in that 
natural incubator, the mouth and upper air passages. 
What is more likely than that a considerable quan¬ 
tity of antibodies is formed and some degree of im¬ 
munity set up as a result of the continual absorption of 
small doses of the toxins and other metabolic products of 
the pneumococcus. It is not surprising to find that the 
opsonin content of normal human serum is on an average 
double that of the normal rabbit, although it must be borne 
in mind that opsonins probably form but one of many anti¬ 
bacterial substances elaborated by the body in its unceasing 
resistance to the attacks of external forces. Assuming the 
opsonin present in the normal human serum to be repre¬ 
sented by unity, the opsonin in the normal rabbit serum only 
reaches half that figure. The figure expressing that ratio— 
viz., 0 • 5—is spoken of as the opsonin index. By the exercise 
of infinite care, however, in the process of immunisation the 
pneumococcus opsonin content of the rabbit’s Berum may be 
raised until it is equal to, and even greatly superior to, that 
of normal human serum. Under these conditions the 
injection of the pneumococcus of sufficient virulence and 
sufficient dose to cause the death of a control rabbit within 
36 hours from acute septicaemia will only give rise to localised 
suppuration. 


Table VII .—Minimal Lethal Dose 0-000001 loop. ( Pneumo- 
oooous Strain “ Sudbury. ’) 


Rabbit. 

Sex. 

Weight. 

Opsonin 

index. 

Dose. 

Result. 

Control a 

M. 

1250 

0'56 

0 0000001 

Unaffected. 

.. b 

M. 

1260 

0-62 

0 000001 

Death in 48 
hours. 

„ c 

M. 

1250 

0-50 

000001 

Death in 36 
hours. 

Immune 

M. 

1240 

1*13 

0 00001 

Local abscess. 




546 The Lancet,] DR. J. W. H. EYRE : THE PYOGENETIC ACTIVITIES OF THE PNEUMOCOCCUS. [Feb. 22,1908. 


Macdonald, who very carefully studied the clinical aspects 
of pneumonia with reference to the formation of pneumo- 
coccic opsonin throughout the course of the disease, pub¬ 
lished his results in 1906 and showed that the movements of 
the curve representing the opsonin index afforded an exact 
record of the measure of resistance opposed by the patient to 
the inroads of the organism. My own observations fully 
confirm Macdonald’s, and, moreover, show that the resist¬ 
ance of the individual so far as can be measured by his 
opsonin response to any given pneumococcus infection con¬ 
forms to one of three main classes which are represented by 
the three accompanying curves. Two of these opsonin 
curves are compiled from estimations carried out in con¬ 
nexion with that clinical form of lobar pneumonia in 
which crisis takes place and that which recovers by lysis 
in order to contrast them with the curve obtained in the 
acute septicaemia which terminates in death ; and although 
we are not immediately concerned with pneumococcus 
infection of the lung tissue I make no excuse for present¬ 
ing them here, as being derived from acute cases they 
illustrate my point much more concisely than would be the 
case if they had been derived from chronic suppurations. 

Chart 1. —The Optonin Index in Pneumococcic Infections; 

Three Leading Typet. 



In the third, represented by the lowermost (continuous) 
curve, the process by which opsonins are elaborated is com¬ 
pletely paralysed, as the result possibly of an extremely 
heavy dose of infective material, or of infection by an 
extremely virulent pneumococcus, or of infection directly into 
the blood stream, or more probably of a combination of all 
of these factors. In the second (dotted line), the production 
of pneumococcus opsonin is temporarily suspended, perhaps 
owing to the existence of, say, any two of the factors just 
enumerated, but after a time recovery of tone takes place, 
production goes on in excess of expenditure, and finally 
sufficient opsonin is produced and thrown out into the cir¬ 
culation to subdue the invader. Incidentally it may be 
mentioned that this type of case is most frequently the one 
in which the pneumonia is associated with suppurative 
lesion. In the first (thick continuous line) the immunising 
machinery promptly responds to the call made upon it, at 
once elaborates opsonin in excess, with the result that the 
pneumococcus is rapidly destroyed and recovery takes place. 
[Occasionally, be it noted, this type of curve after returning 
to the normal suffers a further fall, and some few pneumo¬ 
cocci remaining in some far distant spot, in an almost 
moribund condition, take on a fresh lease of life and some 
small localised suppuration results. In such circumstances 
the opsonin curve would be expressed by tacking the 
beginning of the second curve in the chart on to the end of 
the first.] In other words, in the third instance the immunis¬ 
ing machinery is badly overstrained, in the second under- 
strained, and in the first severely but not unduly strained. 

As suggesting a possible source of the pneumococcus 
opsonin I hare inserted in the two following charts 
(Charts 2 and 3) the leucocyte curve as well as the opsonin 
curve. In the fatal case leucocytosis is absent, the opsonin 
index falls gradually and continuously. In the second case 
the fall in the opsonin index that is practically always noted 


in the early stages of an acute infection is associated with 
a considerable leucocytosis which becomes less marked as 
the amount of available opsonin increases. 

Chart 2. —Fatal Cate of Pneumococcic Septic icmia. 



Upper thin line = temperature; middle thick line = opsonic 
index ; lower dotted line — leucocytes per cubic millimetre 
of blood. 

I cannot conclude without a few remarks upon what may 
be termed the bacteriological therapy of pneumococcic 
infections. Many of the earliest students of the life-history 
of the pneumococcus—the Klemperer brothers, Foil and 
Carbone, and in this country Washboum—showed that the 


CHABT 3 . -Cate of Pneumonia terminating by Oritit. 



Thin continuous line = temperature; dotted line = leuco¬ 
cytes ; thick continuous line = opsonic index. 


blood serum of immunised animals protected other animals 
from the effects of pneumococcus inoculations if injected 
simultaneously or even subsequently. Washbourn early in 
1897 immunised the horse and about the same time Fane 
immunised the donkey and the goat with a view to obtaining 
a potent serum for the treatment of cases in man. Such 
sernm has never been really extensively tested in this 
country and therefore no very definite opinion can be 
expressed as to its value. What little evidence there is 
available is certainly in its favour ; for instance, in a small 
series of six caseB of pneumonia collected by Washbourn the 
serum in three cases exerted a powerful and beneficial effect 













The Lancet,] DR. J. W. H. EYRE : THE PYOGENETIC ACTIVITIES OF THE PNEUMOCOCCUS. [Feb. 22,1908. 547 


upon temperature and upon the pulse and respiration rates ; 
in one case it appeared to have no effect whatever, and in the 
last case it was powerless to avert the fatal issue. Pane, in 
reporting 29 cases with two deaths and a further series of 
nine severe cases of epidemic pneumonia (in Naples) with 
one death, insists on the rapid improvement that follows the 
injection of serum. 

Antipneumococcic serum has, however, nowhere achieved 
the striking results in acute infections that are associated 
with the serum treatment of diphtheria, and it has never 
obtained the confidence of the profession, while in chronic 
and suppnrative pneumococcus infections the serum is quite 
useless. There are man; reasons for its failure. In the 
first place, the pneumococcus elaborates but very feeble 
toxins in vitro, and the serum which is obtained from 
immunised animals is antibacterial only and not anti¬ 
toxic, hence it would appear probable that its admini¬ 
stration would only be effective during the very early 


was absolutely powerless against the fifth. Finally, the 
various brands of serum vary considerably, even in their 
bactericidal power, probably owing to the fact that the 
bleeding of the immune animal is usually carried out at a 
date determined by purely clinical observation, and it is just 
possible that if the animal's blood was examined daily and 
the amount of some antibody—say, pneumococcus opsonin 
—estimated and the bleeding performed when that body was 
present in maximum quantity, vastly superior clinical results 
might follow the administration of such serum. 

Turning now to the employment of killed cultivations or 
vaccines in the treatment of pneumococcus infections a much 
greater measure of success is obtained. The behaviour of 
acute infections such as septicaemia and lobar pneumonia 
under the influence of pneumococcus vaccine has not yet 
come under my own personal observation, but excellent 
results in this direction are reported by American observers. 
I am, however, firmly convinced of the value of vaccines 


Chart 4.—Case op Pneumococcic Septicemia with Various Metastases Showing the Effect op 
Injections of Pneumococcus Vaccine upon the Pyrexia. 



stages of infection or in cases of pneumococcic septicaemia. 
But the symptoms develop in man and the diagnosis 
is made only when the pneumococcus has obtained a firm 
foothold; consequently to be of value a very powerful 
bactericidal serum is needed and experimentally at least the 
capacity to protect against some 300 minimal lethal doses 
per cubic centimetre of serum is the most powerful yet 
available. Many of the symptoms observed in pneumococcic 
infections are, moreover, those of profound toxaemia and a 
purely bactericidal serum would appear to possess very little 
therapeutic value in such circumstances ; on the other hand, 
Fane states that though his serum is bactericidal it does not 
act directly upon the pneumococcus itself but produces its 
beneficial effects by establishing a true active immunity. 
Then, again, Washboum and I elicited the fact that varieties 
exist among strains of pneumococci which can only be 
appreciated by the failure of the serum to protect animals 
infected with them, for in testing Pane’s serum we found 
that it protected against four out of five of onr strains but 


in the chronic suppurative lesions due to the pneumo 
coccus. 

In our early studies of experimental infections with the 
pneumococcus Washbourn and I had observed the fact that 
when immunising rabbits by the method I have already 
described the healing of the subcutaneous abscess which 
followed the inoculation of the first dose of living pneumo¬ 
cocci could be accelerated by a subcutaneous or an intra- 
peritoneal injection of killed broth cultivation ; indeed, in 
some instances, if the injection was made before definite 
fluctuation could be detected in the local lesion, the process 
of tissue necrosis was arrested and resolution took place. 
These happy results were not always attained, the reason, of 
course, being that we had no reliable guide as to when and 
how much to inject. I have already stated that a correct 
appreciation of the movements of the opsonin index forms 
the basis of, and renders possible, the treatment of bac¬ 
terial infections by means of killed cultivations of the re¬ 
sponsible organisms, or, more shortly, "vaccines,” and 









Vaccines upon the Opsonin Index and upon the Temperature. 


548 The Lancet,] DR. J. W. H. EYRE : THE PYOGENETIC ACTIVITIES OF THE PNEUMOCOCCUS. [Feb. 22,1908. 



Thin continuous line = temperature. 
Thick black line = opsonin index. 




























The Lancet,] MR. GRAY: FUNCTIONS OF THE STOMACH AND GASTRO-ENTEROSTOMY. [Feb. 22, 1908. 549 


this i holds good In the case of infections by the 
pneumococcus, and particularly those which are localised 
and are associated with pus formation. Cases such as these 
have yielded most promising results and I could cite 
numerous instances. I have, however, selected two which 
will suffice to show the possibilities of this adjunct to 
ordinary operative procedures. 

The first (Chart 4) was a small girl in whom double lobar 
pneumonia was followed by empyemata, that on one Bide 
being opened on the twentieth day of the disease and on the 
other two days later. A subcutaneous (pneumococcic) abscess 
of the arm was also opened on the twenty-second day. The 
right hip, the seat of suppurative arthritis, was operated 
upon on the thirtieth day and an iliac abscess also was 
drained. On the fifty-fourth day an abscess in the gluteal 
muscles, behind the trochanter, was incised. A vaccine was 
prepared from a pneumococcus isolated from the empyema 
pus and treatment was commenced on the fifty-second 
day. The effect of the injections upon the temperature 
is well seen, and the case, which had been regarded 
as hopeless, was discharged to a convalescent home on 
the eighty-second day. The next case (Chart 5) suggests 
the point I have already referred to concerning particular 
varieties of pneumococci against which certain antipneumo- 
coccic serums were powerless. The boy was under treat¬ 
ment for tuberculous peritonitis complicated by a secondary 
pneumococcic infection, and pus crowded with pneumococci 
was discharged freely through the ruptured umbilicus. On 
the twenty-second day after the patient’s admission to hos¬ 
pital and again on the thirty-third a “Btock ” pneumococcus 
vaccine was injected but without obvious effect so far as 
concerned either temperature or general clinical condition. 
A vaccine was then prepared from the particular pneumo¬ 
coccus Isolated from the peritoneal pus of this patient 
and improvement followed the injection of a dose on the 
forty-fourth day. The improvement was continued, the 
patient put on weight, the pus gradually disappeared, and 
the temperature came down. Tuberculin treatment was then 
adopted and the patient after a short stay in a convalescent 
home will become an out-patient. 

One other application of pneumococcus vaccines to cases 
in which operative treatment is needed—and these remarks 
hold equally in the case of other bacterial infections—and I 
have done. Where the opsonin content of the blood is low 
the preliminary injection of a suitable vaccine by stimulating 
the manufacture of further supplies places the patient in the 
most favourable condition to withstand Bbock and resist the 
further Bpread of infection through the disturbance of the 
tissues involved by the necessary operative procedures. In 
illustration I might mention a case of empyema and 
peritonitis following lobar pneumonia in an adult female 
under the care of Dr. W. Hale White. From the pus, the 
fluid portion of which had an opsonic index of less than O' 2, 
a virulent pneumococcus was isolated, a vaccine prepared, 
and a dose injected. Two days later the empyema was 
opened, when it was found that the pleural cavity communi¬ 
cated with the abdominal cavity and some five or six pints 
of pus were removed. The index of the liquor purls was now 
0'9. The patient convalesced rapidly—a few more injections 
of vaccine were required—and was discharged cured. 


CONSIDERATIONS CONCERNING THE 
FUNCTIONS OF THE STOMACH 
AND THE OPERATION OF 
GASTRO-ENTEROSTOMY. 

By H. M. W. GRAY, F.R.C.S. Edik, 

surgeon anb lecturer on clinical surgery, Aberdeen royal 

INFIRMARY. 


On* account of the usually immediate and striking benefit 
obtained, the operation of gastro-enterostomy has established 
itself as a very valuable and necessary procedure in many 
diseases involving the stomach and duodenum. Nevertheless, 
in spite of careful selection of cases, disappointing results, 
such as regurgitant biliary vomiting or formation of jejunal 
ulcer perhaps with perforation, occur occasionally, even when 
the most modern method (posterior no-loop) has been 
followed. Why such sequelae should occur only occasionally, 
when apparently the same technique has been carried out as 
in perfectly successful cases, is not clear. A possible 


explanation may be that sufficient care is cot taken in the 
selection of the Bite of the opening in the stomach. Mayo’s 
guide (that the opening should lie in a vertical line from the 
cardiac orifice) is probably a thoroughly sound one when the 
stomach is lying undisturbed in the abdominal cavity. When 
the stomach is pulled out, however, or otherwise manipulated 
the proper place may not be chosen, as the organ tends to 
swing round its lesser curvature. This, as I shall endeavour 
to show, may be the reason of untoward results. 

The best operative procedure is that which most nearly 
preserves or restores the natural functions of any part 
requiring such interference. For this, of course, accurate 
knowledge of the natural functions of the part concerned is 
necessary. I venture to assert that this essential is not 
fulfilled in the case of the stomach, at least in so far as its 
motor functions are concerned. 

It would seem that gastric surgery, as developed from 
experience gained in earlier operations on greatly dilated 
stomachs, has persisted in regarding the stomach as a 
“one compartment’’ organ. (Fig. 1.) Operations were 


FIG. 1. 



Tracing of stomach figured by W. J. Mayo In article on the 
Technique of Gastroenterostomy in the Annala of Surgery, 

April. 1906 (reduced to one-third), u, Cardiac orifice; 

6, pyloric orifice. 

planned with the object of “ draining ” these huge stomachs. 
To suit latter-day ideas some other term than “drainage” 
must be found. It does not convey a proper idea of the 
modem operation, which is executed more on the principle 
of a “ short circuit” or, in some cases, of a “ safety valve.” 
Cannon and Blake 1 showed that gastro-enterostomy need 
not be a drainage operation; that, in fact, food preferred to 
pass through the pylorus rather than through the newly 
formed “ stoma,” unless the latter was made very large. 
Their observations have probably been too much emphasised 
in this connexion. They were made on normal healthy cats. 
Leggett and Maury’s 5 more recent experiments prove little. 
Most of their operations, recorded in detail, seem to have 
resulted, more or less, in the old “ viciouB circle.” 

To procure its beneficial results gastro-enterostomy mutt be 
at first a drainage operation ; later, when the gastric secre¬ 
tions and the condition of the pyloric sphincter and of the 
neighbouring mucous membranes have become more normal, 
this function of drainage is not required and food may again 
pass naturally through the pylorus. Where permanent 
pylorio or duodenal stenosis is present, then, of course, 
“ drainage ” is permanent. Cannon and Blake * have shown 
that towards the end of digestion the pyloric end of the 
stomach is the lowest part, owing to the contraction of the 
longitudinal fibres of the stomach, and therefore that the 
“stoma” in gastro-enterostomy should be made as near the 
pylorus as possible. This seems rather at variance with 
their finding, that the operation is not a drainage one, and I 
shall endeavour to show that there sire probably more 
potent reasons why the “ stoma ” should be made as near the 
pylorus as possible. The great reason is that by making the 
stoma in this situation gastric digestion is allowed to become 
more quickly and permanently normal again. 

Professor D. J. Cunningham, 1 the late Professor Birming¬ 
ham, 5 and others have Bhown very conclusively in anatomical 
specimens that the shape of the stomach is very different 
from that described until a few years ago. It is evident 

1 Annala of Surgery, May, 1905. 
a Ibid., October, 19OT. 

3 Loc. clt. 

4 Traniactiona of the Royal Society of Edinburgh, vol. xlv., Part I., 
2 Cunningham’s Text-book of Anatomy, second edition, p. 1052. 




550 Tub Lanobt, MR. GRAY: FUNCTIONS OF THE STOMACH AND GASTRO-ENTEROSTOMY. [Feb. 22,1908. 


that it can no longer be regarded as a “one compartment ” 
organ. (I am very greatly indebted to Professor Conning- 
ham for permission to publish several of his illustrations. I 
should like to say that practically the whole of this paper 
had been written before I knew of Professor Cunningham’s 
excellent work, and I was gratified to find that his ana¬ 
tomical observations supported so strongly the deductions I 
had made from personal clinical observations.) Tracings of 
x ray shadows of the stomach of “ normal ” individuals who 
have taken meals mixed with bismuth subnitrate, made by 
Cannon and Blake 9 and lately by Pfahler, 7 show the differ¬ 
entiation indicated so well by Professor Cunningham, 
although these authors do not point this out. The 
“normal” stomach when at rest—i.e., empty—appears, to 
judge from these anatomical studies, to be tubular in nearly 
its whole extent, the exception being the proximal, larger 
part of the cardiac end, which never loses a more or less 
saccular form. Judging from what one sees on “ screening ” 
a stomach which is disposing of a bismuth meal this normal 
form becomes even more marked than in the resting state. 
This normal form of the stomach is seen in its most perfect 
condition in the stomach of the foetus before term. (See 
Figs. 2, 3, and 4.) 

Fig. 2. 



“Stomach of a full-time fcetuH, showing the physiological 
subdivision into a cardiac saccular portion and a tubular 
portion.” (Cunningham.) 


Fig. 3. 



“ Stomach of a full-time foetus in which the physiological 
division into two parts 1 b seen.” (Cunningham.) 


Fig. 4. 



Tracings of (a) fa-tal stomach at fourth month, and (ii) fa-tal 
stomach at full term. Cardiac portion distended with 
amnfotlc fluid, Ac.; p, pylorus. From specimens in the 
Anatomical Department of Aberdeen CniverBity. 

Having been impressed (from clinical observations) with 
the idea that the adult human stomach iu its natural state 
should more or less conform to this type, I naturally looked 


« Ibid. 

7 Journal of the American Medical Association, Dec. 21st, 1907. 


for confirmation in the formalin-hardened stomachs investi¬ 
gated by Professor Cunningham, and, to my mind, it is not 
wanting. One must remember, in looking at bis illustrations, 
that the hardening fluid was probably never injected earlier 
than 24 hours after death. By this time gas formation occurs. 
This causes irregular relaxation of the gastric wails. In one 
case one part dilates while another remains contracted ; in 
another case the reverse occurs, and so on. The onset of 


Fig. 5. 



time of death the digestive procesB was in a state of 
abeyance, or was just at the point of beginning.” 
(Cunningham.) May not the form be more likely due to 
excessive ante- or post-mortem dilatation ? 


Fig. 6. 



“Stomach of an adult female in the early stage of the 
emptying process.'’ (Cunningham.) 

Fig. 7. 

> A 



“ Stomach of an adult male showing very clearly the physio¬ 
logical sub division into a cardiac sac and a gastric tube.” 

•• B.8., Part of gastric tube formed by the body of the 
stomach.” (Cunningham.) 

death and the loss of contractility of unstriped muscle, in the 
case of arteries, varies with the condition of the individual’s 
nutrition at death. This rule, no doubt, applies also to the 
unstriped muscle of the alimentary canal and must be taken 
into account when suoh observations are made. Thus an 
average must b8 struck in order to arrive at an approximately 








The Lancet,] MR. GRAY: FUNCTIONS OF THE STOMACH AND GASTRO-ENTEROSTOMY. [Feb. 22 1908. 551 



accurate knowledge of the condition of affairs. One 
expects, of course, that where circular muscular fibres pre¬ 
ponderate, there constriction will more frequently be present. 
By making a composite picture therefore of the illustrations 
presented by Professor Cunningham one finds that the 
foetal form asserts itself. (Figs. 5 to 11.) Observations on 
the stomach form (such as those made by Wernstedt 8 ) when 

Fig. 8 


“ Stomach of a young adult male view ed from above, in w hich 
the emptying process is nearly completed.” (Cunningham.) 


Fig. 9. 



Fig. 11. 



“Specimen obtained from the poBt-mortem room. It exhibits 
a form intermediate between that seen in Fig. 7 and that 
. of a true hour-glass stomach.” (Cunningham.) Might 
not post-mortem dilatation explain the difference in¬ 
appearance ? 

The stomach is divided by the so-called “incisnra 
anguiaris” (His), on the lesser curvature, into a more or 
less vertical cardiac part, to the left, and a horizontal pyloric 
part to the right. As stated, the proximal part of the cardiac 
portion is always sac-like. The distal part is well supplied 
withcircular fibres. Into the far end of thisnumerous bandsof 
oblique fibres run from the cardiac orifice (Fig. 14), reaching 
to the greater curvature opposite the incisura anguiaris. 
These are quite well marked and have no doubt a definite 
function to perform. This tubular (?) cardiac part deserves 
greater attention than it has hitherto received, as it is prob¬ 
ably in it that most important preliminary “churning’’ of 
the food takes place. (Figs. 12 and 13.) The food is thus 
thoroughly mixed with the cardiac juices before being passed 
into the pyloric part. The “ incisnra anguiaris ” corresponds 
in many specimens with a well-marked set of circular fibres 
(Figs. 12 and 13) previously known, by physiologists especially, 
as the “sphincter of the antrum ” or the “transverse band.” 
According to Starling 9 this is a physiological and not an 
anatomical sphincter. I suggest that ‘ ‘ rphinuer a ditv r 
veitiiuli" is a more suitable name. The pyloric portion of 
the stomach is subdivided by a slightly marked sulcus on 


"Stomach of an adult female; aberrant form.” (Cunning¬ 
ham.) May not this be merely modified by poBt-mortem 
dilatation ? 


FIG. 10. 



" Stomach of an adult male ; aberrant form.” (Cunningham.) 

even artificial distension ( kunstlioke Dilaticrung) was often 
made previously to the hardening process are obviously of no 
value in settling this question. 


Fig. 12. 



"Section through the stomach of an adult male (aberrant 
form) along the plane of the curvatures.” (Cunningham.) 


the greater curvature into a larger part, the pyloric vestibule*. 
and a smaller, very muscular part, the pyloric canal. 

The proximal sac-like part of the cardiac portion i» 
endowed apparently only with tonic contraction. The more 


8 Archiv fur Anatomie und Physiologic (Anatomische Abtheilung), 
1907. 


9 Recent Advances in the Physiology of Digestion, by E. H. Starling* 
1906, p. 134. 

H 2 


V 






552 The Lancet,] MR. GRAY: FUNCTIONS OF THE STOMACH AND GASTRO-ENTEROSTOMY. [Feb. 22, 1908. 




tabular distal part is capable of peristaltic action as well 
(Figs. 12 and 13). The action of the oblique fibres (Fig. 14) 
would materially aid the sphincter aditus vestibuli. The 
pyloric part of the stomach is normally tubular, tonically 
contracted, and at certain stages of gastric digestion 
affected by strong peristaltic waves which increase in 

FIG. 13. 


“The anterior half of the stomach depicted in Fig. 11.” 

(Cunningham). 

strength as the pylorus is approached, corresponding 
to the increasing amount of circular muscular tissue 
present. All this is easily confirmed by the use of x ray 
screening after a “bismuth” meal. The meal (containing 
from lj to 2 ounces of bismuth subcarb.) should be taken 
in two or three “courses” at intervals of from 15 to 30 
minutes. 

The pyloric portion, as I shall point out again later, thus 
resembles a much-hypertrophied piece of intestine, the 
hypertrophy becoming more marked as the pylorus is neared. 
There is no good reason for thinking that reversed peri¬ 
stalsis should occur here any more than in the small 
intestine. If the pylorus is closed an axial reflux stream 

Fig. 14. 


“This figure shows the muscular fibres of the anterior half of the stomach 
represented In Fig. 10. The mucous membrane and subraueons coat have 
been removed from the interior." (Cunningham.) 


takes place (not necessarily back into the cardiac end). 10 
Yet the common idea seems to be that food is tossed or 
churned backwards and forwards in the stomach as a whole. 
It may quite reasonably be supposed that when food enters 
the easily dilated cardiac portion it becomes mixed with 
“ juices ” secreted there and is passed on from one compart¬ 
ment to another as soon as it is suitably prepared. If too 
much food is introduced some of it is ejected (vomited)— 
e.g., in the presumably normal stomach of the infant. If 
unsuitable food is taken abnormal secretion occurs—e.g., too 
much acid. This may be neutralised in the pyloric portion ; 
if not. the pylorus is irritated and remains contracted, 
regurgitation into the cardiac end occurs, and a “vicious 
circle ” is established and maintained till the stomach is 
emptied by vomiting and a fresh start can be made. This 
very readily occurs in the infant. In these modern days, as 
the individual grows older, the stomach becomes increasingly 
abased, the " natural ’’ state of things is changed, and a 
larger and larger part of the cardiac end goes to form the 
passive reservoir. When the cycle of events has led to 
actual disease (ulceration, pyloric spasm, stenosis, &c.) more 
and more of the stomach is involved till it assumes the 
condition of a large flaccid bag which has little power of 
emptying itself. There are nowadays very few normal 
stomachs to be found. In fact, it is probable that the 
“normal" condition in the adult is, as I have indicated, 
a rather feebly acting cardiac bag and a more forcibly 
acting, but still too frequently relaxed, pyloric tube. 
Such an organ is very easily upset in its digestive 
powers. 

The juices secreted by the different parts of the alimentary 
tract interact upon one another, stimulating or inhibiting. 
For example, as Wertheimer and others have shown, acid in 
the duodenum excites the production of secretin, which in 
turn stimulates the secretion of pancreatic juice. This 
observation applies apparently to the greater part of the 
small intestine, although the response is more feeble in 
the lower parts. On the other hand, according to some 
authorities, secretin or some other substance in the small 
intestine exerts an inhibitory effect on the secretion of the 
gastric (acid) juice. If, then, owing to hyperacidity, pyloric 
spa9m occurs the gastric juice cannot gain access at the 
proper time to the small intestine and the cycle of events 
referred to is broken. The effect of gastro-enterostomy, by 
draining the pyloric portion through the short circuit, is to 
act as a safety valve. A more probable explanation, in the 
light of the opinion of the greater number of physiologists, 
is the following. In a case, for example, of hyperacidity 
causing pyloric spasm mere drainage of the pyloric 
portion removes foodstuffs which serve 
as a chemical stimulus in the produc¬ 
tion of acid and also provides for easy 
escape of the excess of acid tending to 
be present. Therefore the hyperacidity will 
be reduced and consequently the pyloric 
spasm. As Starling 11 remarks: “The juice 
secreted in the second phase must vary 
according to the quantity of gastric hormone 
produced in the pyloric mucous membrane, 
and therefore with the nature and amount 
of the substances produced in the pre¬ 
liminary digestion of the gastric contents 

by means of the psychic juice. The 

second phase of secretion will continue so 
long as there are substances present in the 
stomach to act upon the pyloric mucous 
membrane.” Draining off these will 
necessarily diminish the production of 
juice. 

10 Since this paper was submitted for the accept¬ 
ance of the Editor of The Lincet I have read 
with great interest the valuable article In the 
British Medical Journal of Jan. 18th, 1908, p. Id 0 , 
by I)r. A. F. Hertz. I quote one paragraph which 
has a very direct bearing on what 1 have said: 
• No mixing of the contents of the two parts of 
the stomach occurs. Thus, on a number of 
occasions I have observed that if food mixed with 
bismuth carbonate is eaten shortly after a meal 
containing none of ttie salt, a rounded shadow- 
just under the left half of the diaphragm is 
seen, whilst the pyloric part of the stomach 
remains invisible. After some time the first part 
of the meal passes into the duodenum, and the 
food containing the blBmuth gradually replaces it 
in the pyloric part of the stomach, which therefore 
becomes visible.” 

Loc. cit., pp. 78, 79. 








THE lancet,] MR. GRAY: FUNCTIONS OF THE STOMACH AND GASTRO-ENTEROSTOMY. [Feb. 2?, 1908. 553 


I feel that this view of the anatomical arrangement of the 
adult stomach is the right one owing to the fact that I have 
so frequently observed this condition of affairs during opera¬ 
tions on or near the stomach. As 1 have stated already, one 
finds that, unless the stomach is much dilated as a whole, 


Fig. 15. 



Outlines of three storoachB, removed post mortem, collapsed 
and fiat on a plate. In spite of considerable distension 
having been present, they manifest a distinct tendency to 
form a cardiac sac and pyloric tube. There was no evidence 
of disease in stomach or duodenum of either case. Observed, 
without selectiou, by Dr. Cl. M. Duncan, Pathological 
Department, Aberdeen University. 


the pyloric part when exposed, and especially if bandied, 
looks like a piece of much hypertrophied intestine. This 
part presents in a median epigastric incision. The cardiac 
part is usually flaccid. In cases where gastro-enterostomy 
has been indicated I have found it enlarged as well as 
flaccid. Indeed, the presence of this flaccid enlargement 
may be an. indication that gastro-enterostomy mill do good t 
even although no pylorio stenosis exists. This cardiac portion 
does not appear in the wound, but when pulled out makes a 
striking contrast to the contracted pyloric part and offers 
great temptation to those who believe in the “drainage” 
qualifications of gastro-enterostomy, to make the stoma at 
the most dependent part of the flaccid bag. Moynihan 13 
refers to repeated observations of localised spasmodic con¬ 
strictions “ in the body of the stomach and at the pylorus, 
but never at the fundus.” These I have also observed. They 
are, of course, quite different from the general contraction of 
the pyloric portion which I have just described. In fact, 
they may occur along with this, especially if the stomach be 
mechanically irritated. 

It seems to me that our ideas as to what constitutes patho¬ 
logical dilatation of the stomach must be revised. Without 
doubt such dilatation occurs first in the cardiac end and may 
be the cause of such persistent symptoms as only operation 
will satisfactorily get rid of. Our present diagnostic methods 
of inflating the stomach are ordinarily probably too 
vigorous and too much attention is given to the relation 
of the stomach (the pyloric portion, which may still be 
approximately normal) to the umbilicus. Unless gastric 
resonance, as ascertained in the neighbourhood of the 
mid-line of the abdomen, reaches nearly to, or beyond, the 
umbilicus, there is thought to be no dilatation of the 
stomach. From practical experience I feel sure that more 
attention should be given to the condition of the outline 
of the cardiac portion. Careful external examination will 
often reveal an unexpected amount of dilatation there. 
The more natural the stomach the more decidedly is it in 
the form of “cardiac sac and pyloric tube." This may 
prove of much value in diagnosis. 

In order to explain satisfactorily the symptoms of gastric 
ulcer and the beneficial effects of gastro enterostomy the 
cycle of events in the stomach at work must be somewhat as 
follows. The cardiac portion acts as a reservoir, in which 
food is, in a great measure, prepared for further digestion by 
being subjected to the action of the juices secreted in that 
part. The food is intimately mixed with those juices by the 
churning action of the gastric muscular coats, especially of 
the distal part of the cardiac portion, and by the movements 
of the diaphragm and abdominal muscles during respiration 
and conversation, and still more so during forced respiratory 
movements, such as laughing, sneezing, and the like. (This 
can be confirmed by screening after a bismuth meal.) Hence 
we have possibly a partial scientific explanation of the adage, 
“laugh and grow fat,” and of the custom still extant in some 
quarters of passing round the snuff-mull at the end of a 
meal. These movements, moreover, assist the circulation of 
the blood in the abdominal cavity and thereby are beneficial 
to digestion. The food, having acquired its proper chemical 
reaction, is now (after from 15 minutes to half an hour, 
according to the nature of the food), by the drawing up of 
the greater curvature (Cannon), propelled into the pyloric 
portion which, by its marked peristaltic efforts, thrusts the 
food towards and through the pyloric sphincter. Skiagraphio 
tracings of the human “normal" stomach (e.g., Pfahler’s) 
show that the part well to the left of the mid-line is filled 
with food first (i.e., the saccular and tubular parts of the 
cardiac portion—the vertical portion of the stomach). This 
can easily be confirmed. Even when a considerable quantity 
of food has been swallowed, causing a fair amount of dis¬ 
tension, the vertical cardiac portion is still alone affected. 
It would seem probable that until the time when the drawing 
up of the greater curvature takes place there is no food or 
acid secretion in the pyloric part, ingress of such being 
prevented by its tonic contraction and higher elevation and 
the closure of the “ sphincter aditus vestibuli ” (tucked np 
by the action of the oblique fibres). A well-marked notch 
can frequently be seen (with the fluorescent screen) on the 
greater curvature, corresponding to the position of this 
sphincter, after part of the “ bismuth ” meal has passed into 
the pyloric portion. 

The pyloric portion resembles the duodenum in its 
pathology. The reaction of its secretion is alkaline. Its 


IS Brit. Med. Jour., Feb. 20tb, 1S04, p. 414. 







554 The Lancet,] MR. GRAY: FUNCTIONS OF THE STOMACH AND GASTROENTEROSTOMY. [Feb. 22, 1908. 


secretion is proface and renders the chyme more fluid. 
Hyperacidity of the gastric contents causes irritation or 
ulceration, especially if they are retained long in this 
portion by spasm of the pylorus. The pyloric secretion may 
be insufficient to neutralise this hyperacidity and make the 
chyme of a proper reaction to stimulate relaxation of the 
pylorus. Exacerbation of the pain in gastric ulcer is due to 
irritation thereof by food, acid, or more or less by increased 
movement, la support of the foregoing statement (at the 
end of the la6t paragraph) I point out that the pain of ulcer 
of the pyloric region does not assert itself until a consider¬ 
able interval after food is taken into the stomach, i e., until 
some p irt of it. first rendered acid, has gained access to the 
pyloric part. If the pain is due to increased movement of 
the pyloric part, then this portion must be at rest during the 
earlier stage of gastric digestion (tonically contracted). 

It seems that the mechanical functions of the stomach, as 
hitherto understood, have been deduced (1) from imperfect 
anatomical knowledge ; (2) from direct observation (Ross- 
bach) perforce made under abnormal conditions ; (3) from 
chemical tests made with substances which are adsorbed 
only when they reach the duodenum ; (4) from the persist¬ 
ence in the stomach after varying periods of indigestible 
particles or ordinary food-stuffs introduced ; and (5), possibly 
most important, from x ray screening of the stomach after a 
meal mixed with bismuth. Of these, only (2) and (6) may 
throw light on the action of the pyloric portion ; (3) and 
(4) have reference to the action of the stomach as a ‘ 1 one com¬ 
partment ” organ. With regard to Rossbaoh's observations, 
as already stated, one often sees contraction of the pyloric 
portion in a fasting stomach exposed during operation. The 
churning action, observed at an early Btage and attributed by 
some x-ray observers to the pyloric portion, is apparently 
confined to the part of the cardiac portion adjacent to the 
“ sphincter aditus vestibuli,” which is possessed of peristaltic 
action. 

Physiologists state that the “ two portions of the stomach 
seem to be partially or, in certain animals from time to 
time, completely cut off from each other by the contraction 
of the sphincter of the antrum ’’ (Stewart). The part distal 
to this “sphincter” is in the living stomach tubular 
-(Starling). An obvious difference in colour of the parts of 
the stomach is apparent in such an animal as the rat. This 
is sharply demarcated. 

Developmentally, the greater part of the cardiac end of the 
adult stomach is a mere diverticulum, blown out, as it were, 
from one side of the gastric tube, although it is the most 
-important part of the tube from the standpoint of the gastric 
digestion. 

The predisposition of the pyloric portion to ulceration as 
compared with the cardiac end has already been referred to. 
The constriction in cicatricial hour-glass stomach usually 
occupies the site of the “ sphincter aditus vestibuli.” The 
part of the cardiac portion adjacent to the lesser curvature 
(the remnant of the gastric tube from which the cardiac 
diverticulum is developed) is to be differentiated from the 
rest of the cardiac portion. It resembles the pyloric portion 
and is the usual site of ulceration when this involves the 
cardiac end. 

Thus developmentally, anatomically, physiologically, and 
pathologically, there are great differences between the 
pyloric and cardiac ends of the stomach. 

Taking these differences into consideration, it seems extra¬ 
ordinary that the stomach should be looked upon, for 
working purposes, as a “ one compartment ” oigan. Indeed, 
it seems absurd to suppose that food wss meant to be tossed 
about inside an organ which pours out acid secretion at one 
end and alkaline secretion at the other end. It would be folly 
to think that the one type of secretion does not inhibit the 
action of the other by mere neutralisation alone. That a gour¬ 
mand escapes extreme digestive disturbance even although he 
daily distends his stomach so that cardiac and pyloric portions 
form one cavity, proves merely the extraordinary accommo¬ 
dative power of the human alimentary tract—it does not dis¬ 
prove the theory X put forward. It is apparent even to the 
most unobservant layman that he is the healthiest when he 
eats sparingly 

When the importance of all these points has been appre¬ 
ciated it seems to me that in performing gastro enterostomy 
one must endeavour to preserve as nearly ae possible the 
natural condition of thingB. Finney’s operation (an 
extensive pyloroplasty) fulfils best this desideratum, but it is 
by no means always applicable. The fact that Finney’s 
operation is productive of such good results in suitable oases 
lends great support to what I say. 


The opening in the operation of gastroenterostomy must 
be made as near the pylorus as will permit of a “ comfort¬ 
able " position of the duodeno-jejunal portion to be anasto¬ 
mosed. By fixing this portion to the stomach in a more 
antero posterior line than is usually done one finds that the 
opening can be made an inch or two nearer the pylorus. 11 
(Of course there mnst be no kink formed in the upper part of 
the bowel.) This margin may make all the difference after¬ 
wards. 

The opening should be a large one, as I think it is of great 
importance that it should prtn-ide “drainage," when this is 
necessary, not of the cardiac portion but of the pyloric 
portion, and thus allow exit into the jejunum of the hyper¬ 
acid gastric contents when projected into the pyloric from 
the cardiac end. This will at once place the pyloric end 
practically at rest compared with its previous restlessness in 
attempting to overcome the resistance of the irritated and 
spasmodically contracted pyloric sphincter. The tendency to 
prolonged acidity in the pyloric end will be neutralised by 
“the entrance of the alkaline pancreatic jnice and bile" 
(Paterson). 11 These two factors explain the usually immediate 
cessation of the severe pain of ulceration after gastro¬ 
enterostomy. 

The escape of the acid chyme is not prevented by the 
pyloric sphincter and takes place into the jejunum through 
the new stoma at an early period and will stimulate 
pancreatic secretion at an earlier stage than previously 
occurred in the patient. As Mr. H. J. Paterson points out, 
there will then be a correspondingly earlier diminution of 
the gastric secretion and therefore the hyperacidity will be 
reduced. The early escape of foodstuffs from the stomach 
by diminishiDg normal chemical stimulus might account in 
large measure for this, as previously pointed out. The 
“abnormal excitation of the gastric mucosa which results 
from spasmodic stenosis of the pylorus ” (Paterson) will of 
course be done away with. 

I believe that the tonic contraction of the pyloric portion 
and of the sphincter aditus vestibuli is the usual and 
essential factor in preventing regurgitant biliary vomiting. 
The action of the muscular coats of this part is stronger 
than that of the jejunum, hence will prevent any more than 
a very localised escape of bile and pancreatic juice into the 
stomach, unless placed in such impossible conditions of 
vicious circle as the frequent kinking in the old loop method 
produced In uncomplicated cases of gastro-enterostomy I 
have found, on passing the stomach tube, that bile is not 
present in the cardiac end of the stomach. 19 If the passage 
of the tube causes attempts at vomiting it is quite probable 
that the increased intra-abdominal pressure, especially in 
cases where dilatation existed previously, will cause re¬ 
gurgitation of bile and pancreatic juice into the cardiac 
end. I believe that the cases of biliary vomiting which I 
have heard of occurring after the no-loop method are 
probably due to the fact that the anastomotic opening has 
been made in the cardiac enlargement where the bile 
probably causes irritation and is vomited. In certain cases, 
of course, it is no doubt due to malposition of the anas¬ 
tomosed bowel. Even when the opening has been made in 
the cardiac enlargement, the muscular action of the cardiac 
end may keep or force back bile into the jejunum and thus 
prevent vomiting, but in cases of atony of this part the bile 
and pancreatic juice may follow the line of least resistance, 
fill up the cardiac end, and be vomited. Mr. Moynlhan’s 
case, 10 in which the whole of the bile and pancreatic juice 
had to pass back through the pylorus owing to the operative 
closure of the duodenum, does not necessarily prove that bile 
is non-irritating to the stomach. He does not record to 
what portion of the stomach the jejunum was attached— 
probably to the part presenting in tne wound (the pyloric 
portion), in which case the bile would pass almost imme¬ 
diately into the jejunum. All the same, in many cases, 
“ bile ” in tmall quantity does not appear to cause irritation 
in the cardiac end. When fatty food is taken in excess the 

is On the eve of sending this paper for publication 1 have read Mr. 
B. G. A. Moynlhan's article on “ The Treatment of Chronic Diseases of 
the Stomach." Surgery, Gymecoiogy, and Obstetrics. January, 1908. 
In it he advocates this '* vertical ’’ position of the jejunal loop. 

1* The LiNCKT. Sept. 21st, 1907. p. 816. 

is 1 have obtained stomach contents (from two to four hours after 
a meal) from six cases operated on during the past six months. The 
specimens were examined by Dr. J. M. Mncriueen in the Physiological 
Department, Aberdeen University. In five there was no trace cf bile. 
(In one of these the attempt to pass the stomach tube caused vomit¬ 
ing.) In one there was a very faint trace of bile. In this case, peri- 
colonic adbesionB, found at operation, may have caused slight obstruc¬ 
tion in the efferent loop of jejunum. 

10 Brit. Med. Jour., May 11th, 1901. 




The Lancet,] 


MR. J. HERBERT PARSONS : NIGHT BLINDNESS. 


[Feb. 22. I9C8 555 


normal mechanism of the pjloric apparatus is evidently in 
abeyance. Bile and pancreatic jaice arc allowed to gain 
their way to the cardiac part in small amount, upon which 
the fat there is partly digested—a marvellous provision of 
nature for the bent lit of the gourmand. 

In the majority of cases I believe that the opening is made 
in the pyloric portion but, so far as I can make out, with no 
proper, definite precaution to attain that end. The stomach 
is usually pushed down through an opening in the mescolon 
and, if the pyloric portion is contracted, the cardiac enlarge¬ 
ment may easily be substituted for it The plan, introduced 
I think by Professor H. Littlewood of Leeds, of pushing the 
intestine up through the hole in the mesocolon and making 
the junction with the stomach in more normal position (after 
tearing an opening in the omentum to get at the posterior 
wall of the stomach), makes it much more certain that the 
anastomosis is made in the pyloric portion. The thought 
occurs—Should one make the anastomosis in the cardiac 
enlargement if ulcer of the cardiac end exists, risking re¬ 
gurgitant vomiting, or making a Roux’s (Y) operation right 
away 1 Personally, I do not think so. I have followed the 
usual plan in such cases of cardiac ulceration as have come 
under my care and the only difference I have noticed is that 
the pain took longer to disappear than in pyloric ulcer. The 
explanation of the cure is the same as in pyloric ulcer. 

It is quite possible that making the anastomotic opening 
in the cardiac portion may explain the occurrence of jejunal 
ulcer after gastro-enterostomy, especially in the old loop or 
Y operation. The persistent trickle of acid secretion from 
the cardiac end compared with the intermittent ejection 
through the pyloric stoma may so affect a particular part of 
the jejunal mucosa that ulceration occurs, as the acidity is 
less likely to be immediately neutralised. 

With regard to the effect of gastro enterostomy on the 
motility of the stomach, as to whether it is a "drainage” 
operation, Mr. Paterson’s observations, 17 to my mind, prove 
nothing. The point is, What part of the stomach does it 
"drain ” 1 A careful operator, like Mr. Paterson, is unlikely 
to make the opening in the cardiac enlargement and there¬ 
fore in his cases food will not pass at once into the jejunum. 
It will, as he shows, have practically the same nutritive 
value. I venture to say, however, that his reasoning with 
regard to these facts is wrong. They do not necessarily 
support his contention that gastro-enterostomy is not a 
drainage operation. It must procure drainage or, rather, 
act as a short circuit or a “safety valve” before it can bring 
about the good effects which it does. In Cannon's observa¬ 
tions on cats, which are so frequently referred to, in the 
greater nnmber of cases the opening was evidently a small 
one, and food preferred to pass through the pylorus. In the 
only case in which the opening was without doubt a large 
one, food passed more readily through this opening. This is 
wbat should be aimed at in the human subject. I point out 
that these experiments were carried out in presumably 
normal animals and therefore the conditions are not com¬ 
parable to those demanding gastro-enterostomy in the human 
patient, in whom pyloric spasm or actual stenosis compels 
food to pass through the new opening at all eventB until 
spasm has been relieved by more normal reaction of the 
gastric contents. There need be necessarily no marked 
effect on the emptying power of the cardiac portion when 
the opening in the operation of gastro-enterostomy is made 
in the pyloric portion. (The nutritive value of the food 
should then be as good as in any other individual. It may 
be better so far as the patient is concerned than before 
operation.) In the majority of operations the cardiac portion 
is certainly not drained, and it is into this portion that the 
tube is passed in order to draw off the gastric contents after 
a test meal. Mr. Paterson’s findings appear to me to form 
a strong argument in favour of the “ two compartment ” 
theory I have put forward. 

Results obtained with the "salol test "uphold my con¬ 
tentions. In repeated observations with this test, when the 
operation is done as I have indicated, there it practically 
no departure from the normal in the results obtained. These 
remarks apply as well to cases of pyloric spasm (with ulcera¬ 
tion in the neighbourhood) as to cases of cicatricial stenosis. 
If gastro-enterostomy meant drainage of a “one compart¬ 
ment ” organ, then the salol ought to reach the small 
intestine and hence appear in the urine at a much earlier 
period, especially in cases of actual pyloric stenosis. 

In conclusion, I should like to say that recently I have 


17 Loc. cit. 


endeavoured to practise what I have been preaching, and the 
results are, to my mind, all that could be desired. Since the 
no-loop method was introduced the results of this operation 
have vastly improved, i.e., practically since the opening has 
not been made in the cardiac portion. Before the introduc¬ 
tion of this method absence of evil results, if the Y operation 
was not done, was hailed with satisfaction. Now it is 
looked for almost with certainty. I venture to assert that 
with attention to the points I have mentioned fortuitous 
openings in the cardiac portion will be avoided and the 
results will be more satisfactory still. 

To sum up. (1) The cardiac and pyloric portions of the 
stomach are distinct in development, structure, function, and 
pathology. (2) During the early stage of gastric digestion 
the pyloric portion is normally empty and tonically con¬ 
tracted. When food has attained a proper chemical reaction 
in the cardiac enlargement it passes into the pyloric portion. 
(3) Bearing this in mind, care should be taken in performing 
gastro-enterostomy to make the opening in the stomach wall 
within the pyloric portion, as near the pylorus as possible. 
This will, then, if the stomach has not irremediably lost its 
muscular power, provide against an “ uncontrolled escape of 
the acid gastric contents,” which w asserted by Dr. H. C. 
Cameron 18 to occur in cases of gastro-enterostomy. If 
pyloric spasm be present the stoma will act as a safety-valve 
and remove the spasm. If pyloric stenosis exists the natural 
condition of things will be most nearly approached and the 
“regulating action ” (Pawlow) of the pylorus, so necessary 
to perfect digestion, be most nearly approximated. 

Aberdeen. 


NIGHT BLINDNESS . 1 

By J. HERBERT PARSONS, D.Sc. Lond., F.RC.S Etc., 

ASSISTANT SURGEON TO THE HOSPITAL; ASSISTANT OPHTHALMIC 
SURGEON TO UNIVERSITY COLLEGE HOSPITAL; OPHTHALMIC 
SUHGEON TO THE HOSPITAL f OR SICK CHILDBEN, 

• GREAT ORMOND-STREET, LONDON, W.C. 


Whkn a patient comes to us complaining of inability 
to see in the dusk or in foggy weather we at once think 
of the disease commonly known as retinitis pigmentosa. 
If we were practising in India we should be much more 
familiar with patients complaining of this symptom and 
should be less likely to attach the same importance to it. 
There have recently been several excellent examples of 
retinitis pigmentosa in my clinic aud you have bad the oppor¬ 
tunity of making yourselves fully acquainted with its 
peculiarities. It is only necessary for me, therefore, to 
review very briefly its principal features. The routine 
examination of the patient shows that there is com¬ 
paratively little disturbance of central vision, though 
there are exceptions to this rule. Examination of the 
fundus shows in the early Btages in young patients 
a zone of characteristic retinal pigmentation in the 
neighbourhood of the equator ; both peripheral and central 
to this zone the retina looks almost or quite normal. I 
need not dwell upon the striking characters of the pigmenta¬ 
tion—the spots shaped like bone corpuscles and the aggrega¬ 
tions along the perivascular sheaths of the retinal vessels. 
At this stage we may expect to find a ring scotoma on ex¬ 
amination of the field of vision. My senior clinical assistant, 
Mr. M. L. Hepburn, has recently devoted much attention 
to the nature of this scotoma and has shown amoDgst other 
points that it is seldom complete, but is dotted over with 
areas in which vision is only partially lost. Probably these 
areas sire closely related to the distribution of the vessels, 
but for an exhaustive discussion of the subject I must refer 
you to Mr. Hepburn's admirable paper in the last number of 
the Hospital Reports. At a later stage the zone of pig¬ 
mentation has extended both peripherally and centrally, and 
the field now shows uniform contraction, the peripheral area 
of vision having become abolished. The progress is usually 
very slow and central vision is seldom lost by the extension 
of the choroido-retinal disease to the macular area. Before 
this occurs a posterior cortical opacity appears in the lens, 
which, however, has much the same effect upon the visual 
acuity. This so-called idiopathic retinitis pigmentosa is a 
progressive form of chronic night blindness. It is an 
obscure disease in which heredity and the consanguinity 


1 # Brit. Med. Jour., Jan. 18th, 1908. 

1 Prom a clinical lecture delivered at the Royal London (MoorfieldB) 
Ophthalmic Hospital on Feb. 1st, 1908. 




536 THE Lancet,] MR. CLUTTON & MR. DUDGEON : ANEURYSM OF FEMORAL ARTERY, ETC. [Feb. 22, 1 908. 


of parents play some considerable part. In reality the 
choriocapillarls of the choroid seems to be first attacked, 
the retinal degeneration being secondary. As yon are aware 
the outer layers of the retina are nourished by the chorio¬ 
capillaris and in retinitis pigmentosa the inner layers show 
comparatively little change. These facts help ns to a reason¬ 
able conjecture as to the exact causation of the night 
blindness. 

You will remember that in birds which seek their prey 
at night, such as the owl, the retina contains only rods ; 
there are no cones in the neuro-epithelial layer. You will 
also remember that the visual purple is associated with the 
rods only, so that in animals possessing a fovea, where the 
rods are absent, there the visual purple is also absent. I may 
further remind you that with low illumination in man there is 
much more rapid depreciation of central than of peripheral 
vision, so that we may reasonably conclude that vision in 
these circumstances is chiefly carried out through the agency 
of the rods. Form sense, dependent upon the cones, quickly 
diminishes in passing from the point of fixation towards the 
periphery, but at night acute appreciation of variations of 
light and shade is much more important than accurate 
delineation of objects. These considerations may afford some 
explanation of the night blindness in retinitis pigmentosa, 
as well as of the partial nature of the annular scotoma and 
the comparative perfection of central vision. Of course, it is 
not suggested that the cones escape destruction in the 
affected zonular area, but their loss is discounted by their 
relatively unimportant functions in this situation. 

There is another chronic form of night blindness which we 
occasionally meet with, differing from retinitis pigmentosa in 
the fact that it is stationary. This form is always hereditary 
and shows no gross changes in the fundus. It is a rare 
disease except in the families afflicted with it, when as has 
been recently shown in a very striking manner a large pro¬ 
portion of the members are attacked. Thus Mr. E. Nettleship 
has continued the work of Cunier on a certain family in the 
south of France and has discovered no less than 135 subjects 
of congenital night blindness amongst 2121 members of 10 
generations, the first member of which, a male, himself night 
blind, was born in 1637. Unfortunately, no case of this 
disease has been examined anatomically ; it may possibly be 
found that the retina is deficient in rods or visual purple. 

A group of cases of chronic night blindness in some 
respects intermediate between idiopathic retinitis pigmentosa 
and congenital night blindness is that of syphilitic pig¬ 
mentary retinitis. It does not show the same uniformity 
either of symptoms or of objective signs that are characteristic 
of idiopathic retinitis pigmentosa. The night blindness is 
progressive during the active stage of the disease but may 
then remain stationary for an indefinite period. Funda¬ 
mentally, however, the night blindness must be regarded as 
due to the same pathological processes. Besides these 
chronic forms of disease manifesting this symptom there are 
also acute forms. Though these show a great variety of 
clinical types there is nearly always one feature common to 
all—namely, malnutrition. They are probably much less 
frequently seen in England now than formerly owing to the 
improvement in the conditions of the poor. We generally 
meet with them in badly nourished children and a large pro¬ 
portion of them have xerosis of the conjunctiva. The com¬ 
bination of these symptoms is not so invariable as is some¬ 
times thought. Many cases of xerosis without night blindness 
and vice vena occur. In some cases the cornea becomes 
ulcerated and in the worst there is keratomalacia ; in many 
of these the age of the patient or the severity of the 
attendant symptoms prevents the demonstration of night 
blindness. One fact which may be definitely deduced is 
that there is no inherent relationship between the xerosis and 
the night blindness other than a con mon cause. 

Acute night blindness was at one time common among 
sailors, soldiers, and the inmates of prisons and workhouses. 
In Russia it was, and probably still is, common during the 
Lenten fast. Uhthoff, amongst 500 cases of severe 
alcoholism, found 5 per cent, suffering from xerosis, night 
blindniss, or both together. Less frequently night blindness 
has been found associated with scurvy, malaria, nephritis, 
the pnerperium, vegetarianism, and so on. Most of these 
patients have reflex blepharospasm (“photophobia”) in 
bright sunlight. That in many, most likely all, the lesion 
is peripheral is shown by Mr. Nettleship’s interesting obser¬ 
vation that if a sailor afflicted with the disease covers up 
one eye during the daytime that eye has sufficiently good 
vision at night for the man to carry out the duties of the 


watch. It would appear, therefore, that malnutrition acts by 
lowering the vitality of the retina in such a manner that the 
process of repair is delayed. Probably the visual purple is 
restored more slowly than normal—that is, the anabolic pro¬ 
cesses are defective. To call the condition torpor retinse and 
to regard this as an explanation is futile; it is simply 
describing the condition by another name. 

Another group of cases of night blindness, allied to those 
last mentioned but deserving separate treatment, are those 
associated with jaundice. The symptom is not very un¬ 
common in severe cases of jaundice. In some pigmentary 
changes of slight degree have been found in the retina and 
the condition has been dignified with the name ophthalmia 
hepatica: in most the ophthalmoscopic signs sire negative. 
It is noteworthy in this connexion to recall the fact that bile 
salts are a solvent of the visual purple, as was shown by 
Kiibne. Night blindness is common in India among badly- 
nourished natives, especially during the periodic famines. 
It has been found that the symptom disappears when the 
patients are fed on liver, a fact difficult to correlate with the 
cases occurring with jaundice. The mode of treatment is of 
extreme antiquity, being advocated in the Ebers papyrus 
(b.c. 1500). _ 


A CASE OF ANEURYSM OF THE FEMORAL 
ARTERY IN A MAN, AGED 78 YEARS, 

IN WHICH SUPPURATION TOOK PLACE 
FROM PNEUMOCOCCAL INFEC¬ 
TION; RECOVERY. 

By H. H. CLUTTON, M.A., M.B., M.C. Cantab., 
F.R.0.8. Eng., 

SURGEON TO ST. THOMAS'S HOSPITAL; 

AND 

LEONARD S. DUDGEON, M.R.C.P. LOND., 

BACTERIOLOGIST TO ST. THOMAS'S HOSPITAL: JOIRT LECTURER ON 
PATHOLOGY IN THE MEDICAL SCHOOL. 


For the history and many details of this case we are 
indebted to Dr. A. Bevan who attended the patient through¬ 
out his illness. 

The patient was an old man, aged 78 years, living in a 
hotel who was suddenly taken ill with a rigor and a tempera¬ 
ture of 104° F. on Jan. 18th, 1907. He had a cough and 
rapid respiration but there were no signs in his chest until 
two days after the onset of his illness. Consolidation of the 
upper lobe of the right lung was then found. This was 
followed by a patch of dulness at the angle of the left 
scapula and at the right base. The temperature touched 
normal on the third day of the illness and then fluctuated 
between 100° and 103 ■ 4° until the eighth day, when there 
was a pseudo-crisis with a rise next day to 101'2°. It then 
fell again on the tenth day to 96'4°. The temperature 
fell to 96'4° three times with intervening slight rises to 
97'2°, remaining subnormal for the following ten days. 
There was a very dangerous collapse during this time. The 
pulse-rate fell from 98 to 60, and sometimes could not be 
counted, as many beats failed to reach the wrist. The heart 
sounds were very faint from the combined effect of em¬ 
physema and feeble action but no cardiac murmur was heard 
at any time during the illness. The expectoration was of the 
“ prune-juice ” type rather than rusty. Dr. H. G. Turney, who 
saw the patient in consultation with Dr. Bevan, reports that 
“ the pneumonia was clinically on the whole of the influenza 
type, though the termination was by crisis. The physical 
signs varied a good deal from day to day ; there never was 
really massive consolidation and he sweated a good deal all 
through the attack.” The patient remained in a low and 
feeble condition with a subnormal temperature until 
Feb. 10th. He then improved and the temperature became 
normal, but from the 20th onwards evening pyrexia (99°) 
was constant. There was also at this time a little swell¬ 
ing of the left leg and foot from oedema, and a local 
swelling was noticed about the middle of March in the 
course of the femoral vessels which was thought to be 
due to thrombosis of the left femoral vein. In April Dr. 
Bevan found that this swelling pulsated and regarded it as 
an aneurysm. Towards the end of April it began to increase 
in size and the pulsation appeared to be nearer the surface. 
On examination it was found to be a large swelling situated 
in Hunter’s canal on the left side, with inflammatory exuda¬ 
tion into the tissues around, or the aneurysm may even then 




The Lancet,] MK. CLUTTON k MR. DUDGEON : ANEURYSM OB FEMORAL ARTERY, ETC. [Feb. 22,1908. 557 


have began to leak. In the latter case its size would be in 
part due to extravasated blood. It is also of some interest 
to notice that the femoral artery could be traced over the 
swelling for an inch or more both above and below its centre. 
It therefore seemed probable that we bad to deal with a 
sacculated aneurysm situated on the outer side of the 
femoral artery in Hunter’s canal. In this position it would 
be able to cause compression of the vein against the bone and 
oelema of the leg and foot. This oedema of the left leg was 
the first indication of anything abnormal. As the swelling 
in the thigh increased in size and became more obvious it 
was again carefully examined and fonnd to pulsate. The 
central part of the pulsating swelling at the end of April was 
quite soft and appeared to be approaching the surface. 
There was evening pyrexia rising to 100°. His arteries were 
thick and tortuous and the heart action was rather feeble. 
An operation therefore at the age of 78 years caused us some 
anxiety. On the other hand, the pulse could be felt quite 
plainly at the ankle, and it was hoped that ligature of the 
femoral artery just above the aneurysm at the apex of 
Scarpa’s triangle would be sufficient to arrest its progress. 
The aneurysm with its surrounding swelling now occupied 
the middle of the left thigh just reaching to the apex of 
Scarpa’s triangle 

On May 2nd, four months after the onset of the pneu¬ 
monia, the femoral artery was ligatured just above the 
margin of the swelling. Dr. Bevan gave the antithetic and ; 
had a good deal of anxiety over his patient, who showed 
signs of cardiac distress daring the operation. Mr. C. A. R. 
Nitch gave much valuable help and assistance. The sheath 
was unusually adherent to the artery which had very thick 
walls and was rather tortuous in its course. Two double 
strands of floss silk, making four ligatures in all, were 
passed beneath the artery and separately tied without 
dividing the coats. Pulsation in the aneurysm and at the 
ankle was arrested by the ligature. The pulsation never 
returned at the ankle, but in the aneurysm it was occasion¬ 
ally detected on careful examination during the next fort¬ 
night. The foot remained warm and of good colour 
throughout. The temperature began slowly to rise after 
the sixth day from the date of the operation, when the 
sutures were removed. From May 10th to 22nd there was 
pyrexia (102°) every evening, although the wound appeared 
to be perfectly sound and to have healed by first intention. 
The aneurysm, on the other hand, whilst the temperature 
was rising, steadily increased in size, and finally gave one 
the impression of being an abscess. It roughly extended 
from the inner side of ttie knee to the buttock; the most 
prominent part was situated about the centre of the inner 
side of the thigh. As it was still doubtful whether the 
swelling was due to extravasated blood or to suppuration 
the blood was examined and the result strongly suggested 
suppuration. 

On May 23rd an anaesthetic wae given by Dr. Bevan and 
with Mr. Nitch's assistance an incision was cautiously made 
through the centre of the swelling. What appeared to be 
blood escaped in large quantities. Having preserved some 
of this fluid in sterile tubes the cavity was fully explored and 
found to be very large, extending far beyond the limits of the 
original aneurysm. As it did not appear now that there 
was any direct arterial communication with this cavity and 
that the fluid was old softened blood-clot, the wound was 
left open without either a drainage-tube or gauze plug 
being laser ted. The dressing had to be frequently renewed 
as there was a constant discharge of a large amount 
of blood-stained fluid. At each dressing this fluid could 
be squeezed out of the wonnd and on careful measurement 
amounted in 24 hours from five to eight ounces. The tem¬ 
perature daring this time dropped from 102° to 101°. As 
no farther diminution of the discharge or fall in the tem¬ 
perature took place an antithetic was given on June 11th and 
the wound was freely enlarged. Two counter openings were 
also made, one towards the knee and the other at the back of 
the thigh towards the glnteal fold. A drainage-tube was 
introduced into each opening. The highest temperature in 
the 24 hours quickly dropped to 100°, and by June 20th it was 
only 93°. The whole thigh also began to diminish in size, 
the oedema of the foot disappeared, and the patient improved 
rapidly in general condition. By the end of June the dis¬ 
charge was of slight amount and the highest temperature 
was alwayB below 99”. Our anxiety was thus at an end. On 
July 14th, when the wounds were nearly healed, the 
temperature rose slightly and he complained of pain in the 
Idt groin. The femoral artery, which had been previously 


pulsating up to the seat of the ligature, could not be 
recognised below Poupart’s ligament, and oedema of the leg 
and foot was again apparent. Thrombosis of the artery 
from the seat of the ligature up to Poupart’s ligament had 
obviously taken place. In about a week's time the pain had 
gone, the temperature was 99°, and the artery could be felt 
as a solid cord up to and beneath Poupart’s ligament. The 
oedema of the foot, however, remained. The last drainage- 
tube was removed on July 21st. Early in August he was able 
to leave London for Mr. H. C. Crouch's home at Ascot. The 
wounds were practically healed and the oedema had almost 
disappeared. There was slight pitting on pressure over the 
shin but none on the dorsum of the foot. The artery in 
Scarpa's triangle was a painless solid cord. Once again, at 
the end of August, he had an attack of inflammation in the 
left groin. Pain, tenderness, and swelling round the femoral 
artery with a slight rise of temperature gave the same 
indications as before, and naturally aroused a suspicion of 
farther extension of the thrombosis. But as there was no 
cedema of the foot it was hoped that the inflammation was 
confined to the part previously affected, and that there was 
no extension of the thrombosis to the external iliac artery. 
Within a week the attack had disappeared, leaving the 
artery as it was before. 

Pathological report .—On May 21st an examination of the 
blood was made with a view to determine, if possible, 

1 whether suppuration had occurred in the aneurysmal sac. 
The result was as follows : leucocytes, 22,740 per cubic 
millimetre. A differential count of 500 cells was made, of 
which 86 per cent, were polymorphonuclear neutrophiles and 
1'25 per cent, the Ehrlich type of neutrophilic myelocytes. 

A bacteriological examination of the contents of the sac 
of the aneurysm was obtained on May 24th. Film prepara¬ 
tions were made from the coagulated blood which had been 
received in sterile tubes. Tne cells were chiefly micro¬ 
phages, the remainder macrophages. Diplococci were 
numerous; they were Gram-positive and the majority were 
extracellular. A pure culture of the diplococcus was 
obtained from the coagulated blood. This organism was 
found to be the pneumococcus. It gave the reactions which 
are most commonly obtained in the artificial media employed 
by Andrewes and Horder fo r the differentiation of the streDto- 
cocci. On May 27th a second bacteriological examination 
was made. The contents of the tubes consisted of blood¬ 
stained put, in which there were large numbers of both 
extra- and intra-cellular Gram-positive diplococci. A pure 
culture was obtained but on this occasion the organism was 
extremely difficult to cultivate and died out very rapidly. 
On June 4th a third examination was made. Film prepara¬ 
tions of the pus showed numerous Gram-positive diplococci. 
A few bacilli were also present. The cultivation experiments 
were found to be sterile. 

This case is of interest, even if it were regarded 
merely as an example of suppuration in an aneurysm 
without reference to the intrinsic cause, hut owing to the 
fact that the pneumococcns was obtained in pure culture 
from the contents of the aneurysmal sac, and that the 
patient had only recovered from acute pneumonia quite 
recently, it may be considered as a case of exceptional 
rarity in surgical pathology. The first question which 
naturally arises is whether an aneurysm was present pre¬ 
viously to the attack of pneumonia. Dr. Bevan tells us that 
he is unable to answer this question. If we allow that a 
small aneurysm of the femoral artery was present previously 
to the acute illness, then probably either a clot in the 
interior of the sac became infected by the pneumococcus, 
or an atheromatous patch in the wall of the aneurysm 
became the seat of an acute infection by this organism, with 
subsequent thrombosis. It has already been stated that 
the contents of the aneurysm, when first received in the 
1 Juratory, consisted of coagulated blood, which had under¬ 
gone acute inflammation, while a few days later true 
suppuration had occurred. If we allow for the sake of 
argument that there was no aneurysm previously to the acute 
pneumonia, then we have to decide whether the patient 
developed an acute embolic aneurysm as a result of in¬ 
fective endocarditis, or whether the atheromatous con¬ 
dition of his arteries led to direct pneumococcal infection 
of the wall of the femoral artery. 

It is well known that even the most severe forms of 
infective endocarditis may not be diagnosed during life, but 
even allowing for this fact there was no reason to suspect 
in the case under discussion that acute endocarditis had 
occurred. Dr. Turney, who was called in to consultation 





558 Thk Lancet ] MR. PEARSON : THREE CASES OF POISONING BY CARBONIC OXIDE, ETC. [Feb. 22,1908. 


on several occasions with Dr. Bevan, saw no reason to 
suspect infective disease of the endocardium. There were 
no cardiac murmurs duriDg the whole course of the 
illness. The pyrexia at one time corresponded to the 
attack of acute pneumonia and later followed the course 
of the acute infection of the femoral artery. As soon as 
the suppuration was relieved the temperature fell to normal 
and has remained normal ever since, except for slight pyrexia 
which lasted for a few days during the period of con¬ 
valescence. 

An acute embolic aneurysm which develops during the 
course of acute infective endocarditis is characterised by its 
rapidity of formation, and also by a considerable amount of 
pain at the seat of infection. It cannot be said that either 
of these phenomena was present in the case under discus¬ 
sion. Perhaps the most important argument against infective 
endocarditis is that the patient continues in good health and 
shows no evidence of cardiac disease. The other explana¬ 
tion which we have already referred to is that the patient 
developed an acute pneumococcal infection of an athero¬ 
matous patch in the femoral artery. Careful consideration 
of the facts of the case strongly suggests either direct 
infection of the artery leading to the formation of an 
aneurysm or direct infection of an aneurysm which was 
present previously to the acute illness In either case 
the pathology is somewhat similar. The slow and feeble 
action of the heart, which was such a noticeable feature in 
the first few days after the crisis, and the alteration in the 
coagulability of the blood which is so commonly found in 
such conditions, would favour the formation of thrombosis 
either in the sac of an aneurysm or over an atheromatous 
patch in a degenerated artery. It is impossible to say 
whether acute infection of the arterial wall took place pre¬ 
viously to, or subsequently to, the formation of thrombosis. 
In either case the pneumococcus, which may probably be re¬ 
garded as the cause of the acute pneumonia, set up an acute 
arteritis which finally gave way into the surrounding tissues. 
It is probable that the infection of the tissues took place 
through the wall of the artery before actual leakage occurred. 
In any case, whether the aneurysm was primary or secondary, 
it appears to have been of the sacculated variety, and 
direct communication between the sac and the vessel was 
obliterated before the aneurysm was opened. It is unfortu¬ 
nate that it is impossible to say at what period of the 
patient’s life the aneurysm was formed, but at any rate this 
does not detract from the great interest which centres round 
such a remarkable condition. 


THREE CASES OF FOISONING BY 
CARBONIC OXIDE; ONE 
RECOVERY. 

By R. SPENDER PEARSON, M.R.O.S. Eng., L.R.C.P. 
Lond., D.P.H.R.C.P.S.I., 

LATE MEDICAL OFFICEH OF HKALTH, WIGAN RURAL DISTRICT. 


Casks of poisoning by carbonic oxide appear to me of 
sufficiently rare occurrence to justify a description of those 
which recently happened in the workhouse infirmary, 
Leighton Buzzard, for such a tragedy to take place in the 
wards of an institution the arrangements of which had been 
passed by expert engineers is fortunately uncommon and has 
a special interest. 

On the night of Jan. 20th three women retired for the night 
in a small ward and at 9 p.m. were known to be in their 
usual health. A fire had been lighted in the stove as on this 
day the ward had been cleaned and it is probable that the 
women had closed the only ventilator before going to bed. 
On the following morning at 7 a.m. a workhouse inmate went 
to call the women and fonnd them, as she thought, all 
dead. There was no smell in the room and the gas was 
burning, and the fire in the stove was still just alight. The 
three women were lying as if asleep. On further examina¬ 
tion one of them, aged 76 years, was found to be alive, the 
workhouse master, Mr. Swaffield, at once with commendable 
promptitude performing and continuing artificial respiration, 
thus most probably saving her life. The other two women, 
aged 52 years and 47 years respectively, were quite dead. 
The master sent at once for Mr. L. Worts, the medical 
officer, to whom I am indebted for my subsequent conduct 
of the case and for permission to publish these notes. 


1 was sent for at 10 a m. on the morning of Jao. 21st and 
found a woman, aged 52 yearn, and a woman, aged 47 years, 
lying dead. The body of the first woman had been removed 
from the bed to the floor. She was quite dead ; some white 
foam was issuing from the month. Her attitude was one of 
repose and her complexion and lips were fresh and of a bright 
cherry colour. The body was warm and rigor mortis was 
hardly discernible. The body of the second woman was on 
the bed ; the face was pallid and she had vomited some 
pultaceous matter. She lay on her back with her arms folded 
over her chest; rigor mortis was marked and the body was 
quite cold. The third woman, aged 76 years, was lying on 
the floor, totally insensible, the conjunctival reflex being 
absent. The pupils were equal and of moderate size. She waB 
practically pulseless and was breathing stertorously, the 
cheeks blowing with each expiration. Respiration was slow 
(about 12 to the minute), the lips aud mucous membranes 
were bright, and the complexion was clear. Both wrists 
showed abrasions the result of the continued efforts at 
artificial respiration, and it was noted that the reddened 
skin around the wrists bad a peculiarly bright hue. As 
there was no information to go upon, and as there was a 
suspicion that all three had partaken of the contents of a 
mysterious parcel left by a visitor, after injecting 5 > 0 th of a 
grain of strychnine I decided to wash out the Btomach. 
This was done with warm water and afterwards with weak 
Condy’s fluid till the washing was clear; the washings 
were first of a coffee-ground colour. I then gave one and 
a half ounces of brandy through the stomach-tube, and 
after injection of ether and the application of the inter¬ 
rupted current in the course of the phrenic nerve, after about 
three hours the pulse improved, the conjunctival reflex 
returned, and she responded to outside stimuli. Oxygen was 
sent for but she recovered before it arrived. She was ordered 
to be fed per rectum with “panopeptone" and by 6 p.m. she 
was able to take It by the mouth, and she is now out of 
danger but can remember nothing of what happened. 

Realising that the desperate illness of the third woman 
must be brought about by the same cause which had 
led to the death of the other two I decided to make a. 
spectroscopic examination of the blood of the living 
woman and, being fortunate in possessing an excellent 
stellar spectroscope, used it with most decided results. A 
drop of blood from the finger was received into a test-tube 
two-thirds full of normal saline solution and the tube was 
shaken up ; the resulting solution was of a bright cherry 
colour. On being placed before the slit of the spectro¬ 
scope there were seen the two absorption bands of CO 
hemoglobin most distinctly, and the reaction was unaltered 
on the addition of ammonium sulphide. Next day I was 
present at the post-mortem examination made by Mr. 
Worts Both bodies presented similar appearances. The 
blood 30 hours after death was perfectly fluid and cherry- 
red in colour. The muscles, too, were bright red. There 
was no blood clot found at all. The mucus membranes were 
all bright red and the complexion fresh. The stomach 
of one woman was empty and presented numerous petechial 
hmmorrhages, and similar hmmorrbagic points appeared in 
the cerebral white matter on section ; the cerebral ventricles 
were full of fluid. In both cases the lungs were markedly 
cedematous and the kidneys showed interstitial nephritis ; 
the capsules were adherent. I took specimens of blood from 
both dead women and examined them as before, with a like 
result, the spectroscope giving definite evidence °f CO 
bmmoglobin. 

The ciuse of the carbonic oxide in the atmosphere was, 
on investigation, not hard to find. At first I thought that 
it must be due to the permeability of red-bot cast iron to 
gases, but since then I have had an opportunity of examining 
the stove with the representative of the firm who manu¬ 
facture them. The stove is of ornamental cast iron with 
doors in front which can be opened ; on the top is a circular 
aperture covered by an ornamental perforated cap. The stove 
stands in the room about two feet from the fire place, which 
is blocked up. A six inch cast-iron horizontal pipe passes 
into the brick flue, terminating on its entrance. The flue is 
a long one leading from the floor below, one flue common to 
both landings. Inside the stove is a flame baffler, which 
when rightly set serves to direct the heat into the room 
and direct the current both from the fire and the 
chamber at the top of the stove into the flue. Instead 
of beiDg set thus the baffler was set as shown in the 
diagram, thus allowing any produots of combustion which 
passed the baffler to come into the room (Fig. 2). The 




The Lancet,] DR. C. J. MORTON : X RAY EXAMINATION IN URINARY CALCULUS. [Feb 22, 19C8. 559 


room is oblong, 18 feet X 12 feet x 11 feet high, and has 
a gabled roof; there are two windows on one side and a 
curtained door at the other. Above the door is a primitive 
ventilator formed b; a wooden Sap which is opened and 
closed from ontside. This I am told if left open the 
patients close. It appears that the night of Jan. 20th was 
cold and heavy and the patients closed the ventilator and 
windows. Most probably when the stove burnt low the 

Fig. 1. 

P 


i i 



a. Flame baffler as it should be set. p, Perforated cap on the 
top of the stove. 


Fig. 2. 
p 



B, Flame baffler as it was set on the occasion of the accident. 

draught was insufficient to force its way into the long 
cold column of air in the brick flue and found an easy exit 
past the flame baffler into the room. 

The case was full of interest especially as regards the 
different times of the deaths of the patients ; the youngest 
evidently succumbed first and the other some time later, 
while the eldest alone survived. The insidious nature of 
the poison is apparent; all the patients appear to have 
slept away undisturbed, while the surviving one now 
has no recollection of anything unusual having happened. 
The definite proof by the spectroscope of the cause of 
death is also satisfactory ; and the danger arising from 
the imperfect fixing of what are supposed to be innocuous 
stoves is an important point which cannot be passed over 
lightly. 

Leighton Buzzard. 


Royal United Hospital, Bath.—T he annual 

meeting of the subscribers to this hospital was held on 
Jan. 29th. Mr. S. Bash, the ex-mayor, was awarded a special 
vote of thanks for his successful efforts in raising a fund of 
£6214 to free the hospital from debt. It was stated that the 
legacy from the late Dr. J. Bennett would result in an 
additional income of £700 per annum. The financial 
statement showed that there was a deficit of £654 
on the working of 1907, and the committee decided 
to pay this off from capital so as to commence 1908 
absolutely free from debt. The medical report was 
satisfactory. 


A METHOD OP X RAY EXAMINATION IN 
CASES OF URINARY CALCULUS. 

By C. J. MORTON. M.D. Edin., 

SURGICAL RADIOGRAPHER TO GUY'S HOSPITAL. 


In the examination of cases of suspected urinary calculus 
with the present x ray methods the results are not always 
trustworthy. While there is this uncertainty more reliance 
must be placed on the clinical symptoms and as these are 
frequently misleading accurate diagnosis is impossible and 
many cases are left unrelieved or are operated on un¬ 
necessarily. The chief reason for this appears to be that 
there is no satisfactory way of testing the efficacy of the 
rays and of estimating whether they are in the proper quan¬ 
tity and of the requisite penetrating quality to suit the 
paiticular case. 

I have recently adopted a simple method by which it is 
possible to obtain not only more trustworthy information 
when stone is present, but also in most of the negative cases 
to demonstrate definitely that no stone can be present. 
It consists in the use of a set of calculi of known 
composition and size as a means of testing the actual 
effects of the rays while they are passing through the patient. 
These test calculi are placed between the focus tube ard the 
patient, so that the rays pass first through the calculi and 
then through the part of the patient to be examined. If the 
rays are of sufficient strength shadows of the individual 
calculi will appear on the fluorescent screen and be readily 
recognised. If no shadows can be seen it means that the 
rays are inadequate and they must be modified in quantity or 
in penetrating quality to suit the individual case. The figure 
shows a radiogram of the calculi employed taken directly, 
not through the patient’s body. Sections of three stones are 



1 Z 3 


mounted in a wooden handle with a metal end. Analysis of 
the remaining portions showed that No. 1, next the metal 
end, is composed of pure uric acid. The radiogram, how¬ 
ever, shows that there are also some faint traces of more 
opaque matter, probably phosphates. No. 2, in the middle, 
is a fusible calculus of mixed phosphates,‘ and No. 3 
is a mixed stone, with a nucleus of urate of ammonium, a 
layer of oxalate of lime, and a coatiDg of triple phosphates. 
Their relative size and density are showD in the radiogram. 
The oxalate stone is ths of an inch and the uric acid and 
phosphate each \ of an inch in thickness. Discs of metal of 
corresponding density would be equally serviceable and much 
more easily obtained. In using this as a test the patient is 
placed on a conch and a focus lube fitted with a small 
diaphragm is moved about underneath the couch so that all 
the suspected area can be searched by the central rayB. The 
examiner's eyes must be made sensitive to x ray impressions 
by resting for ten minutes in the dark or for from 15 to 20 
minutes in a very subdued d (fused light. A handle of about 
12 inches in length is useful to get the stones into position 
and also to move them about, as they are then much more 
easily detected on the screen than when they are stationary. 

When the shadows of the test have been obtained they 
are used as a standard with which any opacities in the 
patient oan be compared and a more accurate opinion formed 
of their size, density, and nature. But perhaps the chief 
clinical value of the method is that it provides a means of 
deciding absolutely on the absence of stone. It is known 
that the nearer an object is to the screen the clearer and 
more defined is its shadow. If, therefore, the test calculi 
can be eeen it follows that the shadow of any calculus of 
equal density lying in the patient and therefore nearer to 
the screen will also be seen. If no such shadow is visible 
no calculus can be present. With a suitable fccus tube and 





560 The Lancet,] DR. EWART : “ DAMMED CIRCULATION ” & “ INTERRUPTED CIRCULATION.” [Feu. 22,1908. 


good apparatus it will be found that the test Bhadows can 
easily be obtained in ordinary cases. 

In the same way the method can be used to test the effects 
on the photographic plate. This is of special value when, 
owing to the stoutness of the patient, the shadows cannot 
be shown on the screen. The plate is much more sensitive 
than the human eye to x ray impressions and under certain con¬ 
ditions its results are more accurate. A radiogram is taken 
with the test placed between the tube and the patient in 
the same manner as in the screen examination. If the test 
shadows show on the plate another radiogram taken under 
exactly the same conditions, but without the test, will show 
any calculus in the patient. The tube, however, varies con¬ 
siderably during even one ordinary exposure and a quite 
accurate result can only be obtained by taking a radiogram 
to include both sides of the patient and with the test on the 
side opposite to that under examination. This is especially 
useful in renal cases. When an image of the test is shown 
through one kidney it can be used as before to compare any 
opacities in the other renal area or to prove that if there is 
no opacity there is no stone. 

A convenient plan, when the test shadows cannot be seen 
with the calculi between the tube and the patient, is to 
place the test immediately under the screen. The rays now 
pass first through the patient and then the calculi and 
therefore an image of the test will not prove that a calculus 
in the patient must also be seen. But if the rays can show 
the test they will be found sufficient to give a definite 
image of any calculus in the patient on a radiogram. 

In a comparatively small number of cases, those of very 
stout patients, it will be found impossible to show the test 
calculi by any method. In these the x rays are valueless 
and the diagnosis must be made from the physical signs 
and clinical symptoms. But it is of great practical 
importance to differentiate these patients from the large 
number in which it can be proved that no stone is present 
and thus to decide whether or no an exploratory operation is 
justifiable. A negative result with the ordinary radiographic 
methods may mean either that no stone is present or that 
the rays have failed to show it, and unless the value of the 
rays employed is known the diagnosis is of no practical use. 
Even in a simple case a good photograph showing all the so- 
called typical diagnostic signs may, and sometimes does, fail 
to show a stone and, from its very photographic excellence, 
be worse than useless as a radiogram. 

The method gives the best results by the combined nse 
of the screen and plate. On the former the presence and 
position of any opacity, its size, and relative density are 
noted, and especially when there is any movement on 
respiration, whether it is 'synchronous with that of the 
kidney shadow or of the intestines. The information 
obtained in this way can then be verified by a radiogram 
and in doubtful cases by re examining any suspicious areas. 
Calculi placed outside the body have previously been demon¬ 
strated and a useful modification of the method described 
has been employed in searching for foreign bodies in the 
oesophagus, stomach, &c. In cases of urinary calcnli it is in 
the systematic use of the method that its value lies, and in 
providing a standard of comparison and a practical means of 
estimating the actual diagnostic value of the x ray results. 

Welbeck-street, W. 


"DAMMED CIRCULATION” AND "INTER¬ 
RUPTED CIRCULATION.” 

A NOTE IN NOMENCLATURE 

By WILLIAM EWART. M.D. Cantab., F.R.C.P. Lont>., 

CONSULTING PHYSICIAN TO ST. GEORGE’S HOSPITAL; SENIOR 
PHYSICIAN TO THE BELGRAVE HOSPITAL FOR 
CHILDREN. 

The expression, “Bier's method,” is a sufficient descrip- 
tion for the initiated, but for others it offers no suggestion 
as to what is meant. In the past this same method 
failed to develop and to spread so long as it stood 
without a name of its own, and identified in litera¬ 
ture merely as “ v. Dumreicher's method.’’ 1 At present 
there is no lack of names; the only inconvenience is 
their variety and, according to Dr. Alfred R. Allen,- their 


1 Cf. Karl Niroladonl ; v. Dumreicher's Methods uir Behandlunfi 
drohender Pseudo-arthrosen, Wiener Medicinische Wochenschrift, 187& 
Nos. 5, 6, and 7. 

9 Medical Record, Jan. 4lh, 1908. 


inaptness. “Passive congestion," “passive hypencmia,” 
“stasis hypeiiemia” are all unsatisfactory for him and, 
with perhaps too little faith in our own language, he pro¬ 
poses to look elsewhere for the word. Of course, in our com¬ 
plicated clinical craft there is much in a came. Names 
should be accurate, but also if possible telling in suggestions 
and in reminders ; and it is precisely because agreeing with 
the practical purpose entertained by Dr. Allen that one 
rather shrinks from the formidable Teutonism “Stauungs- 
hypeiiimie ” which he advocates as an improvement for our 
daily use. If one may be allowed to question two of his 
statements, we have not had to search in vain “for a concise 
descriptive term in our own tongne ”; and it is hardly 
in the phrase " Stauungs-hypeiiimie ” that we shall find a 
complete “ mental picture of the mechanics of the method ” : 
except for German ears it could only convey ignetum per 
ignotitis. 

As a fact, this is only an imperfect translation of our own 
original descriptive expression “dammed circulation,” first 
used some 30 years ago by Hugh Owen Thomas, the pioneer 
of the method in tbis country. 9 The English name is more 
strictly inclusive than the German, for it implies the 
manoeuvre and covers the entire field of its operations, 
arteries, veins, capillaries, and, not least important, plasma 
and lymphatics ; whilst “passive hyperaemia " connotes only 
the intravascular condition. As the vast extension of the 
benefits of the method is entirely due to Bier his name 
deserves to be linked with the term, and no further excuse 
is needed for the suggestion which is now submitted in 
favour of the adoption in this country of the expression, 
"Bier’s method of dammed circulation,” which may ulti¬ 
mately be found a convenience in others. But there is 
another reasoD, of clinical ntility. Since the Esmarchian 
era in surgery, and since Harvey Cushing's happy use 
of the tourniquet in Raynaud’s disease, “ interrupted cir¬ 
culation ” has been shown to be an important therapeutic 
agent in clinical medicine and surgery. 4 Whilst this is 
physiologically the reverse of Bier’s method, both are 
vessel-compressing methods, and they need to be strictly 
distinguished by their respective names. It would probably 
be difficult to find less ambiguous terms than “interrupted 
circulation ” on the one hand and “dammed circulation ” on 
the other. Indeed, the names proposed might almost be 
said to be mutually explanatory for the two methods. 

Curzon-street, W. 


Htffel jiffrittbs. 


ROYAL SOCIETY OF MEDICINE. 


SURGICAL SECTION. 

Coxa Yalga. 

A meeting of this section was held on Feb. 11th, Mr. 
J. Warrington Hawarii being in the chair. 

Mr. A. H. Tubby read a paper on Coxa Valga. He said 
that coxa valga was an opening out of the angle made by the 
head and neck of the femur with the shaft, in some cases to 
such a degree that the upper extremity of the femur and the 
shaft appeared to he almost in a straight line. It was the 
opposite condition to coxa vara, in which the head and neck 
of the femur sank down until they were placed at a right 
angle, or even less, with the shaft. A considerable degree of 
terminology and mensuration had grown up in connexion 
with the deformities of the upper end of the femur. 
The most important was the angle of inclination, other¬ 
wise called the angle of depression, the cervical angle, 
or the angle of the femur. It was estimated by draw¬ 
ing one line through the long axis of the shaft of 
the femur, and a second line through the long axis of 
the head and neck. The angle formed on the inner side of 
the point of intersection was the angle of inclination. Other 
lines and angles were Hoffa's line, Alsberg’s angle, Alsberg’s 
triangle, and the angle of declination. A list of museum 


3 Cf. The Principles of the Treatment of Fractures and Dislocations. 
Contributions to Surgery and Medicine, part vi M June, 1886. 

* Interrupted Circulation as a Therapeutic Agent: Illustrated in 
Two Cases of Rheumatoid Arthritis, The Lakcf.t, August 13th, 1904, 
p. 442 ; also Transactions of the Koyal Medical and Chirurgical Society, 
vol. lxxxix., 1906. 



The Lancet,] ROYAL SOCIETY OF MEDICINE: SURGICAL AND CLINICAL SECTIONS. [Feb. 22, 1908. 561 


specimens of coxa valga and an account of the cases hitherto 
described in literature were then read, and particular stress 
was laid upon two cases of Galeazzi of Milan, in which he 
had operated for the condition, and one by Nathaniel Allison. 
As to the causes of coxa valga, they were classified as 
follows : congenital, which were subdivided into those in 
conjunction with congenital dislocation of the hip, and those 
not associated with abnormalities elsewhere. Considerable 
stress must be laid upon the coexistence of coxa valga 
and congenital dislocation of the hip, and its importance 
was great. Coxa valga might not only be a determining 
factor in displacement of the head from movement at or 
after birth, but dislocation once having occurred the nearly 
vertical position of the neck and head of the femur induced 
great difficulties in satisfactory replacement. Mr. Tubby 
then cited three cases occurring in his own practice of con¬ 
genital dislocation of the hip with coxa valga and showed 
x ray photographs and two cases. In one instance 
of dislocation of the left hip the angle of inclination 
was 169°. In a second case, with double dislocation, the 
angles of inclination were 172° and 164°, and in a third case, 
with dislocation of the left hip, the angle was 154°, A 
second cause was traction exerted by a pendent limb, 
such as occurred in extensive infantile paralysis of 
the lower extremity, and in those instances where 
amputation through the Bhaft of the femur had been 
required. A case was shown of infantile paralysis 
of the right leg, together with x ray photographs taken 
in three positions- namely, With the leg fully everted, 
fully inverted, and with the foot to the front. The angle of 
inclination was found to be respectively 204°, 128°” and 
150°, thus showing 76° of difference in the various positions 
of the right limb, as compared with 27° in the left limb. 
Static conditions were also influential in causing coxa valga, 
particularly genu valgum and scoliosis, and a case in point 
was shown. A traumatic form had been frequently 

described, following injuries of the neck and shaft of the 
femur, and an instance which had come under Mr. 
Tubby's care was exhibited, in which, after mal-union of 
the middle of the shaft of the femur, the angle of Inclina¬ 
tion was found to be 152°. The deformity was also met 
with associated with rickets and processes of bony soften¬ 
ing affecting the neck of the femur, B uch as osteo¬ 
myelitis and tubercle. Some authors bad also described an 
idiopathic form but the evidence as to the existence of 
that was not clear. Referring to the pathogenesis, Mr. 
Tubby said it could be shown that the normal shape 
and position of the head and neck of the femur depended 
upon the nice adjustment of certain forces—namely, weight- 
pressure, resistance of the bone, and muscular effort.’ If any 
one of those factors, or all of them, were varied in degree, 
altered in direction or destroyed, changes took place conform¬ 
able with Wolff’s law, and the head and neck of the femur 
assumed different positions and directions. The cardinal sym¬ 
ptoms were abduction of one or both lower extremities, asso¬ 
ciated with external rotation and limitation of adduction 
Pain and spasm were often experienced at the beginning of the 
affection and the gait in unilateral cases was limping with 
the trunk inclined towards the affected side. In bilateral 
cases it was rolling and unsteady. The limb was frequently 
lengthened to as much as two or three centimetres and it 
was abducted and rotated out, whilst movements of adduc¬ 
tion and internal rotation were limited. Trendelenburg’s sign 
was reversed and the patient when standing on the affected 
limb inclined the body towards that side. Flattening over the 
great trochanter was often noticeable, and lumbar scoliosis 
with its convexity towards the affected limb, was sometimes 
present. Very important evidence was obtained by skia¬ 
graphy and the fallacies in connexion with that were 
discussed. The diagnosis must be made from coxitis with 
abduction of the limb, from eacro-iliac disease, and from 
congenital dislocation not complicated with coxa valga 
with reference to the treatment, various forms of operation 
had been performed—namely, cuneiform osteotomy of the 
neck, removal of a wedge of bone with its base inwards from 
the sub trochanteric region, and linear osteotomy through 
the base of the neck. According to the conditions and sur¬ 
roundings of the patient one of the last two plans should be 
chosen. 

After Mr. C. G. Watson had made a few remarks in the 
course of which he observed that he could not understand 
how the weight of the body could cause the condition 
described, Mr. Tubby replied, and the meeting terminated 
with a demonstration by him of several patients, 


CLINICAL SECTION. 

Exhibition of Cates. 

A meeting of this section was held on Feb. 14th, Sir 
Thomas Baki.ow, the President, being in the chair. 

Mr. J. P. Roughton showed a case of Tumour of the 
Right Side of the Face. The patient was a boy, aged 11 
years. The whole of the right side of the face, with the 
exception of the region below, and to the right of, the mouth, 
was occupied by a swelling of a doughy consistency, the 
upper eyelid especially being very swollen. This swelling 
crossed the middle line on the forehead and upper lip. 
There were many cords and knots distributed throughout 
the swelling, especially on the forehead, over the parotid, 
and in the cheek, and there was a distinct cord running 
immediately behind the facial artery over the ramus of 
the jaw. There was no pulsation. The swelling could 
not be diminished or displaced by pressure. There 
was no loss of sensation or movement except that the latter 
was very much impaired by the infiltration of the tissues 
and the muscles readily reacted to faradism. There was no 
leucocytosis. There was an enlarged gland under the sterno- 
mastoid. Eight years ago the mother noticed that the right 
eye looked smaller than the left and shortly afterwards the 
outer canthus began to swell, whence the swelling had 
gradually spread. The family history was good. He was at 
school till last December, when he left on account of pain in 
the upper eyelid which lasted about a fortnight and which 
was the only occasion on which he had had any pain.—Mr. 
R. J. Godi.ee considered it was a case of plexiform neuroma 
and this was also the opinion of Dr. F. Parkes Webeu. —Mr. 
W. G. Spencer and Mr. Godi.ee agreed in recommending an 
exploratory operation and Dr. G. A. Sutherland related the 
details of a similar case reported by him to the Clinical 
Society. 

Dr. H. L. Eason demonstrated a case for Dr. Herbert S. 
French of Tumour of the Mediastinum (! hydatid). The 
patient was a female, aged 42 years. She looked perfectly well 
and her only complaint was that she could not see properly 
with her left eye. For that she had seen Dr. Eason at Guy’s 
Hospital. The cause of the defective vision was inability to 
accommodate. There was complete paralysis of the left 
cervical sympathetic nerve. That dated back for over two 
years. There was slight but decided ptosis of the left upper 
eyelid ; the left pupil was continuously small ; the patient 
could not blush upon the left side of her face and when she 
perspired the right side of the face sweated but the left did 
not. Further examination showed distinct fulness of the 
left external jugular vein and the veins over the upper part 
of the left chest in front were distinctly fuller than those 
over the corresponding part of the right side. Examination 
of the chest with the stethoscope showed complete absence 
of vesicular murmur and of voice sounds over the region 
where the upper two-thirds of the upper lobe of the left lung 
ought to be. The conclusion was that in the region of the 
left upper lobe there was a mass nearly as big as a good- 
sized orange, large enough to displace or to destroy the lung 
there, to extend back far enough to compress the cervical 
sympathetic nerve, and forward enough to compress the left 
innominate vein. The length of history and the general con¬ 
dition of the patient pointed to its not being malignant; 
there had been no improvement under treatment by mer¬ 
curials and iodides, so that gumma seemed unlikely. The 
x rays showed a perfectly globular mass, not connected with 
the aorta (a point less obvious in the skiagrams than it was 
when ihe screen was used in different positions of the 
patient), and of a size precisely corresponding with the 
diagnosis made. Hydatid cyst was suggested as a possi¬ 
bility, chiefly on account of the perfectly globular character 
of the mass. The patient had no symptoms or signs of 
hydatid cyst elsewhere in the body.—This case was discussed 
by Dr. C. Theodore Williams, Dr. A. E. Garrod, and Dr. 
Cyril Ogle. 

Mr. Godlee showed a case of old-standiDg Dislocation 
of the Patella with Osteo-arthritis of the Knee in a man, aged 
50 years, and Skiagrams of an old Fracture of the Humerus, 
with Osteo-arthritis of the Elbow. The patient with the dis¬ 
located patella was a labourer who said that his right knee 
had been out of shape since birth. He knew of no injury in 
early life. It did not cause him much, if any, inconvenience 
until he had a blow upon it six months ago, since which 
time his knee had been painful. On flexing the knee the 
patella slipped right over to the outer side of the joint. 
There was marked genu valgum and the signs of osteo¬ 
arthritis were unmistakable. The patient was not the 






562 The Lancet,] 


ROYAL SOCIETY OF MEDICINE: CLINICAL SECTION. 


[Feb. 22, 1908. 


subject of locomotor ataxy and there was no indication 
that he suffered from infantile paralysis. The case illus¬ 
trated the fact that dislocation of the patella need not 
necessarily interfere much with the utility of the knee 
and suggested that an injury to a joint in early life might 
determine the onset of osteo-arthritis in the joint so affected. 
The skiagrams of the case of old fracture of the humerus were 
from a patient, aged 34 years. 21 years ago, when the patient 
was aged 13 years, he injured his right elbow ; he said it was 
di.located, but he did not know whether it was fractured. 
Three and a half years ago a small, painful swelling appeared 
ne ir the elbow, which was treated in hospital. Soon afterwards 
a swelling appeared on the inner side of the back of the 
forearm, two inches below the internal condyle, which in¬ 
creased in size during the last year till it reached that of a 
walnut. It proved to be a “ ganglion ” with a thin wall, the 
pedicle of which extended up towards the joint along the 
internal intermuscular septum. The cleari jelly-like con¬ 
tents were evacuated and the pedicle was cut short. The 
wound healed by first intention. The skiagram showed 
an old fracture of the internal condyle and irregular 
masses of bone attached' to both the upper ends of the ulna 
and the radius. The movements of the joint were almost 
perfect. The case illustrated the good result which might 
sometimes be obtained after fracture of the lower end of the 
humerus. It also suggested that an injury to a joint in 
youth might determine the onset of osteo-arthritis later in 
life There was at present, however, no creaking in the joint. 
No signs of osteo-arthritis had been discovered in other 
joints.—After Mr. T. H. Openshaw and Dr. Seymour 
Taylor had spoken, Dr. F. J. Poynton remarked that osteo¬ 
arthritis could be produced experimentally in an uninjured 
joint—an injury might diminish the resisting power of a 
joint to some infection.—Dr. Garrod concurred with the view 
expressed in regard to lowered resistance. 

Dr. Seymour Taylor showed a case of Ruptured Aortic 
Valve. The patient, a man, aged 34 years, who had 
worked with lead for nearly two years, complained of 
tightness across the chest, a choking sensation on exertion, 
and a buzzing noise in the chest, which he heard best when 
lying down. These symptoms supervened suddenly after the 
strain of lifting a heavy weight. He denied having had 
syphilis or acute rheumatism but had twice suffered from 
lead colic. He had a typical blue line at the edge of the 
gums. On palpation over the cardiac region a diastolic 
thrill was felt, most intense over the second and third spaces 
on each side. On auscultation a loud murmur was heard, 
loudest over the aortic area, diastolic in period, and musical 
in tone. The musical note corresponded to about B below 
the staff. That point was of some interest, as a similar 
observation was made in a previous case which he had shown 
before the Clinical Society (Transactiont, vol. xxxvi.). The 
murmur was heard all over the chest and even over the 
upper thirds of the humeri. The condition of the valve 
was probably one of perforation of one cusp rather than 
of detachment or true rupture. That diagnosis was 
made on the following grounds, viz. : (1) the sudden 
onset of urgent symptoms after a strain, pointing to 
valve injury ; (2) the musical diastolic murmur ; and 
(3) a marked diastolic thrill. If a cusp were torn from its 
attachments one would expect to bear harsh noises, and 
also to feel a thrill, not only during diastole, but also during 
syetole.—Sir J. F. H. Broadbbnt narrated a case in which 
rupture of an aortic valve was diagnosed, but it was found 
at the necropsy to be one of acute aortitis —Dr. Poynton 
observed that it was possible for an aortic valve -to be 
ruptured without the patient experiencing pain, perhaps only 
complaining of a little discomfort.—Dr. Theodore 
Williams said a ruptured aortic valve might act as a valve 
below the level of the other two valves.—After Dr. Parkes 
Weber had Bpoken Dr. Seymour Taylor replied. 

Dr. Arthur Latham showed a case of Caseating Pul¬ 
monary Tuberculosis treated with Tuberculin (T.R.) and 
Horse Serum, both given by the mouth. The patient was 
a man, aged 26 years, who on June 3rd, 1907, was seized 
with acute pneumonic tuberculosis of the left lower lobe. 
He had continuous fever till the beginning of October when 
he sought advice at Brompton Hospital for Consumption. 
He was admitted to St. George’s Hospital on Oct. 8th and 
kept in bed for one month without reduction of the fever 
and without any evidence of improvement. On Nov. 6th 
10 cubic centimetres of horse serum with ,,,' 00 th mgrm. tuber¬ 
culin were administered by the mouth, followed by a drop in 
the temperature to normal for two days. On Nov. 9th the 


temperature again rose to 101° F. A further dose of serum 
and tuberculin was given on Nov. 11th. On the 12th the 
temperature was subnormal. On the 13th the temperature 
again rose. On the 20th and 2l6t serum and tuberculin 
were again administered with immediate effect. The tem¬ 
perature remained normal till Dec. 12th when the patieDt was 
allowed up; that was followed by immediate auto-inocula¬ 
tion and fever. A further administration of serum and 
tuberculin again reduced the temperature, which remained 
near the normal till Jan. 3rd. On that date three doses 
of serum (10 oubic centimetres) and tuberoulin , s ' 05 th mgrm. 
were administered, with the result of a summation of nega¬ 
tive phase and increased temperature. That proved a 
temporary affair. For the last month the temperature had 
been normal or subnormal. The patient was up and about. 
The weight had increased 17 pounds and the sputum 
diminished from 6 ounces to i ounce. The physical signs 
in the left lower lobe were those of a dry cavity.—Dr. 
Parkes Weber said the case might have some bearing on 
the feeding of consumptive patients with tuberculous meat. 
—Dr. Theodore Williams thought it was important to 
examine the expectoration for traces of lung tissue.—Dr. 
Latham, in reply, said that immunisation by tuberculous 
meat was a'possibility and experiments in connexion with 
that point were being carried out at the Pasteur Institute. 

Dr. Parkes Weber showed a case of Spurious (1) 
Acromegaly. The patient was a woman, aged 46 years. 
The case was shown because of its remarkable resemblance 
at first sight to acromegaly. The patient wa9 married, 
rather corpulent, and very anaemic. Her face and head, 
with the large lower jaw, prominent chin, and big nose, 
could be used as a model for an illustration of acromegaly. 
She had thick, fleshy hands and thick fingers, but she had no 
ocular symptoms of acromegaly and her occasional headaches 
and shortness of breath seemed to be connected with her 
amemia, which in its tuin might be accounted for by frequent 
hacmorrhoidal bleeding from which she had suffered during 
the last six or seven years. There was no amenorrhcea, as 
there was in many genuine cases of acromegaly. Moreover, 
there was no evidence of any progressive change having 
occurred in the shape or size of the hands, feet, face, 
skull, or other bones of the tody since she ceased growing at 
the ordinary age. An old photograph (the only one obtainable 
for comparison) which was taken three or four years ago 
showed her face looking just as it did now. She bad had six 
children, all healthy, and at least one of the daughters some¬ 
what resembles the patient in the Bhape of her chin. The 
case bad probably been more than once accepted as one of 
genuine acromegaly. 

Mr. Spencer showed a case of Lateral Curvature 
rapidly developing in a boy, aged three years, who was an 
inmate of a Poor law school, and was all at once noticed to 
have a marked lateral curvature, the only previous observa¬ 
tion beiDg that he seemed a little ameraic. He had a marked 
left thoracic smd lumbar scoliosis and walked with lordosis ; 
both of the curvatures disappeared when he was suspended 
by the arms. The muscles of the left side of the spine 
appeared unduly weak, the abdomen was irregularly pro¬ 
tuberant, but there was no definite hernia, either inguinal or 
ventral. The biemoglobin was 74 per cent. Bsyond that 
examination had discovered nothing distinctly abnormal; the 
reflexes were normal, the muscles of the spine reacted to 
faradism and galvanism ; no muscles were absent. 

Mr. R. P. Rowlands showed a case of Excision of the 
Body of the Scapula. The patient was a man, aged 35 years, 
from whom the whole of the body of the left scapula had 
been excised for enohondroma IS months ago. It was 
possible, and deemed advisable, to save the coracoid process 
with its important muscleB and ligaments, the glenoid cavity 
with the capsular ligament of the shoulder-joint, and the 
acromion process with the attachments of the deltoid 
and trapezius to it. The patient showed that both the 
disability and the deformity following that procedure 
were much lesB than after complete excision of the 
shoulder-blade. The man had been able to do his work as 
a painter’s labourer from two months after the opera¬ 
tion. Extreme abduction was the only movement that 
was imperfect. Radiograms were exhibited to show 
the comparative effects of the operation adopted in the 
patient and of complete excision of the scapula for extensive 
sarcoma by Mr. L. A Dunn, who had kindly allowed Mr. 
Rowlands to make use of his case. Photographs were also 
exhibited which showed the differences of function and degree 
of deformity in the two cases. Rotation of the shoulder-joint 




Thh Lancet,] 


OPHTHALMOLOGICAL SOCIETY. 


[Feb. 22,1908. 563 


was limited to one-half the natural extent and the abduction 
to 45° in the case of complete excision. A posterior 
T-shaped incision was used and through that the three 
groups of large vessels were tied early in the operation to 
minimise haemorrhage. It was claimed that preservation of 
the processes and glenoid cavity was both practicable and 
advisable in preference to complete excision of the scapula 
for inflammatory conditions and innocent growths and 
possibly for some maligDant growths. 

Mr. Openshaw showed a case of Multiple Disloca¬ 
tions, including congenital dislocation ot both hips, in a 
child two weeks old, incontestably the result of malposition 
in utero. The patient was taken to him as an out-patient 
at the London Hospital on Feb. 7th last presenting dis¬ 
location of both shoulders, both elbows, both hips, and both 
knees, and extreme double equino-cavo-varus. The child 
otherwise was well formed; the cranium presented no 
deformity. There were a large umbilical hernia and a history 
of snuffles. The mother had five other children and bad 
had three miscarriages. The position in which the child lay 
in ntero could be definitely reconstructed. The limbs in 
their abnormal position fitted closely to the body ; the hips 
fully flexed, the knees hyper-extended, and the feet twisted 
into the position of equino-varus. The arms were flexed and 
rotated in at the shoulders and the hands were situated in the 
armpits in a position of acute flexion at the wrists. The head 
and neck of the right femur were rotated outwards upon the 
shaft to an angle of 30°. The head was dislocated and 
lay outside, and in front of, the anterior superior spine. 
The thigh was acutely flexed on the abdomen, the 
inner surface of the femur resting in contact with the 
abdomen. The condyles were visible in the popliteal space, 
the knee being retroflexed to an angle of 100°. The knee 
could only be flexed even with force to an angle of 160° and 
immediately dropped back to an angle of retroflexion of 110°. 
There was extreme congenital equino-varus, the os calcis 
resting on the leg and the sole of the foot looked upwards. 
The scaphoid was the lowest bone of the tar.-us. The left 
leg presented a similar condition, except that the knee was 
byper-extended to an angle of 110° and could only be flexed 
to an angle of 170°. The left foot presented the same con¬ 
dition as the right; the scaphoid was the lowest bone. 
There was a large funnel shaped umbilical hernia which 
bulged between the knees when the legs were in the position 
in which they were in utero. There was a subcoracoid dislo¬ 
cation of the right shoulder. At the right elbow both bones 
were dislocated backwards and outwards. There was marked 
pronation of the right forearm. The fingers were well 
formed but excessively hyper-flexed at the metacarpo¬ 
phalangeal joints. The transverse metacarpal ligaments were 
extremely stretched, so that the heads of the metacarpals 
could be separated and the hand stretched out to a width 
equal to double the length of the palm. The left arm pre¬ 
sented a similar condition. Mr. Openshaw considered that 
it was incontestably a case of congenital dislocation of hips, 
knees, shoulders, and elbows from intra uterine malposition. 
He had seen two other cases where congenital dislocation of 
the hip bad been associated with congenital recurvation of the 
knee and talipes in the same leg due to intra-uterine mal¬ 
position and pressure. 

Mr. C. A. R. Nitch showed a case of Myositis Ossificans in 
a girl, aged 10 years. The disease commenced in the muscles 
of the neck when the child was aged three and a half years 
and within a few months the pectoral, scapular, and lumbar 
muscles were involved. Plaques, bosses, and spicules of 
bone could be felt in the following muscles : the erector 
spinm, latissimus dorsi, trapezius, and pectorales of both 
sides ; the right rhomboideus major and minor, the left 
rhomboideus minor, the left levator anguli scapulfe, the 
left infra spinatus, the geniohyoid, the sterno-mastoids, the 
right vastus externus, and the muscles in the popliteal 
space. Microdactyly of both great toes was present. The 
back and neck were now quite rigid, movements at the 
shoulder-joints were very limited, full extension of the right 
leg was impossible, and owing to the fixation of the thorax 
respiration was purely diaphragmatic. 

Dr. F. E. Batten and Dr. J. Graham Forbes communi¬ 
cated a note on two cases of Infection with the Bacillus 
Eoteritidis of Gaertner They described two caseBof prolonged 
fever and dlarrhcea in infants, the blood of whom, though 
repeatedly tested, gave a negative Widal reaction. The 
first was that of a child, aged 12 months, in whom the 
disease laBted for 35 days. On the nineteenth day the blood 
was tested with the bacillus enteritidis of Gaertner and 


gave a marked reaction. Purpura developed during the 
course of the disease. The child died and at the necropsy 
numerous ulcers were found throughout the small intestine. 
A pure growth of a Gram-negative motile bacillus was 
obtained from the spleen and mesenteric glands. The 
organism gave the characteristic reaction of the bacillus 
enteritidis of Gaertner. The second case was similar but 
towards the termination developed symptoms suggestive of a 
general tuberculous infection. The child died and at the 
necropsy no evidence of tuberculosis was found. The bacillus 
enteritidis of Gaertner was isolated from the stools. 


LARYNGOLOGICAL SECTION. 

Exhibition oj Casa and Specimens. 

A meeting of this section was held on Feb. 7tb, Dr. 
J. Barry Ball, the President, being in the chair. 

The following cases and specimens were shown :— 

Dr. F. Parkes Weiier: A case of Multiple Hereditary 
Developmental Angiomata (telangiectases). 

Sir Felix Semon (for Dr. Sidney P. Phillips) : A case of 
Multiple Telangiectases. 

Dr. A. Brown Kelly: Sketches of three patients with 
Multiple Telangiectases. 

Dr. J. Donblan : (l) Specimen and microscopic sections 
of a Tumour of the Thyroid Gland from a case shown at the 
last meeting ; and (2) a case of Intranaeal Hypertrophy 
associated with continual sweating of the nose. 

Dr. StClair Thomson: (1) A case of Syphilitic Pachy¬ 
dermia; (2) a case ot Propcosis due to distension of the 
frontal sinus ; and (3) a radiograph to show how the orbito- 
ethmoidal and frontal cells can be defined before operation. 

Dr. P. Watson Williams: (1) Microscopic sections 
illustrating the pathogenesis ot some forms of Nasal Polypi ; 
and (2) a universal Laryngeal Forceps for use by the direct 
and indirect methods. 

Dr. W. JonsoN Horne : A case of Unilateral Paralysis of 
the Tongue. 

Mr. W. J. Chichele Nourse ; (1) A case of Sarcoma of 
the Nose atter operation ; ana (2) a case of Epithelioma of 
the Tongue and Fauces after operation. 

Mr. W. Stuart-Low : A case of Complete Closure of the 
Anterior Nares with Partial Atresia of the Pharynx ; and 
(2) cases after the Radical Maxillary .Antrum Operation 
exemplifying a simplification of the after-treatment. 

Dr. Andrew Wylie : A case of Swelling of the AryteDoid. 

Mr, Herbert Iillby : A case of Early Epithelioma of the 
Vocal Cord. 

Mr. C. A. B. Horsfopd : A girl, aged 17 years, with a 
baritone voice. 

Dr. Dan McKenzie : A case after removal of an Endo¬ 
thelioma of ti e Palate. 

Dr. J. Dundas Grant and Dr. Dan McKenzie : A case 
after operation tor Median Cervical Fistula. 

Dr. W. H. Kelson : A case of Nasal Ulceration. 

Dr. Dundas Grant : A case of Epithelioma of the 
Fauces. 

Dr. G. William Hill : A case of Laryngeal Tuberculosis. 


OPHTHALMOLOGICAL SOCIETY. 


Some Primary Facts of Colour Perception.—Exhibition 
of Cates. 

A clinical evening of this society was held on Feb. 13tb, 
Mr. E. Treacher Collins being in the chair. 

Dr. F. W. Edridgi: Green gave a lantern demonstration 
on Some Primary Facts of Colour Perception, and an 
interesting discussion resulted in a resolution being passed, 
on the proposition of Mr. C. D. Marshall, that a com¬ 
mittee of the society should be appointed to go into the 
question ot colour-blindness and the tests for its detection 
and to report to the society. 

Mr. L. J. Paton showed a case of Detachment of the Retina 
treated by operation. The patient abd been sent to the National 
Hospital for the Paralysed and Epileptic with the diagnosis of 
double optic neuritis and the remark that both nasal fields 
were lost. The right eye had been useless for 36 years and 
for a year there was mistiness in thelelt. A’ision was then 
now it was To get at the train point of detachment be 
trephined above the tendon of the external rectus and pulled 
the eye well forward by a tenotomy hook under the external 
rectns. He cauterisrd through the sclera until the subretinal 



564 The Lancet,] 


SOCIETY OF ANrESTHETIBTS. 


[Feb. 22, 1906. 


fluid escaped and aspirated the rest with a lacrymal syringe. 
He then perforated the retina above and below. In the 
middle of January the field was quite full. 

Mr. Horseord showed a case of Buphthalmia with Mal¬ 
formation of the Iris, and the causation of the condition was 
discussed. 

Mr. J. F. Cunningham showed an Orbital Case for Dia¬ 
gnosis. It was thought to be apical periostitis, or caries of 
the apex of the orbit, or an optic nerve tumour. 

Mr. J. H. Fisher showed a patient with Microphthalmia 
and a case of Fundus Changes resulting from injury at 
birth. The second of these patients wa3 born with great diffi¬ 
culty and there was a huge haematoma of the left frontal 
region, and soft tissues in the right temple and orbit were 
much damaged and lacerated by forceps. Possibly the optic 
nerve was damaged and there was limmorrhage from the 
lacerated vessels into the hyaloid canal, the clot forming the 
basis for the connective tissue organisation. He did not 
think there was any shrinking of the globe. 

Mr. P. C. Bardsley showed a case of Retinitis Proliferans. 
A large bundle of connective tissue came forward into the 
vitreous. He regarded it as congenital, as there were a large 
detachment of the retina and only a very small field. There 
was no history of injury, either at birth or Bince, but the 
eye had been defective as long as the parents could 
remember. 

Mr. C. Wray showed a case of Follicular Conjunctivitis 
which he considered to be perfectly curable. It was con¬ 
tagious, and among 1400 children in the Croydon schools 
there were 12 cases of the condition. 

Mr. J. H. Parsons showed a patient the subject of a condi¬ 
tion which be thought was probably Metastatic Neuro-retinitis. 
A woman had a glistening mass of exudate over the left 
disc with considerable swelling and some hicmorrhages on 
the diBC. Then she suddenly lost the sight of that eye. The 
exudate diminished, leaving a glistening white star re¬ 
sembling that seen in albuminuric retinitis. She had no 
albuminuria. 


SOCIETY OF ANESTHETISTS. 


The Statue Lymplidliout in Relation to General Antesthesia. 

A meeting of this society was held on Feb. 7th, Dr. 
R. J. Probyn-Williams, the President, being in the chair. 

The discussion on Status Lymphaticus adjourned from the 
last meeting was resumed by Mr. R. Gill who congratulated 
Dr. IV. G. McCardie on his paper and directed his remarks 
chiefly to two features which Dr. McCardie had mentioned as 
existing in the status lymphaticus—viz., (1) some naso¬ 
pharyngeal obstruction, and (2) anicmia. These two factors 
were very intimately connected with the action of chloro¬ 
form. Patients with nasal obstruction exhibited a long 
induction period and anajmic people required very little 
chloroform. A combination of these conditions produced a 
patient to whom it was difficult and dangerous to give chloro¬ 
form. And this combination occurred in people who were 
not subjects of status lymphaticus. It was difficult to see 
that there could be any relation between the enlargement of 
such organs as the spleen, liver, glands. Arc., and sus¬ 
ceptibility to chloroform, so he concluded that there was not 
sufficient evidence that the status lymphaticus in itself was 
the cause of these deaths under chloroform. 

Dr. Dudley W. Buxton could not agree that Dr. 
McCardie’s conclusions followed his premisses. He could not 
help feeling that the status lymphaticus which had been 
discovered in many cases of deaths under chloroform was 
coincidental and not causal. Dr. McCardie had used the 
word “idiosyncrasy," but he (Dr. Buxton) did not believe 
in idiosyncrasy to chloroform. Everybody had his dose for 
chloroform and it was the duty of the amesthetist to discover 
it. There were two schools as to the cause of death in these 
cases : one said they were cases of respiratory obstruction, 
the other called them cases of syncope. The pathological 
conditions in status lymphaticus would produce more or less 
respiratory obstruction, and if expiration in particular were 
obstructed the chloroform would become locked up in the 
chest and absorption and poisoning would occur, especially 
as the myocardium in status lymphaticus was feeble to start 
with and the dilatation from chloroform might not be re¬ 
covered from. As to these deaths being due to syncope, Embley 


and Martin had shown that a certain percentage of chloro¬ 
form in the circulation would prevent vagal inhibition, but 
that with a larger percentage vagal inhibition would not be 
prevented and would not be recovered from. If a given 
percentage of chloroform enabled a heart to escape from 
vagal inhibition in a normal patient might not a patient the 
subject of status lymphaticus with the same percentage of 
chloroform not escape vagal inhibition and not recover from 
it? Patients with status lymphaticus required less chloro¬ 
form. Syncopes and asphyxias might be avoided by regulating 
the dose and only giving as much as was required. Some 
German authors referred to “thymus deaths ” in adolescence, 
but these people did not die as suddenly as the ones under 
chloroform, they had glottic spasm, vomiting, &c., more like 
post-chloroform poisoning. The latter was probably due to 
lymphatic hyperplasia. 

Dr. J. Blumfeld disagreed with Dr. McCardie who 
doubted if death ever occurred from chloroform per te: many 
cases had been reported in which status lymphaticus was not 
present, and even in some of Dr. McCardie's own cases status 
lymphaticus was probably not present, especially some of the 
cases of goitre. Dr. Blumfeld also disagreed with Mr. Gill 
who seemed to doubt the existence of the status lymphaticus 
as a pathological entity ; and finally he disagreed with Dr. 
Buxton in considering all these deaths as due to simple 
over-dosage, because cases had been reported in which 
corneal and movement reflexes were present when death 
occurred. 

Dr. J. F. W. Silk regarded the enlargement of tonsils and 
adenoids in these cases as important factors in causing death. 
The signs and symptoms of status lymphaticus were so 
numerous and widely distributed that any case of death 
under chloroform might be dragged into the status lym¬ 
phaticus net. He pleaded for a better definition of the con¬ 
dition and agreed with Dr. Buxton that they should, and 
usually did, avoid trouble by adjusting the dosage to the 
patient’s requirements. 

Dr. Ll Powell asked if pathologists could say whether a 
persistent thymus was not occasionally found in people dying 
from some independent disease. 

Dr. G. A. li. Barton said that the status lymphaticus was 
a question for the pathologist. How could it be recognised ? 
Might not a committee be formed to make blood counts of all 
patients anieithetised to see if it were dangerous to give 
chloroform to people with lymphocytosis ? Might not some 
deaths be due to too little and not too much anaesthetic? 
Dr. Barton did believe in idiosyncrasy to chloroform ; he had 
seen idiosyncrasy to iodide, belladonna, and morphine, then 
why should it not occur to chloroform ? But even if the 
physiologists were right that 2 per cent, of chloroform could 
not kill, he maintained that 2 per cent, would not always 
produce anaesthesia and that death might occur from other 
causes than the anassthetic. 

Dr. Buxton apologised for getting up again and said that 
although he held no brief for the physiologists, yet it was 
possible clinically to obtain and maintain anaesthesia with 2 
per cent, of chloroform. 

The President said that the question whether status 
lymphaticus was a clinical entity or not must be left to the 
pathologists to determine. Until they could point to some 
more definite lesions it must be considered “ not proven." 
As to Mr. Harvey Hilliard’s case, he had invited criticisms and 
the President saw no reason why the patient should not have 
been given gas and ether. 

Dr. McCardie, in reply to Mr. Gill, said that in no case 
had obstructed breathing been reported. Amemia would 
make the anaesthetist careful to equate the dose of chloro¬ 
form to the patient’B requirements, but he did not think 
these two factors sufficient to account for the sudden 
deaths. To Dr. Buxton he said he did believe in idio¬ 
syncrasy, and overdose was ruled out because so many cases 
occurred during light anaesthesia. To Dr. Blumfeld he 
explained that he did believe death from chloroform might 
occur apart from status lymphaticus. To Dr. Silk he 
declared his belief that status lymphaticus was a clinical 
entity and in one suspected case the x rays showed enlarge¬ 
ment of the thymus. He agreed with the President that 
more pathological work was necessary and referred to the 
two cases mentioned by Mr. H. T. Wightman in which the 
status had been diagnosed. As to its mode of action in 
decreasing resistance to chloroform he did not know, but 
probably it was due to a form of lymphotoxiemia. He 
always gave ether when he suspected status lymphaticus. 




The Lancet,] 


LIVERPOOL MEDICAL INSTITUTION. 


[Feb. 2?, 1908. 565 


LIVERPOOL MEDICAL INSTITUTION. 


The Treatment of Jhemoptysis by Nitrite of Amyl.—The 
Physiological Importcm.ee of the Calcium Salts. 

A meeting of this society was held on Feb. 13th, Mr. 
T. H. Bickerton, the President, being in the chair. 

Dr. G. A. Crace-Calvert read a note on the Treatment of 
Hemoptysis by Nitrite of Amyl. He stated that until recently 
the treatment of hemoptysis had not been satisfactory and 
that nearly all drugs except morphine had been described as 
useless. Dr. F. W. E. Hare had called attention to the use of 
the nitrite in checking hemorrhage and pointed out that it 
acted partly by oausing a marked reduction in the arterial 
blood pressure and partly by producing an intense anemia of 
the lung parenchyma, and so gave time for clottirg to take 
place. Dr. Crace-Calvert had tried it in about 25 attacks of 
hemoptysis—many of them profuse—and always found that 
it checked the bleeding almost instantly. Afterwards if 
there was excitement of any kind he gave a quarter of 
a grain of morphine. He considered that nitrite of amyl 
was the drug par excellence to be used first, as it saved 
the patient unnecessary loss of blood and prevented large 
accumulations of blood in the air passages. It was 

especially useful in sanatorium work where the patient was 
seen at the beginning of the attack.—Sir James Barr 
congratulated Dr. Crace-Calvert upon pointing out the 
value to be obtained from the use of nitrite of amyl 
and such other agents in cases of haemoptysis. He said 
that they often heard of blood pressure in numerous diseases 
without the observers having any clear idea as to what was 
meant by blood pressure. Blood pressure was purely a 
relative term, and what might be considered a very high 
blood pressure in pulmonary tuberculosis would be a low 
pressure in renal disease. In pulmonary tuberculosis the 
heart was small and weak, and a comparatively small 
resistance was more than it could cope with ; therefore 
any slight rise in the arterial pressure in cases of pulmonary 
tuberculosis was very apt to dam back the blood in the 
pulmonic system. The great advantage of the use of 
morphine or morphine and atropine in cases of pulmonary 
tuberculosis arose from the fact that they generally 
stopped the cough and thus prevented any rise in the 
arterial pressure. Personally he had for many years used 
nitro glycerine in cases of h®moptysis and as a rule he pre¬ 
ferred it to nitrite of amyl because of its more last¬ 
ing effect. If the blood was deficient in lime salts it 
was very important that lime salts should be administered.— 
Dr. Nathan Raw could not agree that nitrite of amyl had 
any specific action in the control of ba-moptysis. Whilst one 
occasionally met with an overpowering haemorrhage which 
was rapidly fatal, the fact remained that the great majority 
subsided spontaneously with care and rest. He could not 
agree that haemoptysis was due to increased blood pressure, 
but rather to erosion of some small blood-vessel. He advocated 
absolute rest in the recumbent posture, a hypodermic in jection 
of morphine, ice to suck, and cold turpentine applications to 
the chest. He had seen excellent results from adrenalin 
chloride in long-continued but small haemorrhages from the 
lungs. By lowering the blood pressure it was possible that 
nitrite of amyl was occasionally useful.—Dr. W. B. War¬ 
rington said it had long been recognised that a hypodermio 
injection of morphine was the most satisfactory drug in the 
treatment of hemoptysis and for some years past nitrite of 
amyl in addition bad been the routine treatment at the 
Northern Hospital.—Dr. A. G. GULLAN said that there seemed 
to be varied opinions on the blood pressure of pulmonary tuber¬ 
culosis and he believed that in many cases it was lowered. 
Yet everyone was well acquainted with the excited and strong 
action of the heart and the strong and quick pulse which 
arose on the sudden occurrence of a serious haemoptysis. 
The arterial blood pressure was then undoubtedly greatly 
increased and it was in this condition that the amyl nitrite 
was beneficial as a rapid means of lowering it. At the same 
time such good results had been obtained by rest, morphine, 
and purgatives in the past, and moreover these methods were 
invariably used in conjunction with amyl nitrite, that he felt 
too much credit for the good results obtained should not be 
given to that drug.—Dr. R. J. M. Buchanan drew attention to 
the fact that cases of pulmonary tuberculosis associated with 
good blood pressure generally did well and that biemoptysis 
more often occurred in chronic and relatively favourable cases. 
The hsemoptysis was in a large majority of cases the result 


of raised blood pressure in the systemic arteries, and nature 
pointed out a method of treatment in that the hsemoptysis 
itself lowered pressure and thus arrested bsemorrhage. 
Taking the lesson from nature, the use of nitrite of amyl 
acting in the same way was a rational therapeutic measure 
and the results justified its administration.—The President, 
Dr. T. Bushby, Dr. T. R. Bradshaw, and Dr. J. H. Abram 
also took part in the discussion, and Dr. Crace-Calvert 
replied. 

Dr. W. Blair Bell read a paper on Some Observations on 
the Physiological Importance of the Calcium Salts. He said 
that his observations had been made incidentally during 
the work he was at present engaged upon in reference to the 
calcium metabolism in menstruation and pregnancy, and he 
considered them of sufficient importance to bring forward 
as he himself could not carry them any further. His method 
of calcium estimation, already described, 1 had been largely 
employed In the investigation. The diurnal variations and 
the value to be attached to the blood index and the inter¬ 
pretation thereof were fully described. He discussed what 
he described as the reparative function of calcium salts and 
stated that be considered there was always a determination 
of these salts to an injured or a diseased region. He also 
thought that there was no such thing as calcareous degenera¬ 
tion per se, but rather calcification—a reparative process— 
in diseased structures. The effect which lime salts had upon 
involuntary muscles was next mentioned and Dr. Blair Bell 
alluded to the work of Ringer and others in this direction. 
He went on to describe the attempts made by himself to dis¬ 
cover the regulating factors in the calcium metabolism, and 
discussed his experiments and observations in regard to the 
thyroid, pituitary, and other ductless glands, which he con¬ 
sidered acted in association, anabolically or katabolically, in 
connexion with the lime salts. The question of calcium 
and the coagulability of the blood was discussed and be 
brought forward evidence to show that the reduction of the 
coagulability of the blood on the administration of an excess 
of lime salts was due not to an excess in tne blood but to an 
active resistance or immunity on the part of the subject, or 
increased excretion brought about probably by thyroid 
interference. The power which the leucocytes possessed 
of absorbing calcium probably in solution, and con¬ 
veying it for the processes of repair and for other 
functions, was considered and evidence was adduced 
to show the probability of this property. Lastly, Dr. 
Blair Bell described some interesting observations upon 
gelatin and the contained calcium. He illustrated the fact 
which he had discovered that if calcium is precipitated 
from gelatin it will no loDger coagulate by passing round a 
control and a specimen prepared several days before.—Sir 
James Barr said that be considered this one of the most 
important papers that he had heard for a long time. He had 
himself been using calcium in disease for many years, and 
therefore felt very grateful to Dr. Blair Bell for giving a 
more accurate method for estimating the amount of calcium 
in the blood. Hitherto they had had to go by the coagula¬ 
bility of the blood, and in such a disease as pneumonia by the 
amount of the adhesiveness of the secretion. In cases of 
pneumonia it had a very great value, especially in those cases 
in which the seoretion was liquid or haemorrhagic. Cceteris 
paribus , the more scanty and viscid the expectoration in 
pneumonia the better the prognosis ; hence in such a 
disease he had condemned the use of expectorants for 
many years. The calcium salts bad a wonderful effect 
not only in increasing the secretion but in toning up 
the vessels. The variable amount of lime salts in the blood 
at different periods of the day scarcely affected the diseased 
conditions, because in the infective process the calcium was 
thrown out of the blood into the tissues, and in such cases 
there was always a tendency to a deficiency. 81r James Barr 
also discussed the action of calcium on the blood and cir¬ 
culation.— Dr. Buchanan considered Dr. Blair Bell’s method 
of calcimetry by the use of the hsemccytometer sufficiently 
accurate for clinical purposes and that it stood on a par 
with erythrocytometry and leucocytometry in abnormal blood 
states.—Dr. F. Hick said that although the total calcium 
of the blood was not precipitated by Dr. Blair Bell's method, 
all the “ ionised ” calcium was, and that it was in this state 
that the calcium took part in such active processes as the 
clotting of blood, and the method gave a measure of the 
available calcium. Also that the calcium chloride and 
calcium lactate given by the meuth occasionally gave no 


i Brit. Med. Jour., Afril ZOtl-, 1907. 



566 The Lancet,] 


ROYAL ACADEMY OF MEDICINE IN IRELAND. 


[Feb. 22,1908. 


rise In the calcium content of tbe blood, which seemed to 
■bow that in these cases inorganic salts or tbe calcium salts 
of the simpler organic acids were not capable of absorption. 
—The President and Dr. W. Gordon Little also discussed 
the paper and Dr. Blair Bell replied. 


ROYAL ACADEMY OF MEDICINE IN 
IRELAND. 


Section ok Anatomy and Physiology. 

The Iliac Colon in Relation to Hernia.—Exhibition of 
Specimens. 

A meeting of this section was held on Jan. 24th, Pro¬ 
fessor A. Fraser being in the chair. 

Dr. R. A. Stonky read a paper on the Anatomy of the 
Iliac Colon in Relation to Hernia, which we hope to publish 
at an early date. 

Mr. Adrian Stokes exhibited a Foetus showing Trans¬ 
position of the Viscera and a Tricoelian Heart. It was 
obtained by Dr. Henry Jellett in 1896 and was described by 
him in The Lancet of March 27th, 1897, p 878. The fcelus 
was well formed and lived for a few minutes. Only the 
thoracic and abdominal cavities had then been opened, bat 
in 1907 Mr. Stokes dissected the specimen and found other 
abnormalities. The heart had a single large ventricle 
and two auricles. The left or systemic auricle had 
no direct communication with the common ventricle, its 
blood passing through a large patent foramen ovale into the 
right or pulmonary auricle in order to reach the ventricle. 
This must be an extremely rare condition. There had been 
a few cases recorded in which the pulmonary auricle did not 
communicate with the ventricle, but none, so far as Mr. 
Stokes could find, in which the systemic auricle did not do so. 
The pulmonary artery also lay behind the aorta. Professor 
A. H. Young lately described a case of a tricoelian heart in 
a man aged about 37 years. I a it tbe chambers of the heart 
were in their normal positions, but the aorta arose in front 
of tbe pulmonary artery. The condition of transposition of 
the viscera was rare. Only a few cases had been exhibited 
in Dublin, among which the best known was the one ex¬ 
hibited by Professor Fraser before the Academy of Medicine 
in 1894. 

Professor Fraser exhibited—(1) the Hemispheres of an 
Encephalon, with well marked Interruption of Both Central 
Sulci; and (2) a Duodenum of Unusual Form. 

Professor E. P. M'Lougiilin exhibited—(1) a case of 
Dorsal Origin of the Right Subclavian Artery, with asso¬ 
ciated Vascular Irregularities; and (2) a case of Unusual 
Position of the Large Intestine. 


Section op Medicine. 

Nephritis. 

A meeting of this section was held on Jan. 31st, Dr. J. M. 
Bedmond, the President, being in the chair. 

The President of tbe Academy (Dr. J. Magee Finny) 
opened a discussion on the Prognosis and Treatment 
of Nephritis, limiting his remarks entirely to those 
infi immations included in the varieties— (a) acute nephritis 
due to toxic influences or exposure to cold; (A) sub¬ 

acute or chronic parenchymatous nephritis ; and («) 
chronic interstitial nephritis. He pointed out, how 
over, that in every variety of nephritis there was more 
or less diffuse inflammation involving the glomeruli, the 
parenchyma, and the interstitial tissue. He then proceeded 
to discuss three principal features to be found in these cases : 
<l) albuminuria, (2) dropsy, and (3) the urremic syn¬ 
drome. He called attention to the harm which might 
be done to a patient’s prospects in life by rejecting 
him for insurance or for admission to a post in the 
public services on account of albuminuria, pointing out that 
the condition might be due to adolescence or might be tbe 
result of temporary weakness of the heart. The treatment 
of albuminuria by medicine was as little encouraging as the 
ate of hemostatics in the hematuria of renal inflammation. 
The indications for treatment were to place the kidneys in 
physiological rest by cutting off all protein diet, such as 
meat, soups, beef extracts, and eggs ; by feeding the patient 
at first with starvation diet when the inflammation was 
acute and the urine bloody and very scanty, and then 
allowing a very restricted diet of milk and starchy foods, 


with cream and sugar. The amount of liquid permis¬ 
sible at first mast not exceed two pints in 24 hoars, 
as the oliguria was due to renal inefficiency, and it was 
as harmful to try to produce diuresis by copious liba¬ 
tions as by diuretic medicines. As soon, however, as 
the kidneys showed recovery by secreting more urine 
it was beneficial to flush them with water, or lemon 
and water with a small quantity of cream of tartar. This 
treatment by deprivation of liquids was especially necessary 
when the oliguria was accompanied by dropsy, local or 
general. The next indication for the treatment of acnte 
nephritis was to save the kidneys by calling the bowels and 
the skin into activity. In some cases of acute nephritis 
where urtemic symptoms were at an early stage developed in 
a previously healthy and vigorous patient, it was right to 
bleed to the extent of 15 or 20 ounces from the arm or, as 
Baccelli had suggested, from the dorsal vein of the foot. In 
addition to local or general depletion the use of hot-air 
baths, hot packs, or hot baths was advisable, and in most acute 
cases of albuminuria or of dropsy this treatment alone wonld 
be followed by diuresis. The state of high tension of the 
arteries might be reduced and regulated by a systematic use 
of nitroglycerine, trinitrites, or sodium nitrite for weeks and 
months, as under their use tension was reduced and the left 
ventricle was enabled to recover from a state of dilatation to 
the normal state of hypertrophy present in cirrhosis of tbe 
kidney. 

Dr. Henry C. Earl read a paper on the Pathology of 
Nephritis. Heconfined hisattention principally to three main 
points—(1) the etiology of nephritis, (2) the classification of 
the varieties, and (3) the changes in the cardio vascular 
system —Dr. R. Travers Smith said that in nephritis 
nature had two lines of defence, namely, (l) high arterial 
tension and hypertrophy of the left ventricle, and (2) oedema. 
Looking upon oedema, as well as upon high arterial tension, 
as conservative processes, he thought that there were 
certain cases of extremely severe uraemic symptoms where 
it might be a good thing to induce cedema. He had given 
sodium chloride to a man who had been for some time in 
orsemic convulsions and coma, with the result that at the 
end of 24 hours he became markedly oedematous and made a 
good recovery from all his symptoms.—Sir John W. Moore 
said that he concurred with the view "put forward by Dr. 
Travers Smith as to the beneficial influence of cedema in 
cases of chronic renal disease, with regard to which he had 
read a paper before the British Medical Association at the 
Oxford meeting. _ 

Forfarshire Medical Association.— A meeting 
of this society was held on Jan. 15th, Dr. J. A. Dewar, Vice- 
President, being in the chair.—Dr. W. J. Dewar showed a 
boy, aged ten years, the subject of Haemophilia, who always 
bled for about three weeks after any cut ; a maternal uncle 
and a younger brother were also affected with the disease. 
He also showed a boy, aged seven years, the third of the 
family to be affected with Club foot.—Dr. J. D. Gilruth 
showed a young woman who 6even years ago had a Gastric 
Ulcer excised but who since then had periodic attacks of 
severe pain and vomiting probably caused by adhesion of the 
stomach wall to the parietes. In May, 1907, Mr. D. M. Greig 
performed an anterior gastro-enterostomy and since then the 
patient had remained free from all her former discomfort. 
—Dr. Gilruth also showed a man, aged 35 years, who had 
suffered for some years from an Ulcer of the Duodenum upon 
whom a posterior gastro enterostomy had been performed.— 
Dr. Middleton Connon showed specimens of a Salivary 
Calculus and an Unusual Foetal Monster in which could be 
seen only one foot, no legs, arms, or hands. It was a twin 
pregnancy and the first bora was a healthy well-formed live 
male child.—Mr. Greig read a paper on Ankylosis after Dis¬ 
location of the Elbow. He stated that up to recent times 
considerable doubt existed as to the true cause of such con¬ 
ditions. It had been frequently observed that after an 
ordinary simple dislocation backwards of both bones at the 
elbow considerable stiffness with very limited movement at 
the joint sometimes occurred several weeks after the dis¬ 
location had been reduced; this was generally said to 
be due to a fracture into the joint. Since the advent 
of x rays it was now possible to determine at the time 
of the accident if any fracture existed. He de¬ 
scribed and discussed two cases in detail, including the 
origin of new bone formation after these injuries such as 
bad caused the ankylosis in his second case and mentioned 
the theories that had been propounded to account for its 




The Lancet,] ABERDEEN MEDICO-OHIRURGICAL SOCIETY.—MEDICO-LEGAL SOCIETY. [Feb. 22,1908. 567 


occurrence, of which he had no doubt. Loss of resilience in 
the soft parts from the swelling associated with a tearing 
away of the periosteal attachment of the muscle in the 
efforts to reduce the dislocation had been the starting point 
of the new growth which, like callus, was derived from the 
osteoblasts of the periosteum. He discussed the treatment 
which he intended to adopt and by removing this new growth 
of bone he hoped to get a good result. He mentioned how 
careful one had to be when seeing an old injury to the elbow 
in which there was stiffness not to conclude that there had 
been a fracture when no opportunity had been given to see 
an x ray photograph of the condition before and after reduc¬ 
tion.—Dr. G. A. Pirie then gave an account of the Routine 
Use of X Ray Photography in Private Practice and exhibited 
a series of photographs showing many interesting condi¬ 
tions in bones and chest whioh bad occurred in his 

practice.-A meeting of this society was held on 

Feb. 6th, Professor A. M. Stalker being in the chair.— 
Hr. Greig showed a man after Excision of the Patella for a 
Chronic Periostitis of that bone. He had been invalided 
from the naval service as unfit, but as a result of the opera¬ 
tion he had once more a perfectly useful limb. On com¬ 
paring the legs the only visible difference was a diminution 
in the size of the quadriceps muscle. He commented 
on the rarity of the operation.—Dr. W. E. Foggie 
showed a man, aged 48 years, who had syphilis when 
28 years of age. Two and a half years ago he had 
a fall from a horse injuring his right ankle. After this 
a progressive muscular weakness set in, first in the 
right leg and passing to the left. Then the right and 
the left arms became affected and he now exhibited all 
the symptoms of progressive muscular atrophy, the unusual 
feature being the onset in the lower limbs following the acci¬ 
dent.—Dr. J. S. Y. Rogers showed a man with well-marked 
symptoms of Raynaud’s disease who had been treated for 12 
months with x rays for an ulcer in the ear said to be lupus 
but which was probably Raynaud’s gangrene.—Dr. G. F. 
Whyte showed a man with small ulcers (Raynaud’s gangrene) 
on both ears, who exhibited signs of that disease in both 
hands, the hands having been affected fer several weeks 
with coldness and stiffness before the ear conditions de¬ 
veloped.—Dr. A. J. Duncan read notes on the successful 
treatment of an obstinate case of Sciatica in a woman by 
the subcutaneous injection of air. The condition had 
existed in the left leg for four months and had resisted all 
the ordinary methods of treatment by drugs, the pain, 
which was so severe as to cause loss of sleep, only being 
relieved by morphine. The method adopted was that recom¬ 
mended by Dr. A. S. Gubb of Algiers ' Air was pumped 
into the tissues along the line of the nerve till a condition 
resembling surgical emphysema was produced. Repeated at 
intervals of three and five days, this followed by massage of 
the parts quickly resulted in a diminution of the pain. He 
quoted in further detail from Dr. Gubb's paper, in which he 
mentioned many successful cases, and thought that the 
method was worthy of a further trial.—Dr. G. T. Guild read 
notes on two cases of Cholesteatoma of the Temporal Bone. 
He said that some authorities regarded these formations as 
inflammatory products, others as tumours derived from endo¬ 
thelium, and called them endotheliomata, but Ziegler was 
of opinion that they had an origin from epidermic epithe¬ 
lium. In the ear they generally occurred during the course 
of chronic suppuration of the middle ear and were accom¬ 
panied by a foetid discharge which might be very scanty and 
apt to be overlooked. They tended to increase slowly in size 
and to cause destruction of the mastoid cells and walls of 
the antrum.—Dr. J. Rogers read notes on a case of Multiple 
Arthritis which he showed. The patient was a boy, aged 
six and a half years. He discussed the diagnosis of such 
conditions.—Dr. G. Halley described two unusual cases of 
Inguinal Hernia upon which he had operated.—Dr. Whyte 
described a case upon which he operated similar in many 
ways to one of Dr. Halley's cases. 

Aberdeen Medico-Chircrgical Society.— A 

meeting of this society was held on Feb. 6th, Dr. George 
Williamson, the President, being in the chair.—Dr. J. 
Wallace Milne described two cases of Resection of 
the Bowel for the relief of acute obstruction supervening 
in a chronic condition of partial obstruction. The first case 
was that of a girl, aged 10 years, who was admitted to the 
Aberdeen Royal Infirmary with an intussusception of six 
days’ standing. As the obstruction was not complete and 


her symptoms were not urgent Dr. Milne resolved to watch 
the case. On the seventh day after admission the patient 
developed symptoms of acute obstruction. Laparotomy was 
performed and an intussusception of the triple or telescopic 
variety was discovered. The ileum was seen disappearing 
into the caecum, carrying with it the appendix. As there 
were no adhesions, the susceptum was easily expressed from 
the ascending colon and a tight gangrenous intussusception 
of the ileum was discovered. This was resected. Upon the 
forty-fourth day after the operation the patient developed an 
empyema on the left side. This was treated by resection of 
a rib and drainage. The subsequent history of the case was 
good. The second case was that of a male, aged 48 years, 
who was suffering from symptoms of acute obstruction due 
to a malignant stricture of the descending colon. The con¬ 
dition of the patient was too bad to permit of resection 
and a short circuit of the transverse colon to the sigmoid 
flexure was therefore made by means of Murphy’s button. 
The condition of the patient rapidly improved and on 
the thirty-sixth day the tumour with six inches of the 
descending colon was resected. This patient made an un¬ 
interrupted recovery. He has gained nearly three stones in 
weight and has been able to return to work. With the excep¬ 
tion of a slight faacal fistula his general health is excellent.— 
Professor D. W. Finlay contributed particulars of a case 
of Chronic Pleuritic Effusion which after two ordinary 
tappingB, yielding respectively 66 and 47 ounces of sero¬ 
fibrinous lluid, was treated on four subsequent occasions 
after Sir James Barr’s plan of paracentesis, a solution of 
adrenalin chloride varying in quantity from one to five 
drachms (strength 1 in 1000) being injected. The quantities 
of fluid removed on these four occasions were 47, 75, 
70, and 70 ounces respectively. There was a distinct 
lengthening of the periods between the tappings after the 
use of the adrenalin, but the pleura had filled up again 
and there was thus no permanent improvement.—Mr. 
H. M. W. Gray agreed with Professor Finlay about the 
adrenalin treatment. He considered that the injection of air 
into the pleural sac tended to reduce adhesions and to favour 
expansion of the lung. He was in favour of repeated tap¬ 
pings in such chronic cases rather than resection of the ribs 
with the risk of empyema.—Dr. G. Rose in this connexion 
quoted long-standing cases of empyema where cure resulted 
only after resection of ribs.—Professor Finlay, in reply, 
described briefly two other cases which required fre¬ 
quent tapping. He was of opinion that in this case resec¬ 
tion of the ribs might be tried. He would recommend a 
tolerably free opening which might subsequently be extended. 
— Dr. T. O. Mackenzie read a paper on the Recognition 
and Treatment of Incipient Mental Disease in General and 
Hospital Practice. He commented upon the importance of 
treating mental cases in their early and incipient stages. 
These cases were not provided for under the lunacy law and 
were as a rule unprovided with hospital treatment. He 
gave an analysis of the earliest signs and symptoms in 
cases of insanity recently admitted to the Aberdeen 
Royal Asylum. Of these, headache, sleeplessness, loss of 
appetite, general feeling of unwellness, constipation, previous 
mental attack, and influenza were the most important. In 
the early recognition of cases of insanity a concurrence of 
these signs with a history of hereditary predisposition to 
insanity was of great importance. Dr. Mackenzie then dealt 
with the recent correspondence in the Seotrman concerning 
“ Wards for Incipient Mental Diseases in the Edinburgh 
Infirmary.” Personally, he thought that such wards were very 
desirable. They had been worked with success in Glasgow 
and on the continent and he thought that wards of this 
character, under the charge of a specialist, should be pro¬ 
vided in every teaching hospital. He described several cases 
which illustrated the necessity for hospital wards where 
acute and transitory cases of mental disorder could be treated 
without the patient requiring to be certified as insane, 
instancing such cases as delirium tremens, epileptic con¬ 
fusion and excitement, and some cases of puerperal fever. 
Medico-Legal Society.— A meeting of this 

society was held on Feb. 11th, Sir William J. Collins, M.P., 
ex-President, being in the chair.—Dr. L. Freyberger read a 
paper entitled “An Analysis of 74 Cases of Sudden Death 
while under the Influence of Anaesthetics.” The clinical facts 
relating to many of these cases, all of which occurred in one 
coroner's district in the last six years, were given. In each 
instance Dr. Freyberger had made a post-mortem examination 
and had given evidence before an inquest jury. In his opinion 
it was necessary to diagnose the possible presence of status 


1 Brit. Med. Jour., Nov. 9th, 1907. 





568 The Lancet,] 


NOTTINGHAM MEDICO-CHIRURGICAL SOCIETY. 


[Feb. 22, 1908. 


lymphaticns, as such patients needed special care when being 
amcjthetised.—Dr. F. W. Hewitt regarded the whole ques¬ 
tion as most pressing, for many of the deaths just previously 
narrated were preventable. The older view, that a small 
number of deaths is inevitable, was incorrect. Anaesthetics 
were not dangerous drugs unless placed in incompetent 
hands. The facts of the case should be stated plainly. The 
conditions ceased to exist as dangers when experience had 
been protitably gained with the use of these drugs. In fatal 
cases the fault did not rest with the surgeon, the patient, 
the operation, or the drug. The principle to be followed was 
that the respiratory functions were affected: the anaesthetised 
patient might suffer from an intercurrent asphyxia, especially 
in cases in which the respiration was liable to be spasmodic. 
On the post-mortem table no evidence of this spasmodic 
condition might be manifest. Much greater and more 
special attention should be given to the practice of anaes¬ 
thetics in medical schools. He doubted if sudden cardiac 
and circulatory failure was ever fatal in such circum¬ 
stances. 11 Fatty heart" was now rarely offered as the 
cause of death ; status lymphaticus might also before 
long cease to be suggested. The real cause of death 
was auto-asphyxiation which could be guarded against if 
very special care was taken by the anesthetist.—Mr. 
R. Henslowe Wellington did not think that 74 cases was 
relatively a large number in six years’ inquest practice, 
especially as several were merely coincidental with the 
amejthetisation.—Dr. Leonard E. Hill affirmed that the danger 
lay in paralysis of the heart. The vagus nerve centre was 
rendered irritable by the drug and the nerve itself was 
excited ; the failure of respiration was due to the great fall 
of the blood pressure owing to the gradual poisoning of the 
heart. The heart could not be revived after paralytic dilatation 
unless it was infused with normal blood. A mechanical con¬ 
trivance must be invented whereby a safe dose of the drug 
could be given.—Mr. John Troutbeck explained how the cases 
had come under his notice as coroner for one-eighth of the 
metropolis. Few deaths under anesthetics were reported by 
private medical practitioners, possibly because it was not 
generally known in the profession that all such cases must be 
considered by the inquest jury. The anaesthetist should be a 
person in authority and not a junior practitioner whose 
freedom was biassed by the expressions of opinion of a 
senior surgeon. Very seldom did the relatives complain in 
hospital cases. A pathologist should be instructed to 
investigate the case who was neither the ansesthetist nor 
the surgeon interested, although both the latter should be 
allowed to be present at the necropsy and to give evidence. 
He had not gained much help from the lists of questions 
which had been published from time to time as a guide in 
these cases. Each coroner after some experience learnt 
what questions it was most profitable to put.—As the dis¬ 
cussion had aroused great interest it was decided, on the 
motion of Dr. F. J. Smith, seconded by Dr. F. S. Toogood, 
to adjourn the meeting until Tuesday, March 24th, at which 
session certain medico-legal aspects of the question will be 
discussed. Mr. Justice Walton, the President, will be in the 
chair. 

Nottingham Medico-Chirorgical Society.— 

A meeting of this society was held on Feb. 5th, Dr. L. W. 
Marshall, the President, being in the chair.—Mr. R. G. 
Hogarth showed a boy, aged seven years, the subject of 
Multiple Exostoses affecting the Ribs, Phalanges, Radius and 
Ulna at the Wrist, Tibia and Femur. A complete removal 
had been made of all present four years ago, but in view of 
their painlessnesB and rapid recurrence no further operation 
was now contemplated.—Dr. F. H. Jacob showed a breast¬ 
fed child, eight months old, who was a well-marked case of 
Urticaria Pigmentosa. The rash dated from birth and pre¬ 
viously to vaccination.—Mr. W. Morley Willis and Dr. J. H. 
Thompson showed a girl, aged 15 years, in whose breast a 
painless, globular, vascular Tumour probably of sarcomatous 
nature had appeared a few weeks before. She had 
menstruated four times ; a slight enlargement of an axillary 
gland could be made out and a somewhat cystic feel was 
given by the tumour in places.—The cases were discussed by 
the President, Mr. Willis, Mr. Hogarth, Dr. J. A. 0. Briggs, 
Dr. Thompson, Dr. J. Watson, and others.—Dr. C. H. Cattle 
read a paper on Some Difficulties in the Diagnosis of 
Mediastinal Tumours. Practically these resolved themsekves 
into the question as to aneurysm or tumour, the latter in the 
vast majority of cases being of a malignant nature. Refer¬ 
ring to the case of a man, aged 58 years, who had been in 
hospital for three months nnder observation, it was remarked 


that many of the symptoms and signs usually associated 
with aneurysm might at times be due to tumour. 
Eventually, as the post-mortem specimen showed, the 
growth surrounded the heart and thoracic aorta, so 
as to exert pressure upon the left recurrent laryngeal 
nerve, the left bronchus, and the sympathetic nerves. 
There were al 60 a systolic basal murmur, an accentuated 
second sound, and increased pulsation to the left of the 
sternum, all due to the growth enveloping the aorta and 
causing shrinkage and compression of the left lung. Whilst 
in hospital this patient gained steadily in weight. Another 
Bign met with was compression of the left subclavian vein and 
enlarged superficial veins about the thorax and shoulder. 
This was distinctly in favour of tumour. A new growth 
surrounded, compressed, and invaded the veins, while an 
aneurysmal sac more frequently displaced them. On the 
other hand, alterations of the arterial circulation—e.g., in 
the radial pulse—were in favour of a diagnosis of aneurysm. 
A second case was related occurring in a man, aged 34 years, 
whose symptoms began with breathlessness and expectora¬ 
tion of blood-stained phlegm. The evening temperature 
varied between 102° and 104 = F. and often remitted as 
much as 3° in the morning. Friction-sounds were heard 
near the left nipple and in the lower axillary region. 
When admitted be was pale and wasted, short of breath, and 
unable to get about. He was hoarse and the left vocal cord 
was paralysed. There was dulness at the left apex in front 
and at the base behind. The breath sounds were weak over 
the left lung in general, but of tubular quality at the apex. 
Fain was practically absent, but there were attacks of 
spasmodic cough. The puzzling features of the case were 
the rapid wasting, marked adynamia, and the hectic tempera¬ 
ture without much expectoration. Aiter an illness lasting for 
about four months the patient died suddenly from a profuse 
haemorrhage. The clinical symptoms were thought to have 
pointed to rapidly growing sarcoma of the lung. At the 
necropsy the right lung was found greatly distended and the 
left was collapsed. A small aneurysm had compressed the 
left bronchus close to the bifurcation of the trachea, into 
which it had ruptured. The left pleural cavity contained 
three-quarters of a pint of fluid and the visceral pleura was 
thickly coated with recent fibrin. 

Manchester Medical Society.—A meeting of 

this society was held on Feb. 5th, Dr. A. T. Wilkinson, the 
President, being in the chair.—The President read a paper 
opening a discussion on Alcoholic Cirrhosis of the Liver. He 
urged that due recognition should be given to tympanites as 
a diagnostic sign of advanced disease and claimed that this 
condition was equal in significance to the classical signs 
of ascites, jaundice, hiematemesis, and cerebral symptoms. 
A typical caBe was described in illustration of this thesis. A 
tympanites of three weeks’ duration ia a well-nourished man, 
aged 36 years, who felt in his usual health, was the sole 
prominent symptom. Alcoholic cirrhosis was diagnosed and 
the patient died nine days later from coma. The diagnosis 
was confirmed by necropsy. The President drew attention 
to the neglect of this symptom of tympanites by the text¬ 
books. In most works the matter was not mentioned ; in 
others tympanites was referred to as a sign which might 
mask others, such as ascites. There was a failure to recognise 
tympanites as a prominent sign per ee. The pathology of 
acute painless tympanites in alcoholic cirrhosis was then 
discussed and the condition was attributed to back pressure 
from the portal system whereby the delicate neuro-muscular 
apparatus of the intestine was thrown out of gear. 
In speaking of the treatment of advanced hepatic cirrhosis 
the time-honoured pill of mercury, squill, and digitalis, 
of each 1 grain, was advised as the most trustworthy diuretic. 
As regards the etiology of cirrhosis the President declared 
his belief in alcohol as the causative agent to be unshaken. 
It was the steady * ‘ sober ” drinkers, not the habitually 
drunken who filled our inebriate homes, who were the victims 
of alcoholic cirrhosis. A brain sensitive to alcohol was actually 
a safeguard against alcoholic cirrhosis. Gastric catarrh did 
not, in his experience, bear any causative relation to 
cirrhosis. It was those who " stood alcohol well ” who 
suffered from this hepatic change.—Dr. E. S. Reynolds 
agreed with the President as to the different suscepti¬ 
bility of the “ drinker ” as distinguished from the 
“drunkard” to alcoholic cirrhosis. He believed hepatic 
cirrhosis to be not uncommon in children, their livers 
being specially susceptible to alcohol. Splenic enlarge¬ 
ment was inversely proportional to the amount of ascites. 
In ascites he believed tapping should be persevered with; 


Tax Lancet,] 


REVIEWS AND NOTICES OF BOOKS. 


[Feb. 22, 1908. 569 


this manoeuvre was sometimes successful if at the same time 
alcohol was prohibited.—Mr. M. J. Chevers mentioned a 
case of “hob-nail liver” in which he had reason to believe 
the patient had always been a teetotaler.—Dr. F. Craven 
Moore laid stress on the presence of dilated abdominal veins 
as a diagnostic feature. He noted the change of form which 
post-mortem examination in recent years revealed in cirrhotic 
livers. The old “ hob-nailed ” liver was now rarely seen, its 
place being taken by livers of normal size with a granular 
surface.—Dr. R. W. Marsden thought that this change of 
type might be due to the change of habits in present-day 
drinkers. 


anfc fto&es of $ook 


1 ext-bonk of Comparative General Pathology for Practitioners 
and Students of Veterinary Medicine. By Professor 
Th. Kitt of Munich. Authorised translation by Dr. 
William W. Cadbury, Assistant Demonstrator of 
Pathology in the University of Pennsylvania. Edited 
with notes and additional illustrations by Dr. Allen J. 
Smith, Professor of Pathology in the University of 
Pennsylvania. With four coloured plates and 131 illus¬ 
trations. London: Bailllbre, Tindall, and Cox. 1906. 
Pp. 471. Price 26s. 

It is a singular fact that great as the contributions 
afforded to our knowledge of the nature of pathological 
processes by the study of the natural or experimentally 
produced diseased conditions of animals have been, most 
text-books or treatises on general pathology have been 
written from the standpoint of the practitioner of human 
medicine and illustrated by reference to the lesions 
found in the human subject. The veterinary student 
and practitioner have thus been to some extent at a 
disadvantage, for although the essentials of pathological 
processes are closely similar in most mammalia the morbid 
anatomy and histology of the resulting lesions frequently 
differ in different animals in very important points. Professor 
Kitt, recognising that the education of veterinary students, 
to be rational and scientific, entails as a necessity a study of 
comparative pathology, set himself the task of writing a 
text-book on this subject with illustrations of the various 
morbid processes from the domesticated animals. We may 
at the outset say that he has succeeded in producing a 
most valuable book and one which will well repay study 
from the standpoint of human pathology. A knowledge 
of comparative pathology is of great value in the eluci¬ 
dation of some of the problems of disease in man, 
and in view of the great advances which the study of 
pathology is daily making, and of the valuable additions 
which it promises to afford to our therapeutic measures, 
is likely to become of increasing importance. Pro¬ 
fessor Kitt writes clearly and well and the translator has 
done full justice to his style, so that the book hardly conveys 
the impression of having been written in another language. 
The accounts given of pathological processes and conditions 
are concise without being sketchy and their results are care¬ 
fully classified. 

A short history of pathology with especial reference to 
veterinary pathology is given and it is pointed out that 
research in comparative pathology was completely dormant 
from the fourth to the eighteenth century. This is followed by 
a section entitled “Predisposition towards Disease,” in 
which the recent studies on the nature of immunity are 
summarised and an intelligible and intelligent account 
of Ehrlich’s theories is given. The causes of disease are 
categorically studied, among which the bacterial agents 
and the animal parasites are considered in some detail. 
Among other matters worthy of special mention is the 
section given up to the description of circulatory disturb¬ 
ances. The accounts of haemorrhage, dropsy, thrombosis, 
and embolism are as good as any that we have read. The 


note contributed by the editor on the conditions leading to 
the production of ansemic and haemorrhagic infarcts is espe¬ 
cially worthy of notice, for it is much more intelligible 
than the accounts usually found in text-books of pathology. 
The retrograde changes and necrotic processes, including 
the degenerations and infiltrations, are also dealt with at 
some length, while the descriptions given of these processes 
and the discussion of their nature are thoroughly com¬ 
mendable. 

Perhaps the best criterion for forming an opinion on a 
text-book of pathology is the account given of the process 
of inflammation and in this book the account leaves nothing 
to be desired. It is well written and clearly expressed and 
the various factors are separately studied, while the results 
and varieties of the processes are each considered in detail. 
Like most pathologists. Professor Kitt has his own definition 
of inflammation and it is a good one. Regenerative and 
reparative processes are described in detail and an interesting 
section on tumours follows. Some of the theories of tumour 
formation are given and luminously criticised. 

The book is thoroughly well illustrated, the editorial notes 
appended are in all cases explanatory of the text, and they 
are in many instances valuable additions. There are but 
few misprints, though we notice on p. 259 “ ecshare ” for 
“eschars.” We can cordially recommend this book to any¬ 
one who wishes to gain a clear knowledge of the principles 
of general pathology from a comparative point of view. 


Diseases of the Par. By Hunter F. Tod, M.D. Cantab., 
F.R.C.S. Eng., Aural Surgeon to the London Hospital, 
.to. Oxford University Press : Henry Frowde. London : 
Hodder and Stoughton. 1907. Pp. 317. 15 figures and 
18 plates. Price 5s. 

The first two chapters of this practical book are devoted 
to the diseases of the external ear and contain a short and 
useful account of the various diseases and malformations of 
the part, with their treatment. It is interesting to note 
here that the view is expressed that the old method of 
operating by means of a burr for the removal of exostoses 
through the canal Is falling into disuse as being un- 
surgical as well as dangerous. Cutting away the growth 
through the meatus by means of a gouge is one of the 
surgical procedures described. The third chapter is 
devoted to diseases of the tympanic membrane. Acute 
myringitis, apart from a traumatic lesion, is described, 
and, as Mr. Hunter Tod remarks, it is met with clinically, 
though we cannot say that we consider this sufficient 
argument for considering myringitis as a separate disease. 
The fourth chapter deals with diseases of the middle 
ear and, in common with the preceding ones, is prefaced 
by a short description of the anatomy of the part. 
In this chapter the tests for hearing are dealt with. 
There is a fairly full description of Rinnfj's teBt, with 
some directions as to its application, and after the tests have 
been discussed and their employment indicated a brief 
summary is given, and it is stated that in middle-ear deafness 
“Weber is referred to the affected side, bone conduction is 
increased, Rinnd is negative, &c., while in internal ear 
deafness bone conduction is diminished,” although this does 
not complete the summary. We think that such a state¬ 
ment should not be made without very considerable quali¬ 
fication. In describing the methods of inflation of the 
middle ear a very excellent series of reasons is given to 
show which method is preferable and in what cases. 
On p. 89, in discussing the time at which inflation of 
the middle ear may be performed, an unfortunate printer's 
error causes it to read “ 84 ” instead of 48 hours. Chapter V. 
deals with chronic middle-ear catarrh and contains a 
very admirable and short account of the disease. In 
disoussing the treatment of it a wise statement is made. 




570 The Lancet,] 


REVIEWS AND NOTICES OF BOOKS. 


[Feb. 22, 1908. 


that bougies should only be employed by experts. The 
chapter on acnte inflammation of the middle ear contains 
quite a full account of the subject. Chronic middle-ear 
suppuration, together with its complications and sequelae, is 
very fully described. The remaining chapters deal with 
diseases of the internal ear, specific diseases of the ear, 
deaf-mutism, and allied diseases of the nose and naso¬ 
pharynx, and are quite np to the standard of the rest of the 
book. 

We consider that this work is one well adapted to supply 
the needs of the stndent and as a handbook of reference 
for the general practitioner. 


LIBRARY TABLE. 

Text book of Organic Chemistry for Medical Students. By 
Dr. Cl. von Bunge, Professor of Physiological Chemistry in 
the University of Basle. Translated, with Additions, by 
R. H. Adeks Plimmer, D.Sc. Lond. London : Longmans, 
Green, and Co. 1907. Pp. 260. Price 6*. net.—Professor 
Bunge’s well-known faculty of presenting the principles and 
facts of chemistry in general, and of organic chemistry in 
particular, in a clear light has always gained for him a large 
circle of readers. Moreover, his experience in his position 
of professor of physiological chemistry in the University 
of Basle has brought him into contact with the needs of 
medical students in regard to that knowledge which is most 
useful to them in connexion with their particular study. 
There can be no doubt, as he says, that the domain of 
organic chemistry has been widened to such an enormous 
extent by the increasing labours of the last decades that 
those who devote their life to the study of organic chemistry 
can no longer be masters of the whole subject. If that be so 
it is obvious that the position of the medical student in regard 
to making a sound acquaintance with the facts and principles 
of organic chemistry grows increasingly difficult year by year. 
Y’et he is necessarily compelled to acquire some knowledge, as 
otherwise his study of physiology, pathology, and so forth 
will be beset with obstacles. The fact is that he has to pick 
out for himself those portions of the science which bear more 
intimately on his medical studies. The purpose of this 
volume, in short, is to save him the labour of consulting 
voluminous works on the subject and to bring him into 
contact with just those points which concern him most as a 
stndent of medicine. In these days of rapid ad\ances this 
crystallising process is obviously difficult, but in the 
hands of such an experienced teacher as Professor Bunge 
a groundwork at any rate is laid which is sufficient for 
the purpose in view, while of course the student if he 
should demand more can afterwards devote himself to 
more comprehensive works onj the subject. We can 
congratulate the student who starts the strictly medical 
side of his studies with such an excellent knowledge 
of principles and facts as is outlined in this readable 
treatise. He further will appreciate the fact that the trans¬ 
lator has made several additions which were introduced to 
meet the extra requirements of the English curriculum as 
compared with the German. As a companion to physiological 
and pathological study the book will be found most 
nBeful. 


JOURNALS AND MAGAZINES. 

Journal of Physiology. Edited by J. N. Langley, 
Sc.D., F.R.S. Vol. XXXVI., Nos. 4 and 5. Dec. 31st, 1907. 
London : C. F. Clay. Price 10 a.—T he following are the 
contents of the two numbers of this journal. 1. F. 8. Locke 
and O. Rosenheim : Contributions to the Physiology of the 
Isolated Heart : the Consumption of Dextrose by Mam¬ 
malian Cardiac Muscle. 2. W. M. Bsyliss : Researches on 
the Nature of Enzyme Action on the Causes of the Rise 
in Electrical Conductivity under the Action of Trypsin. 


3. Lncas Keith : On the Rate of Variation of the Exciting 
Current as a Factor in Electric Excitation. 4. J. Bancroft 
aud G. R. Mines : The Effect of Hirudin upon the Gases in 
Arterial Blood. 5. A. E. Boycott and G. C. C. Damant : A 
Note on the Quantities of Marsh Gas, Hydrogen, and Carbon 
Dioxide produced in the Alimentary Canal of Goats. 6. John 
Mellanby: The Precipitation of the Proteins of Horse Serum. 
7. Keith Lucas and G. R. Mines : Temperature and Excit¬ 
ability. 8 J. N. Langley : On the Contraction of Muscle 
Chiefly in Relation to the Presence of Receptive Substances. 
Part 1. 

The (Quarterly Journal of Microscopical Science. Edited by 
Sir E. Ray Lank ester, K.C.B., F.R.S., with the cooperation 
of Adam Sedgwick, M.A., F.R.S., Sydney J. Hickson, 

[ M.A., F.R.S., and E. A. Minchin, M.A. With lithographic 
plates and text figures. New Series, No. 205. Vol. LII., 
Part 1. London : J. and A. Churchill. Price 10s. net.—The 
contents of this part of the journal are : 1. Spirochseta (Try¬ 
panosoma) Balbiani (Certes) and Spirochajta Anodontae (Keys- 
selitz) ; their Movements, Structure, and Affinities, by H. B. 
Fantham, B.Sc. Lond.. Derby Research Scholar, University 
College, London, with three plates and 11 text figures. 2. 
The Structure and Life-History of Copromonas Subtilis, nor. 
gen. et nor. spec.; a contribution to our knowledge of the 
Flagellata, by C. Clifford Dobell, B.A., Scholar of Trinity 
College, Cambridge, with two plates and three text figures. 
3. Notes on some Parasitic Protists, by C. Clifford Dobell, 
with a plate. 4. Studies in Spicule Formation : VIII., Some 
Observations on the Scleroblastic Development of Hexa- 
clinellid and other Siliceous Sponge Spicules, by W. Wood¬ 
land, the Zoological Laboratory, King's College, London, with 
a plate. Mr. Fantham’s memoir on the spirochseta Balbiani 
and spirochseta anodontae is of great interest. It contains a 
good historical introduction. The specimens were obtained 
from English oysters, in which they occupy in particular the 
crystalline style and adjoining parts, few being found in the 
posterior part of the intestine or in the rectum. A j per 
cent, solution of methylene blue was found to be a useful 
intra ritam stain. The gut contents were fixed as quickly as 
possible and while still wet with osmic vapour. Of the 
various stains tried on fixed material the most successful 
results were obtained with alcoholic gentian violet, iron- 
alnm hsematoxylin, and other hematoxylin solutions. The 
length of the spirochmta Balbiani is from 150/x to 
50 m and it is 3/i to 2/i in breadth. It is composed of 
homogeneous protoplasm and a nucleoid composed of 
about 60 rodlets of chromatin disposed transversely along 
the body at nearly equal distances. Attached to the body of 
the animal is an organella or spirally wound membrane, 
which is longitudinally striated and executes undulating 
movements with great speed. The movement of the organism 
as a whole is in jerks and partly results from a spiral 
thrusting motion due to the membrane and partly to an 
undulatory flexion of the body due to contractions of 
myonema fibrils of the periplast. Various formB of move¬ 
ment are described. The animals live by endosmosis. A 
very carefully drawn up account of the changes observed in 
the nucleus in division is given. The drawings which accom¬ 
pany the memoir are very interesting and show how much 
may be learned of the structure of extremely minute 
organisms. Mr. Dobell’s article on Copromonas Subtilis is 
also full of interest and iB well illustrated. 

Journal of Anatomy and Physiology. Conducted by Sir 
Wm. Turner, K.C.B., Ai.ex. MacAlister, D. J. Cunning¬ 
ham, Arthur Thomson, and Arthur Keith. Vol. XLII., 
Third Series. Vol. III., Fart 2. London : Charles Griffin and 
Oo. January, 1908.—It was intended that this part should 
be the first of a journal of physiology published separately 
from a journal of anatomy but it has been found to be im¬ 
practicable to break up the well-known Journal of Anatomy 




The Lancet,] 


REVIEWS AND NOTIOES OF BOOKS. 


[Feb. 22,1908. 571 


and Physiology into these two divisions, and hence that 
journal will continue to be issued as heretofore and the 
present part constitutes the Becond part of the forty-second 
volume. The contents of this part are : 1. The Comparative 
Anatomy, Gross and Minute, of the Thyroid and Parathyroid 
Glands in Mammals and Birds, by David Forsyth, M.D. Lond. 
In this research the first-mentioned glands obtained by careful 
dissection from 77 animals were submitted to microscopical 
inspection. The thyroid gland was found to be invari¬ 
ably present in mammals. Parathyroids are found in 
most, but not in all, members of the series. When 
present their total number is two, three, or four. 2. 
A note on the Development of the Septum Transversum and 
the Liver, by Peter Thompson, M.D. Viot. 3. The Brains of 
Aboriginal Natives of Australia in the Anatomy School, 
Cambridge University, by W. H. Duckworth, M.D,, Part II., 
with 13 figures in the text, showing the sulci in different 
brains. 4. Studies in the Anatomy of the Pelvis, with 
special reference to the Fascise and Visceral Supports, by 
G. Elliot Smith, M.D., F.R.S. These studies are drawn 
from the examination of 20 adult subjects and a series of 
foetuses and children, with many illustrations. The author 
accords high praise to Delbet's, Pasteau's, and Rieffel’s 
contributions on this subject to the second edition of Poirier 
and Charpy's treatise on human anatomy. 5. An Unusual 
Daodenal Diverticulum, by Professor C. M. Jackson, M.S., 
M.D. 6. A case of Accessory Lobe of the Right Lung, by 
G. C. E. Simpson, M B., B.So. 7. Further Observations 
on the Development of the Teeth of the Australian 
Aboriginal, by W. Ramsay Smith, M.D. Edin. 8. Note on 
a Tendon found in Association with the Insertion of the 
Peroneus Longus and Origin of the First Dorsal Interosseous 
Muscles, by Lieutenant-Colonel J. C. Lamont, I.M.S. 

Revue de Psychiatric , Nos. 9, 10, and 11, 1907.—The first 
of these numbers (No. 9) contains a report of the Congress of 
Alienists and Neurologists of France and the Latin Countries 
held at Geneva and Lausanne in August of last year. Dr. 
M. G. Ballet was the rapporteur on the subject of medico¬ 
legal evidence and the question of responsibility, and 
advances the thesis that the medical witness should confine 
himself solely to the diagnosis of disease and should not 
commit himself to the extent of the responsibility of the 
person on trial. In the subsequent discussion Dr. Grasset 
said that if responsibility was a function of the mind it 
might, in disease, be diminished or abolished and that the 
medical witness was competent to decide on the extent of 
the enfeeblement of that function. In a discussion on the 
Periodic Psychoses Dr. Rfigis avowed that he regarded the 
conception of maniaco-depressive insanity as subversive of the 
well-established classifications in so far as it suppressed the 
entities of idiopathic mania and melancholia. To justify the 
exclusion of these, the partisans of the maniaco-depressive 
theory find it necessary to sustain the proposition that cases 
of mania and melancholia always relapse, but this, according 
to Dr. Rfigis, is a simple affirmation which has nothing to 
support it. Dr. Ballet denied the existence of the simple non¬ 
relapsing forms but suggested the terms “ excito-depressive ” 
or ‘ * maniaco-melancholic ” as being more appropriate than 
the present term. Dr. Schnyder, rapporteur on hysteria, 
desired to refuse to hysteria the characters of a clinical 
entity and to define it as a psychic modification in which 
there are an exaggeration and perversion of physical and 
psycho-physical reactions. -No. 10 contains an interesting 
article by M. Lucien Picqui: on Surgical Psychotherapy. 
The author divides the more severe psychoses which are 
liable to complicate surgery into those that are primary and 
undergo exacerbations with the occurrence of some bodily 
injury and those that are secondary to trauma either of some 
part of the nervous system or of some other part of the body. 
He indicates the importance of the part that psycho-thera¬ 
peutics may play in the treatment of such psychoses and of 


the various forms of hypochondriasis that are so frequently 
met with in surgical practice. This number also contains 
an account of the proceedings of the Amsterdam Congress. 
—In No. 11 Dr. Damaye gives accounts of certain cases of 
Stupor and Mental Confusion in which the iodides appear to 
have been of therapeutic value. He suggests as a possible 
explanation of the benefits which appear to be derived from 
their administration that the mononuclear leucocytosis, which 
is at least sometimes coincidental with the taking of these 
salts, acts as a means of defence on the part of the organism 
against the toxins in the circulation. 

The Liverpool Medico- Chintrgieal Journal —The January 
issue of this journal contains several papers of more than 
ordinary interest. Dr. Andrew Cassels Brown contributes an 
admirable account of the glimpses of medical matters at the 
time of the Wars of the Roses shown in the “ Paston 
Letters." We commend it and the documents upon which 
it is founded to the attention of all medical antiquarians. 
Dr. Charles J. Macalister writes on the Personal F'actor in 
Diet and points out that, although the physiologists may 
draw up ideal diet tables for the average man, actual 
individuals differ widely in their needs and idiosyncrasies as 
to food. On this ground are to be explained the theories set 
forth as to the advisability of mankind living on nuts, 
fruits, and so forth, which may suit some peculiar people. 
In the Surgical Section is a valuable article by Mr. 
F. T. Paul on his experience in abdominal surgery. The 
continuation of Mr. William Alexander's reports on Epilepsy 
presents some novel views on the treatment of this malady, 
and some interesting cases of disease of the gall-bladder are 
recorded by Mr. G. Reinhardt Anderson. 

The Dublin Journal of Medical Science .— In the January 
number appears a paper by Sir John W. Moore, entitled 

Diphtheritic Fever," in which are reported the notes of a 
series of cases of anomalous diphtherial infection without 
formation of false membrane. In most of the cases there 
was coryza with fever and the appearance of a rash, giving 
rise to a very puzzling clinical picture. Bacteriological 
examination proved the presence of somewhat attenuated 
Klebs-Liiiller bacilli. Dr. Alfred de Roulet pleads for the 
treatment of many gynaecological conditions without recourse 
to operative measures. 

The Birmingham Medical Revieiv .—Two papers on Pre¬ 
vention of Disease appear in the December number of this 
journal, the first by Mr. J. Jameson Evans on Prophylaxis in 
Ophthalmology, which deals with a large number of different 
conditions, toxic and occupational, as well as infective ; and 
the second, by Dr. John Robertson, on Prevention of Infective 
Disease. The latter writer notes the failure to prevent the 
occurrence of the commoner infections—measles, scarlet fever, 
and whooping-cough—due to the difficulty of recognising 
them at their very onset. Dr. James W. Russell records 
some cases of cerebral hemorrhage occurring in connexion 
with acute endocarditis. 

Guy’s Hospital Gazette .—The issue of this journal of 
Jan. 25th contains some remarks made by Mr. R. Clement 
Lucas on Inherited Syphilis, in opening a discussion on this 
condition at a meeting of the Society for the Study of 
Disease in Children. Dr.' H. C. Mann’s observations on 
Arterial Blood Pressure in Health and Disease are con¬ 
tinued, the present instalment being devoted to diseases of 
the heart. 

The London Hospital Gazette. The January number opens 
with a paper on Lupus Vulgaris of Mucous Membranes by 
Mr. H. Emlyn Jones, with some illustrations of the con¬ 
dition. Some Hints on Extraction of the Teeth are given by 
Mr. Frank M. Farmer. The Clinical Supplement is devoted 
to an article on Massage and Exercises in the treatment of 
surgical cases, and a short note signed “ A. K.” calls attention 
to a recently issued book by Mr. C. E. Walker on the gametoid 


572 Thu Lancet,] 


NEW INVENTIONS. 


[Ebb. 22, 1908. 


phases of cancer cells which is commended to the perusal 
of all who are interested in the stud; of malignant growths. 

Annals of Otology, Rhinology, and laryngology, September, 
1907.—This number contains ten articles, either original 
communications or papers which have been read at meetings 
of societies. The first is by Dr. C. R. Holmes, on the Etiology 
of Erysipelas and its Relation to the Nasal Cavities, and 
Destructive Effects upon the Eye. It is a long article of 
nearly 100 pages and is an interesting rttume of the subject. 
There are three papers on secondary disease of the labyrinth, 
and several others. 

Journal of Laryngology , Rhinology , and Otology. 
December, 1907.—This number contains two original 
articles, the first on 'Brack eo- Bronchoscopy. by Dr. Chevalier 
Jackson of Pittsburg, and the second, part of an article by 
Dr. H. M. Fish of Chicago, on a study of 36 consecutive 
cases of Optic Neuritis, with Nasal Accessory Sinus Disease 
present in 26. 


Stefo Jnfantifftts. 


ABDOMINAL WOUND SUTURE AND RETRACTOR 
FORCEPS. 

These consist of a pair of forceps as seen in the illustra¬ 
tion. Two pairs are used, for the right and left sides 
respectively. They have two flat blades, the lower being 
the smaller, set on a curved shoulder with long handles and 
a rack. The blades are tempered so that they meet at the 
points first and by means of the rack any pressure desirable 
may be obtained. They are designed for use in the following 
way. The abdominal wound having been made and the 
peritoneum opened to the desired extent, the lower blade, or 
smaller of the right forceps, is introduced and placed parallel 
to the incision, half an inch from 
the cut edge on the peritoneal 
surface; the forceps are then 
closed and the upper blade 
presses on the skin parallel to 
the incision and half an inch 
removed from it ; a firm grasp is 
thus taken of the one side of the 
incision. The left forceps is then 
similarly introduced and fastened. 
It is then easy for an assistant 
standing well towards the thighs 
of the patient to rotate each 
handle onward, that is to say 
away from the wound, and there¬ 
by to evert the edges of the 
abdominal wound, at the same 
time retracting it. If it be 
thought advisable to protect the 
edge of the wound in the abdo¬ 
minal wall, as in dealing with 
some focus of septic matter 
within the abdomen, this can 
be accomplished by placing a 
piece of sterile gauze round the 
edge of the wound before apply¬ 
ing the forceps, when they will 
hold it firmly in position during 
any manipulation within. When 
the wound has to be closed layer 
to layer, the assistant by a little 
pressure can approximate the 
edges of the wound with th« out surfaces everted, so that it is 
easy to pass a continuous suture along the cut surfaces of the 
peritoneum and another along aponeurosis or muscle, leaving 
the last stitch slack until the forceps are released and the 
lower smaller blades withdrawn, when the stitches may be 
drawn tant and tied together. This materially facilitates 
the closing in layers of the abdominal wound and thereby 
saves time. The forceps could also be used for bowel clamps 
and would be useful in enteranastomosis. 

These forceps have been made for me by Messrs. Reynolds 
and Branson, Limited, of Leeds. 

B. Mayhew Bone, M B., C.M. Edin., F.R C.S.Edin. 

Lancaster. 


THE MECHANICAL TREATMENT OF PULMONARY 
TUBERCULOSIS. 

We have received from the Roborat Company a specimen 
of Kuhn’s Suction Mask for the treatment of pulmonary 
tuberculosis according to Professor Bier's treatment by 
passive hypersemia. The apparatus consists of a light cellu¬ 
loid mask fitting over the mouth and nose, divided by a cross 
partition into two chambers, for mouth and nose respectively. 
In both chambers free expiration is permitted by means of 
valves, while inspiration can occur only through an adjust¬ 
able slit in the portion allotted to the nose. The margins of 
the mask are well padded by means of a rubber air tube 
which causes the minimum of pressure, and the natural nasal 
inspiration, by means of the slit just referred to, can be im¬ 
peded in a graduated manner for the desired length of time 
without discomfort to the patient. Untoward consequences 
are said not to occur. On placing the mask over the mouth 
and nose with the slit only slightly open a distinct impedi¬ 
ment to free inspiration is experienced. In this manner a 
certain amount of passive hyperremiaof the lungs is induced ; 
the circulation of the lymph stream, however, is maintained. 
This method of treatment is stated to have been tried by 
Professor von Leyden in the medical clinic of the Charite at 
Berlin with encouraging results. The following effects have 
been claimed by the use of the mask: improvement of respira¬ 
tion and diminution of dyspmea ; considerable widening of the 
thorax, reduction of the frequency of respiration, cessation 
of cough, and disappearance of expectoration, bacilli, and 
adventitious sounds in the lungs. The colonr of the patient 
improves owing to the improvement of the blood and there 
is increased appetite. Further, in consequence of the im¬ 
provement in the circulation, the respiratory musculature is 
strengthened and the heart's power is raised. We shall watch 
with interest to ascertain if these results are corroborated by 
English physicians. _ 

A NEW FORM OF URINE TRIAL GLASS. 

The accompanying illustration represents a modified form 
of urine trial glass which I have found to be a decided con¬ 
venience in the examination of the urine of patients and 
proposers for insurance. The apparatus is well adapted (1) 
by its wide mouth, to enable urination to be performed int& 
it without splashing ; (2) by its narrow calibre, to allow the 



specific gravity of a minimum amount of urine to be tested ; 
and (3) by the bottom being tapered conically, to facilitate 
the collection of the sediment. These points have been 
effectively carried out by the manufacturers, Messrs. Mayer 
and Meltzer, 71, Great I’ortland-street, London, W. 

Alountpottioger, Belfast. R. M. FRA8KR, B.A., M.B.R.U. I. 


The Society of Tropical Pathology of Paris 
has elected Dr. David N. Nabarro a corresponding member 
of the society. 






The Lancet,] 


THE SANITARY ADMINISTRATION IN INDIA. 


[Feb. 22,1908 . 573 


THE LANCET. 


LONDON: SATURDAY, FEBRUARY 22, 190S. 


The Sanitary Administration in 
India. 

We have been long accustomed to keep our readere in¬ 
formed of the progress of sanitary affairs in India and of the 
chief events in connexion with the work of the Indian 
Medical Service. The problems resulting from the considera¬ 
tion of these matters have grown greatly in importance 
during recent years, with the result that lately official 
opinion in India, and even to some extent in our own 
country, has been compelled to recognise their gravity, and 
indeed to consider them as amongst the most vital concerns 
of the administration of our great Eastern dependency. 
Truly vital are they in this, that on them hangs the 
life or death of hundreds of thousands of our fellow 
beings. Signs are not wanting that this has at last 
been driven home to the Indian bureaucracy and that 
it is setting itself seriously to work to promote the sani¬ 
tary welfare of its country, and especially to combat 
that awful soourge which for over ten years has raged 
amongst the people whose destinies are in its keeping. 
In earnest of this we publish on another page a letter 
addressed some two months ago by the Secretary to 
the Home Department of the Government of India to 
all local governments and administrations under its 
control, stating its views on the subject of Sanitary 
Reform in India and asking for their advice and co¬ 
operation in the matter. Without considering them in 
detail at present we may say that the proposed plan seems 
to us to be laid on a broad and safe basis, but many im¬ 
portant decisions must be come to before the best course is 
made manifest through a sea of conflicting perplexities. In 
calling attention to this new activity of the Indian Govern¬ 
ment it must not be considered that we think the sanitary 
administration in India has been neglected by the officers 
of the Indian Medical Service who are charged with its 
actual performance, for only recently we published a 
refutation of a shameless and anonymous calumny aimed 
against its members.' That service has a record for 
steady continuous hard work, conspicuous even in India, 
which has been served by its military and civil officials, 
working in many spheres and often under most arduous 
and disheartening conditions, with a loyal devotion of 
which any country might well be proud. But men, 
though they be as giants, cannot work miracles, and 
the task which to-day confronts the sanitary service in 
India is one with which its administration can hardly 
cope under present conditions. In support of this opinion 
the terrible plague problem comes at once to mind. We 
have dwelt on this matter often and it will be our duty to 


dwell on it, even to weariness, until by some means its 
ravages have been stayed. The last available reports received 
in this country state that from the beginning of last year 
to the end of October more than 1,100.000 deaths had 
occurred from plague in India. Plague has not left the 
country since its outbreak in 1896, and since that year has 
claimed at least 5,500,000 victims, the lowest yearly 
mortality duriDg this century having been 274,000 in 1901. 
Chiefly on this account, but partly from other causes, the 
death-rate of all India has greatly increased since that 
year. To face this task we have urged that a special 
Plague Service is essential, for it is not within the 
power of the Indian Medical Service to stem that tide 
without well-organised assistance, however courageously 
it sets about doing so. 

There are other factors which make the sanitary adminis¬ 
tration of India a ta9k of increasing difficulty. Our methods 
of rule, including the very existence of that administration, 
have greatly increased the population with whose needs it 
must cope. In former days, moreover, we had to deal 
with enormous masses of people unversed in Western know¬ 
ledge and ruled by feudal overlords whose education differed 
widely from our own. Now we have raised up a middle class 
of young Indians, highly trained in many directions, with a 
keen appreciation of modern scientific methods and with a 
growing influence on popular opinion in their country ; these 
men cannot be dictated to on matters of science as though 
they were an ignorant peasantry, and though their support 
may be of the greatest value in the sanitary reformation 
of India, yet they must be honestly convinced of the sound¬ 
ness of our methods and not coerced into accepting them. 
As will be seen in the circular letter of the Indian Govern¬ 
ment, it proposes to open up the Sanitary Service as a 
useful and suitable career for this growing class. What¬ 
ever reforms are proposed in the direction of increasing 
the service, it must be remembered that before the 
country can derive the fullest advantage from its medical 
service there are certain grievances to the removal of which 
its officers are justly entitled and to which we have from 
time to time called attention, such as the period of their 
service, the multiplicity of their duties, and the limitation 
of the emoluments which they may derive from civil 
practice. 

Being thus fully alive to the growing importance of this 
complex problem we intend to devote an increased amount of 
space to reports of Indian medical and sanitary affairs in 
future. We are enabled to do this largely by the courtesy 
of the governors, lieutenant-governors, and commissioners 
of the various provinces and the principals of the medical 
schools of the Indian Empire, who have consented to 
forward regularly to us the published reports dealing with 
these matters. Out of a very large pile of figures and facts 
we hope to present our readers with a digest which will 
fairly summarise the position of the many matters under the 
control of the Indian Medical Service, and the first of these 
articles is published in this issue. Amongst the subjects 
with which we shall deal will be the administration of 
hospitals, lunatic asylums, and gaols, the work of medical 
colleges, the progress of research in bacteriological and 
pathological laboratories, general sanitary administration, 
and the measures employed to suppress plague. We hope that 


1 The Lajjcet, Jan. 4th, 1908, p. 37. 


574 The Lancet,] 


NEW ZEALAND AND PUBLIC HEALTH. 


[Feb. 22. 1908. 


maDy of our readers will follow these articles, even though 
they have no direct interest in India, for we hold that medical 
men as a body can exercise a notable influence on public 
opinion in subjects of which they have special knowledge. 
A strong body of public influence may materially hasten 
the time when the Medical Service in India shall be 
reorganised on lines sufficient for the demands made on it 
by present conditions. 


New Zealand and Public Health, 

We have received a copy of the report of the Department 
of Public Health for the colony of New Zealand for the 
year 1906-07, dated June 1st, 1907, and, with Its appendices, 
covering 112 folio pages. A considerable amount of this 
space, of course, is occupied by matter of a kind undis- 
tinguishable from that with which we are familiar at home, 
such as the statistics of vaccination and other similar 
matters ; but even here attention cannot fail to be arrested 
by a return which shows the infantile death-rate of the 
colony to be under 70 per 1000. In this respect it is not 
uninteresting to note that illegitimate children become 
legitimatised by the subsequent marriage of the parents, 
or in any case in which a man marrying a woman 
with illegitimate children registers them after the 
marriage as his own. An Act to this effect was 
carried in 1894 and has been taken advantage of in the 
case of 849 children ; while two years later an Act was 
passed for the better protection of infant life, by which it 
was enacted that no one may take charge, for payment, of 
an infant to maintain or to nurse for more than three days 
without holding a licence as an “infant’s home keeper.” 
The house of every such person must be registered as an 
infants' home, and all these homes are periodically inspected 
by the police. The Police Commissioner reports that for 
the year ending March 31st, 1906, there were 557 of such 
registered homes in the colony, containing 862 infants, 
against 528 homes and 728 infants in the year preceding. 
21 deaths occurred in the homes during the year and four 
licensees, three of whom were convicted, were prosecuted 
for breaches of the Act ; but no licence was can¬ 
celled and no neglect on the part of licensees was 
disclosed at inquests. It is difficult, of course, and perhaps 
impassible, to institute any fair comparison in snch matters 
between the colony and the mother country ; but it must at 
least be admitted that the conditions of infant life there 
must in many respects be far better than those which exist 
at home. To take one of these respects only, we read that 
“there has been no epidemic of any serious nature during 
the past year.” MeasleB and scarlet fever have occurred in 
certain districts, but the cases have been limited in number 
and the deaths few Vaccination is being largely neglected, 
over 81 per cent, of the children born during the year under 
consideration being still unprotected ; but the neglect is 
attributed chiefly to an indifference arising from ignorance 
of the nature of small-pox. When that disease appeared 
in Christchurch in 1904 11,120 people were voluntarily 
vaccinated in three months ; and the chief health officer. 
Dr. J. M. Mason, seems to be of opinion that any 
manifest danger of a small pox outbreak would again 
ocoasion a rush for protection. In the meanwhile, one of 


the most pressing dangers to public health appears to arise 
from the prevalence of hydatids, and special injunctions 
concerning the precautions to be taken in keeping and 
feeding dogs occupy a prominent place in the report. 

The most remarkable feature of the document, however, 
and one which might profitably receive careful considera¬ 
tion from the legislatures of older countries, is the history 
of a campaign against certain forms of dishonesty and of 
quackery which haB been set on foot by the agency of what 
is described as a" modest and unassuming amendment ’’ to 
the Postal Act. By this amendment the Postmaster-General 
of the colony is empowered to issue under his hand an 
order forbidding the registration, forwarding, or delivery 
of any letter or postal packet to any specified address, 
or the issue of any money order to the same address, 
he having reason to believe that the correspondence thus 
estopped is part of a system of betting, gambling, pro¬ 
fessed prediction of future events, of any “fraudulent, 
obscene, immoral, or unlawful business or undertaking,” or 
of any “advertising in direct or indirect terms the treat¬ 
ment of diseases of the sexual organs.” In commenting 
upon this amendment of the law and upon its effects the 
chief health officer points out that “ most of the vultures 
who fattened on the fears of the misguided youth or the 
simplicity of the elderly man about town have, so to speak, 
been warned off the course.” They have, he says, used in 
defence such weapons as might have been expected. News¬ 
papers have been threatened with loss of revenue, the cry 
of medical oppression has been raised, and some have 
attempted bribery, but, in spite of all, he is pleased to place 
on record that every paper of standing in the colony has not 
only gladly agreed to accept the Postmaster-General’s ruling 
but has endeavoured in every possible way to throw out 
advertisements which were demonstrated to be proclaiming 
wares or services which were not in the best interests of the 
State. “I have no hesitation,” he continues, “in saying 
that in no part of the world could a cleaner advertisement 
page be found than in New Zealand.” Many of the operators 
have left the colony and the reasons assigned for their 
departure are curious and varied. One, because his New 
Zealand clients have become numerous, has determined to 
transfer his operations to Sydney, and on account of the 
greatness of his reputation he asks his New Zealand patients 
to send their letters to another address and inscribed to 
another name, “ No one,” writes the chief health officer, 
“ is foolish enough to believe that quackery and fraud can be 
stopped entirely, but the inclusion of this section of the Post 
Office Act Amendment amongst our laws has satisfied me 
that much can be done.” 


The Supply of Pure Milk to 
Hospitals. 

The question of the supply of pure milk to the London 
hospitals has during the last year been engaging very 
seriously the attention of the bodies responsible for their 
administration. Our readers may remember a report which 
appeared in our issue of May 11th, 1907, p. 1311, of a 
conference of the United Children’s Hospitals of London 
which dealt with this important matter, and we have now 
received from the Central Hospital Council for London the 




The, Lancet,] 


THE SUPPLY OF PURE MILK TO HOSPITALS. 


[Feb. 22,1908. 575 


report of a committee appointed by the Council in last Jnly 
to consider a reference in the following terms—namely, 
“ Whether the London hospitals should be advised to take 
joint action with a view to insuring the purity of their milk- 
supply. ” The committee has had the advantage of very 
expert evidence in its deliberations, as it consulted several 
large distributors of milk on the one hand and medical 
officers of health and analysts on the other. It finds that the 
practice at present prevailing in 12 hospitals is to require from 
the milk contractors certain percentages of total solids and 
fat in the milk supplied; one hospital has no form of milk 
tender at all, whilst eight, in addition to the percentages, 
require the notification of the farms of supply and also the 
periodical certification of the health of the cows from which 
their milk is derived. The committee recommends the 
constituent hospitals of the council, which represents all 
the larger London hospitals, to require their respective 
contractors to agree to the following conditions which it is 
advised are fair and reasonable :— 

1. That the milk afaall be pure, genuine, with all its cream aa yielded 
by the cow, absolutely free from any and every kind of adulteration 
(including preservatives), and shall be of such quality as will, between 
the months of August and January, both Inclusive, produce at least 
3'5 per cent, of butter fat, and for the remainder of the year 3 25 per 
cent, of butter fat. 

2. That the miik shall be supplied from a farm or farms whose 
name or names and locality are to be notified by the contractor to 
the hospital. 

3. That It shall be permissible for an authorised representative of the 
hospital to visit and inspect such farm or farms and the herds there at 
any reasonable times. 

4. That the cows supplying the milk shall be In a good state of 
health and that the contractor shall give the hospital s certificate by a 
veterinary surgeon to that effect in the annexed form* without coat to 
the hospital in the first Instance, and shall give subsequent certificates 
whenever required by the hospital at the hospital’s expense. 

5. That the milk shall be strained and cooled to the temperature of 
cold water, not exceeding 60 degrees, at the farm, arid there canned 
and sealed with a die to be supplied by the hospital, and that all cans 
shall be dust and rain-proof. 

6. That the contractors shall guarantee the cleanliness of the milking 
operation and of the men’s hands and of all receptacles into which the 
milk is put. all of which receptacles shall be properly cleansed with a 
solution of boiling water and soda. 

7. That the cans shall not be opened in transit except at the London 
railway station by the public sanitary inspectors and it so opened shall 
be immediately re-sealed for delivery to the hospital and shall in 
every case be delivered direct from the London railway station to the 
hospital. 

8. That the milk shall not be pasteurised or treated otherwise than 
as mentioned in Clause 5 without tho written sanction of the hospital 
authorities. 

The percentage of butter fat insisted on is rather above the 
average amount found in London milk and even above that 
yielded by many cows, but it must be remembered that for 
most of the children in the hospitals and for many of the 
acutely ill, especially in such cases as those affected with 
enteric fever, milk forms the staple of the diet, and therefore 
milk of quality above the average is not unreasonable. 
The last section of the report recommends certain precau¬ 
tions outside the contracts to be observed by the hospitals, 
the chief of which is the securing of the cooperation of the 
medical officers of health of the districts in which the farms 
are situated in supplying reports of their sanitation and the 
freedom from infectious disease of their employees. It 
advises at least one weekly analysis of the milk, made on 
irregular days, and suggests the joint employment by a 
gronp of hospitals of an inspector to visit the farms. It is 
further suggested that the contracts should be framed with 


* This paper contains a form for the veterinary surgeon's report on 
the cows, an undertaking to be signed by the contractor not to supply 
milk from any animat found to be diseased, and on the back a blank 
form for the description of the disease of such animals and of their 
treatment. 


a summer and winter price for the milk instead of with an 
average all the year round price. The committee is of 
opinion that in view of the serious interests involved the 
risk of a slight increase in price which these more strict 
conditions will entail may be justifiably incurred, and with 
this opinion we are in complete concord. The committee has 
been well advised to make its conditions such that any 
well-equipped farm can reasonably comply with them. The 
aim in the imposing of the above conditions has been to 
insure not merely the delivery of milk of a high quality as 
regards the percentage of its important constitnects but 
also the absence of harmful substances, whether accidentally 
present or added with a view of preventing decomposition. 
It will be noticed that no bacteriological test is suggested ; 
the reason for this omission is that the committee reco¬ 
gnised the difficulty of applying any such test ; the avoid¬ 
ance of the presence of harmful micro-organisms must be 
insured, not by occasionally looking for them in the milk 
but by the maintenance of hygienic conditions in the 
farms whence the milk comes and amongst those engaged 
in the milking. 

It is, however, not enough to lay down elaborate condi¬ 
tions under which the milk is to be produced and de¬ 
livered ; it is essential that by inspection the maintenance 
of these conditions should be assured. One of the con¬ 
stituent hospitals has for several years required that the 
farms whence its milk comes shall be liable to inspection 
by a representative from tbe hospital, but on no single 
occasion has any farm been visited. It is very harmful to 
lay down stringent conditions without taking care that 
these conditions are maintained, and it may well be that 
worse milk is supplied than if no conditions had 
been imposed, for the more conscientious milk pro¬ 
viders will gradually be shut out and will cease to 
tender. For if a milk provider knows that the conditions 
will never be enforced, and if he be not perfectly scrupulous 
he will be able to underbid those who fully intend to carry 
out the letter of their tenders, and therefore the milk 
supplied will be worse than the conditions imply. It is of 
the first importance, therefore, that any condition inserted 
in a tender should be enforced by the hospital authorities 
and this requires not only that the milk supplied should 
be periodically tested at the hospital but also that 
the farms, the cows, and the personnel of the farms 
should be periodically inspected. An individual hos¬ 
pital could not afford to employ regularly an in¬ 
spector, but if all the hospitals in London were to 
combine the cost of inspection need not be great. 
The visits must be fairly frequent and at irregular intervals 
if they are to be really useful. It is possible that the 
Central Hospital Council might serve to organise such an 
inspection. The quantity of milk consumed by the hospitals 
in London must be so enormous that they should be able 
to carry out great reforms in the methods of production and 
supply of milk, and indirectly to improve the quality of the 
milk obtained by London. 

Weston-super-Mare Hospital.— On Jan. 21st 

a ward containing a single bed wsb formally opened at this 
hospital by the Rev. Prebendary Salis in the presence of a 
large gathering. The ward is called the “ Poole Ward,’’ as 
the late Mr. E. Poole bequeathed £1200 to endow the bed. 




576 The Lancet, 1 


A WARNING TO PRACTITIONERS.—OFFICIAL ILLNESSES. 


[Feb. 22, 1908. 


Jmtfffata. 


" No quid nlmli.” 


A WARNING TO PRACTITIONERS. 

The Registrar of the General Medical Council has addressed 
a circular letter in the following terms to the licensing 
bodies, teaching institutions, hospitals, infirmaries, and 
asylumB in the United Kingdom, some 1500 in all:— 

It is very desirable that practitioners should not lose the privileges 
attaching to registration owing to their names ceasing to appear iu the 
Medical Register. It has been found, however, that many practitioners, 
not fully appreciating this, especially within a short time of qualifying 
and registering, fail to give to this office from time to time an address 
at which official communications wilt reach them and they thus incur 
the risk oi their names not being retained on the Register. In the 
interests, therefore, of the practitioners themselves the inclosed notice 
has been drawn up and I shall be greatly obliged if you will cause it to 
be displayed in a prominent place in your institution so that it may be 
brought to the attention oi registered practitioners. 

Yours faithfully, 

H. E. Allen, Registrar. 

The “enclosed notice ” is a glazed card on which are printed 
the provisions of the Medical Act which enjoin regiotration 
on practitioners and rehearse the disabilities to which the 
disappearance of a name from the Medical Register renders its 
owner liable. All that is necessary for anyone to remember 
is to notify the registrar at the branch where registration 
was effected originally whenever a move is made which will 
be more than temporary. The chief offenders against this 
rule are probably young practitioners engaged in a series of 
resident hospital appointments. It is surely not much 
trouble to send a post-card when a change of appointment is 
made. 


OFFICIAL ILLNESSES. 

Legislation has of late been busy with various forms of 
sickness or disease, when, that is to say, they affect 
employees. We are also promised a new and drastic Educa¬ 
tion Bill, but whether it will deal with the sicknesses to 
which teachers are liable is, of course, not yet known. The 
custom nowadays is to make it compulsory for the ratepayers 
to put their hands in their pockets for most expenses in 
education, and even where endowed schools exist there is a 
tendency “to improve" them out of existence. Oar pious 
forefathers not only endowed schools for secular education 
but also provided for the teaching of religion, and, more¬ 
over, acting after that charity which the Apostle declared 
was the greatest of the three Christian virtues, made 
provision for the sickness of the teachers, or at least 
of one of them. Thus, we find in the statutes of 
“The School of St. Paul,” founded by Colet in 1509, 
the following regulations as regards the Surmaister who 
was not, be it noted, the head or high master. “In seke- 
nesse curable, as axis, 1 or suyeh other sekenesse for a time 
he shall be tollerated and have his full wagis.” But the 
most remarkable statute is the following which shows a 
large-mindedness such as we doubt any educational authority 
would show now. “ Yf after his commynge he fall sick 
into sickenes incurable, as Lepry, or Frenche Poxe, or after 
his long labour in the Soole fall into age ympotent, thenne 
I commit him to the charite of The Mercers, they of the 
cofer of the Scole to provide him a lyving as it may be 
possible, praying them to be charitable in that behalfe.” 
Colet doubtless had a fellow feeling for those who were ill. 
The statutes for his school received their final shape in 1518 
and in that same year he had his third attack of sweating 
sickness, of which there had been a severe epidemic in 1517. 
But it would be interesting to know why the “ Surmaister ” 
was allowed so much latitude in his ailments. 

1 Explained os being the febris accessus ot Pliny, or ague. 


A ROYAL COMMISSION ON WHISKY. 

We note with satisfaction that a Royal Commission has 
been appointed to make inquiry upon the whisky question. 
The personnel is a strong one and includes the names of 
Lord James of Hereford (chairman); Mr. Laurence N. 
Guillemard, deputy chairman of the Board of Inland 
Revenue; Mr. Walter Adeney, D.Sc., F.C.S., of the Royal 
University of Ireland ; Mr. J. Rose Bradford, M.D., D.Sc., 
F.R.8.; Mr. Horace T. Brown, LL.D., F.R.S. ; Mr. George 
S. Buchanan, M. D., medical inspector and inspector of foods 
to the Local Government Board ; Mr. John Y. Buchanan, 
F.R.S.; and Mr. Arthur R. CushDy, M.D., F.R.S. The 
terms of reference are :— 

1. Whether, in the general interest of the consumer or in the 
interest of the public health or otherwise, it is desirable (a) To place 
restrictions upon the materials or the processes which may be used iu 
the manufacture or preparation in the United Kingdom of Scotch 
whisky, Irish whisky, or any spirit to which the term whisky may he 
applied as a trade description ; (fo) to require declarations to be made 
as to the materials, processes of manufacture, or preparation or age of 
any such spirit; (c) to require a minimum period during which any 
such spirit should be matured in bond ; and (rt) to extend any require¬ 
ments of the kind mentioned in tfie two sub-divisions immediately pre¬ 
ceding to any such spirit imported Into the United Kingdom. 

2. By what means, if it be found desirable that any such restrictions, 
declarations, or period should be prescribed, a uniform practice in this 
respect maybe satisfactorily secured. Andtomake the like inquiry 
and report as regards other kinds oi potable spiritB which are manu¬ 
factured iu or Imported into the United Kingdom. 


THE OFFER OF A RECEPTION HOSPITAL FOR 
ACUTE MENTAL DISEASES IN LONDON. 

Dr. Henry Maudsley has made the munificent offer of 
£30,000 to the London County Council to provide a hospital 
the main objects of which shall be, in his own words : 
“(1) The early treatment of cases of acute [mental disorder, 
with the view, as far as possible, to prevent the necessity 
of sending them to the county asylums; (2) to promote 
exact scientific research into the causes and pathology 
of insanity, with the hope that mnch may yet be done 
for its prevention and successful treatment; and (3) to 
serve as an educational institution in which medical 
students might obtain good clinical instruction.” The 
letter containing the offer was read at the meeting of the 
council on Feb. 18th, the soheme having already been 
before the asylums, the finance, and the general purposes 
committees. The council passed a unanimous vote of thanks 
to Dr. Maudsley for his offer. 


THE GERMICIDAL EFFICIENCY OF LIQUOR 
CRESOLIS COMPOSITUS. 

A correspondent writes: “ In Th e Lancet of August 24th, 
1907, p. 544, it was shown that the liquor cresolis compositus of 
the United States l’harmacopoeia was a more efficient germicide 
than carbolic acid. Another formula for this preparation is 
given in the German Pharmacopoeia differing from the former 
in containing alcohol. Both contain 50 per cent, by weight 
of cresol or cresylic acid. The alcoholic preparation has been 
examined bacteriologically with favourable results by Mr. 
Ernest Quant. 1 Mr. Quant, adopting the Rideal-Walker 
method, determined the value of the preparation in terms of 
carbolic acid. In the case of bacillus typhosus he found 
that in a solution of 1 in 400 the cresol solution was equal 
in germicidal power to a 1 per cent, solution of pure carbolic 
acid. Further experiments were conducted with a 2 per 
cent, solution of the cresol solution to ascertain what length 
of time would be required for the destruction of active 
strains of typhoid and diphtheria bacilli. A series of ex¬ 
posures lasting from one to ten minutes, was made and 
in every instance the bacilli were killed, thus demonstrating 
that these organisms may be destroyed by exposure for 
one minute to a 2 per cent, solution of liquor cresolis com- 

posituB.” __ 

1 Pharmaceutical Journal, Dec. 14th, 1907, p. 77S. 



The Lancet,] 


SUNSHINE AND RAINFALL DURING 1907—WHAT IS VINEGAR? [Feb. 22, 1908. 577 


SUNSHINE AND RAINFALL DURING 1907. 


- 


Total 

number of 
hours 
sunshine. 

Difference 

from 

average. 

5 

a 

s,i 

Q 

< 

3 

o 

H 

Difference 

from 

average. 

East Coast (England). 




Ins. 

Ins. 

Scarborough. 


1488 


179 

22-7 

-4*6 

Whitby. 


1551 


150 

22-0 

-3*7 

Hull. 


961 

* 

195 

24-8 

-10 

Skegness. 


1739 

* 

201 

21 -8 


Cromer . 


1667 


213 

22*0 

• 

Lowestoft . 


1719 

* 

172 

21-4 

-2*3 

Felixstowe . 


1726 

* 

154 

20-3 

• 

Clacton. 

South Coast (England). 

1729 


150 

16 7 

* 

Margate. 


1628 

+ 88 

171 

20-4 

-2*8 

Broadstairj . 


1799 


171 

227 

» 

Ramsgate . 


1786 

• 



* 

Folkestone . 


1783 


155 

19*2 

-3-8 

Hastings . 


1803 

+ 20 

177 

23*3 

-5*8 

Eastbourne . 


1848 

+ 109 

177 

26*4 

-4 5 

Brighton . 


1691 

- 40 

165 

20 6 

-7 0 

Worthing . 


1781 


158 

21 8 

-5 2 

Bognor . 


1809 

*■ 

193 

238 

» 

Bournemouth . 


1790 


18-3 

31*0 

* 

Southampton . 


1709 

+ 44 

182 

30*8 

-0*1 

Totland Bay. 


1706 

* 

163 

25-8 

-23 

\ entnor. 


1736 

+ 13 

178 

24 2 

-5 4 

Torquay. 


1739 

+ 8 

201 

33*2 

-10 

Plymouth . 


1665 

+ 5 

226 

36*3 

+0 4 

Falmouth . 


1563 

-203 

220 

45-1 

-0*3 

Guernsey . 


1860 

- 46 

192 

34*0 

-3 6 

Jersey . 


1839 

- 88 

201 

28*6 

-56 

Scilly . 

West Coast (England and 

1588 

-223 

211 

29-3 


Wales). 







Newquay . 


1660 

- 27 

211 

30*9 

— 4*1 

Tenby . 


1643 

- 43 




Pembroke . 


1574 

- 68 

223 

37*2 

+2 1 

Aberystwyth . 


1368 


_ 



Aberdovey . 


1458 


221 

41 0 

* 

Llandudno . 


1640 

4- 84 

203 

26 3 

-4*5 

Rhyl. 


1640 


211 

24 2 

-18 

Hoylake. 


1493 


208 

26‘3 


Southport . 


1474 

+ 8 

206 

32 6 

-0 3 

Blackpool .. 


1520 

+m 

217 

33 3 

-0-5 

Carnforth . 


1368 


209 

430 

• 

Douglas, Isle of Man... 


1514 

- 86 

214 

44 0 

+1*7 

Places Inland. 







Durham. 


1333 

+ 16 

187 

24 8 

-2*4 

Newcastle . 

... 

1022 

- 44 

183 

25-2 

-2*2 

York. 


1265 

- 11 

211 

25 6 

+ 0*3 

H udders field. 


1068 


231 

35 5 

» 

Bel voir Castle . 

... 

1545 


227 

25*8 

+0 4 

Sheffield. 

... 

1428 

* 

208 

31*6 

-10 

Aspatria. 

... 

1379 


211 

43 0 

+4 0 

Stonyhurat . 

... 

1181 

-175 

220 

50*0 

+3*2 

Frestwich . 


1137 

+ 3 

223 

404 

+3 4 

Manchester City. 


894 


224 

33*9 

-1*3 

Birmingham. 

... 

1105 


173 

2c 9 

+ 1'5 

Nottingham. 

... 

1260 


197 

23 5 

-13 

Cirencester . 

... 

1575 

+ 67 

175 

289 

-1*8 

Harrogate . 

... 

1354 


220 

341 

+ 4 6 

Cheltenham. 

... 

1602 


174 

29*0 

+ 1 4 

Bath. 


1674 

* 

187 

32*3 

+ 1*8 

Tunbridge Wells. 


1635 

+ 47 

179 

28*6 

-10 

Llangammarch Wells 

... 

1278 

» 

236 

48 9 

# 

Bettws-y-Coed .. 

... 

1282 


227 

45 9 

» 

Oxford . 

... 

1521 

+ -3 

176 

26*9 

+ 1 9 

Cambridge . 

... 

1484 

- 76 

169 

21 2 

-1*5 

liothamsted. 


1556 

+ 23 

210 

25*3 

-2 6 

Marlborough. 

London District. 

*•* 

1354 

- 42 

223 

29*3 

-2*6 

Westminster . 


1234 

+ 90 

162 

19 5 

-4*9 

Bunhili How, B.C. ... 


1183 

+ 43 




Greenwich . 

... 

1417 

- 85 

163 

22 3 

-1*8 

Tottenham . 


1424 

* 

149 

23 8 


Norwood, S.E. 


— 

» 

183 

23*0 

-1-9 

Kew. 

... 

1463 

- 4 

182 

23 8 

-02 

Scotland. 







Edinburgh . 


1178 

+ 22 

tl97 

30 7 

+ 70 

Strathpeffer. 


1191 


216 

29 0 

-3 2 

Fort Augustus . 


957 

+ 68 

228 | 

42*0 

- 2'6 

Glasgow. 


1012 

- 83 

204 ! 

42 6 

+3 9 

Nairn . 


1368 


233 

28 7 

+4*0 

Aberdeen . 

Ireland. 


14C0 

- 1 

217 

1 

28 7 

-2*0 

Dublin, Trinity College 


1215 

* 

195 

25*7 

# 

Birr Caatle .. 

... 

1245 

-105 

250 

33 9 

+0*9 

Armagh. 

... 

1233 

- 57 

237 

31*6 

-0 S 

Markree.. 


1211 

- 46 

259 

45 2 

+3*2 

\ alencia I. .. 

... 

1333 

-124 

268 

50*8 

-57 


* No trustworthy overage. t Thl« rainfall Is for Leith. 


The figures above represent the number of hoars of bright 
sunshine, the number of days with rain (at least 0 1 01 inch), 
and the aggregate fall for 1907. All the figures have been 
published by the Meteorological Office and the sunshine 
values have been obtained by the burning recorder known as 
the Campbell-Stokes instrument. Along the east coast the 
sunniest spot was Skegness with 1739 hours, followed closely 
by Clacton-on-Sea, Felixstowe, and Lowestoft; and on the 
south coast the brightest reBort was Eastbourne, with an 
aggregate of 1848 hom-s. This resort was, with the excep¬ 
tion of Guernsey, the sunniest place in the Kingdom, although 
Jersey, Bognor, and Hastings were not far behind. In the 
south west of England none of the resorts equalled Torquay 
with its total of 1739 hours, while in the north-west the 
brightest place was Rhyl with 1640 hours. Among the 
inland localities the brightest was Bath, with 1674 sunny 
hours, followed by Tunbridge Wells with 1635 hours, while the 
dullest was Manchester, with no more than 894 hours. In 
the metropolitan district Kew received about three-quarters 
of an hour per day more sunshine than the City, but the City 
station, Bnnhill-row, had more than three quarters of an hour 
per day more than Manchester. The mean daily difference 
between the City and Eastbourne was nearly two hours, 
while the mean difference between the two extremes, East¬ 
bourne and Manchester, exceeded two and a half hours per 
day. It will be seen that most places in the south-west, 
and also those in Ireland, had less sunshine than usual, and 
that the greatest plus differences from the average were at 
Blackpool and Eastbourne. Referring to the rainfall it will 
be observed that Clacton-on-Sea was the driest place, with 
less than 17 inches of rain, and that inland the driest place 
warn Westminster, where the total was 19 5 inches. Over 
the country as a whole the rainfall was almost identical with 
the normal, but most places in the south and east were drier 
than during an average year. 

WHAT IS VINEGAR ? 

Some interesting information on the preparation and sale 
of vinegar in relation to the administration of the Sale of 
Food and Drugs Acts is contained in a recently issued report 
to the Local Government Board by Dr. J. M. Hamill. It 
appears that various questions relating to alleged adul¬ 
teration and misdescription of vinegar have been 
brought to the notice of the Board from time to 
time by vinegar manufacturers, public analysts, and 
others. Dr. Hamill in the coarse of his inquiry has 
visited the works of somo 20 important firms of vinegar 
makers in London and the provinces and also those of smaller 
manufacturers of different kinds of vinegar. He has also 
gained information from public analysts, chemical advisers 
of vinegar brewers, acetic acid importers, and others. The 
view of many vinegar makers and public analysts is that 
a set of official definitions is demanded, and the following 
suggestions are made: 1. That vinegar or brewed vinegar 
should be a product obtained wholly by the alcoholic 
and subsequent acetous fermentation of a saccharine fluid 
obtained from malted barley, unmalted cereals, grain, or 
Bugar, and should contain not less than 4 per cent, of acetic 
acid (in malt vinegar, in addition, the saccharine fluid 
should be obtained either wholly from barley malt or 
from a mixture of malted and unmalted barley, together 
with such proportions of additional substances as may 
from time to time be permitted by official regulation). 
2. That artificial vinegar should be any vinegar or 
substitute for vinegar containing any added acetic 
acid which is not wholly the product of alcoholic 
and subsequent acetous fermentation and should contain 
not less than 4 per cent, of acetic acid. 3. That 
distilled vinegar and distilled artificial vinegar should be 
respectively the products of distillation of vinegar and 
artificial vinegar and contain not less than 4 per cent. 












578 Thb Lanobt,] A CASE OF PAPILLOMA OF THE TRACHEA.—THE REEK OF THE CIGAR. [Fbb. 28, 1908. 


of acetic acid. 4. That spirit vinegar should be vinegar 
obtained wholly by acetons fermentation of a dilate alcoholic 
liquor which has been obtained by distillation and contains 
not less than 4 per cent, of acetic acid. Similar definitions 
are suggested for wine vinegar, cider vinegar, and fancy 
vinegars. It is further suggested that a system of super¬ 
vision over the vinegar factories should be organised, a 
system which would be welcomed by many vinegar makers 
as a necessary part of any proposal to require the nature of 
different vinegars to be stated to the public in terms which 
conform to prescribed definitions. 


A CASE OF PAPILLOMA OF THE TRACHEA. 

Although the trachea may be involved by growths in 
organs adjacent to it, such as malignant tumours of the 
oesophagus or of the thyroid body, primary growths of the 
trachea are of great rarity. Dr. M. Zondek of Berlin 
records an interesting case in the Berliner Klinische 
Wockenschrift of Feb. 3rd. The patient was a woman, 
aged 28 years, who for three years had suffered at intervals 
from soreness of the throat, cough, and difficulty in breathing, 
usually as a result of catarrhal attacks, to which she was 
very liable owing to her home being in a cold, damp, marshy 
district. She never complained of hoarseness at any time. 
About 15 months before admission to the Jewish Hospital 
in Berlin she began to suffer from persistent dyspnoea 
which gradually increased until she eventually had a 
severe asphyxial attack which lasted for some minutes 
and was only relieved after the expectoration of a 
considerable quantity of muco-purulent sputum. On 
admission the patient was pale, with cyanosed lips, 
and was breathing rapidly with marked inspiratory stridor. 
The muscles of the aim nasi and of the neck were strongly 
contracted during inspiration but the larynx only moved 
slightly. The head was held forward and the chin was 
thrown upwards. The voice was clear and natural but speech 
was slow and interrupted. This position of the head and this 
manner of speaking both dated from childhood. On 
palpation of the trachea it was found to bulge forward 
slightly on the right side. The thyroid was not enlarged ; 
there were no glandular enlargement and no difficulty in 
swallowing. The pupils were equal and reacted normally. 
On laryngoscopic examination a tumour with a rough surface 
was seen on the anterior wall of the trachea, on the right 
side just below the vocal cords which appeared to be 
natural. The tumour appeared to reach so far into the 
lumen of the larynx that only a small chink was seen 
between it and the left vocal cord; it did not, however, 
extend beyond the middle line and did not move either on 
respiration or phonation. There were no signs of syphilis 
or of tuberculosis. An endo-laryngeal operation was out of 
the question, so tracheotomy was performed. The thyroid 
body was pushed downwards. A large quantity of purulent 
material escaped from the tracheotomy wound which was 
then prolonged upwards to the cricoid cartilage. The tumour 
when exposed was found to be of the size of a walnut and 
its base of attachment was about the size of a sixpence, its 
upper margin being a thumb’s breadth below the vocal cord. 
The consistence was soft and there was no infiltration of the 
surrounding mucous membrane. It was removed by means 
of a sharp spoon, together with a small part of the adjacent 
mucous membrane. There was very little bleeding. Re¬ 
covery was rapid and uneventful. On microscopical examina¬ 
tion the tumour proved to be a papilloma. About five 
months later the patient returned to the hospital and at the 
site of the operation a tumour of the size of a bean had 
appeared. This was removed, together with some mucous 
membrane, by Professor Israel after tracheo-cricotomy. 
About three years later the patient again suffered from 
the same symptoms at her home and died under amesthesia 


during an operation. The interest of the case lies in its 
rarity and in the characteristic nature of the symptoms, 
demonstrating an obstructive condition of the main air 
passage not involving the cords. Owing to the peculiar 
carriage of the head and the interrupted speech Dr. Zondek 
is of opinion that the tumour originated in childhood. The 
condition is thus comparable to the laryngeal papillomata 
which occur in children. 


THE REEK OF THE CIGAR. 

Smoking nowadays is commonly tolerated in the house, 
and even in the drawing-room a cigarette is sometimes 
permitted. The smoking of a cigar, pleasant though it 
may be to the smoker, and however irreproachable its 
quality, is banned by most careful housewives in their sancta 
tanotorum because its reek is so persistent. The stale 
smell of cigar smoke in a room is peculiarly unpleasant 
and peculiarly difficult to get rid of. It clings to the cur¬ 
tains and to most of the articles of furniture which 
present any sort of an absorbent surface. It is not 
so to the same extent with cigarettes or with pipes. 
In the case even of a single cigar books, papers, 
and textiles reek of its stale flavour and the room 
requires abundant airing before that flavour is com¬ 
pletely eliminated. Air is an excellent scavenger but 
ozone is more active in removing the smell. The effect 
may be traced to the fact that the smoking of a cigar 
produces a larger quantity of pungent aromatic oils than 
does the smoking of a cigarette or pipe. In the case 
of the cigarette oils are probably burnt even if they are 
formed, in the pipe they condense in the stem, while in 
the case of the cigar they are probably for the most part 
discharged into the air. In the form of a cigar tobacco 
would appear to produce more oils than in the form 
of a cigarette or when burnt in a pipe. Such common 
observations are not without hygienic significance. Pyrri- 
dine, the most poisonous oil produced in the semi-com- 
bustion of tobacco, is an abundant product in cigar smoking, 
as it is also in the pipe, but in the latter there is condensa¬ 
tion while in the former there is little or none. In the 
cigarette, so intimately in contact with the air is the 
burning portion that the production of distilled oils 
is, comparatively speaking, trifling. The symptoms of 
tobacco-smoke poisoning are not necessarily due to nicotine ; 
they are more often due to pyrridine, or poisoning 
from tobacco tar oils. The tobacco heart is more often 
traceable to free indulgence in cigar smoking than to a 
similar indulgence in the pipe and the cigarette. Young 
boys can smoke—to their great damage, nevertheless—a 
considerable number of cigarettes or even pipes, but an 
equivalent in cigars more than satisfies their tobacco 
appetite so soon are the toxic effects of cigar smoking 
made apparent to them. The danger of excessive cigarette 
smoking is that though no marked symptoms may be mani¬ 
fested or experienced, yet in the long run decided harm is 
done and a dangerous habit, akin to 1 ‘ nipping, ” is cultivated 
which it is often found very hard to abandon. 


HIRUDIN AND BLOOD GASES. 

That the blood flowing from the bite of the leech does 
not coagulate has long been known and has been attri¬ 
buted to the action of a material secreted by the salivary 
glands of that animal. The advantages which it offers 
in the investigation of the gaseous exchange of the organs 
of the body by preventing clotting are obvious and have 
recently been made the subject of a research (recorded in 
the Journal of Physiology ) by Mr. J. Barcroft and Mr. G. R. 
Mines who have set themselves the task of determining 
whether it produces any alteration in the gases of the blood. 
The quantity of the active principle, hirudin, prepared for 
them in Leipsic, which they injected waa 0’2 gramme 




Tbs Lancet,] THE LATE DR. W. S. PLAYFAIR.—THE LOCKING OF MILK CHURNS. [Feb. 22, 19C8. 579 


for every live kilogrammes of body-weight of the animal, 
the strength of the solution being about 1 per cent. It was 
found in some preliminary experiments that hirndin has no 
specific effect on the gases in drawn blood. When sub¬ 
cutaneously injected it was found that the oxygen in the 
arterial blood rose to a variable extent whilst the carbonic 
acid fell. The respiration was quickened, an effect that 
followed quickly upon a considerable fall in the blood 
pressure. The fall in blood pressure is consequent upon dila¬ 
tation of the peripheral vessels in the visceral area and pre¬ 
sumably elsewhere. Cerebral anaemia is thereby caused and 
consequently increased respiration. The increased respiration 
decreases the amount of carbonic acid in the blood to a slight 
extent and tends also to increase the oxygen. If hirudin be 
injected too rapidly death may occur. 


THE LATE DR. W. S. PLAYFAIR. 

The sum of £1000 has been collected among the patients 
and friends of the late Dr. W. S. Playfair and is to be pre¬ 
sented to King’s College Hospital with a view to erect a 
memorial to him at the institution with which he was so 
long associated. In view of the eminent services rendered 
to the hospital In the past by Dr. Playfair, and in deference 
to the wishes of his family, it has been decided by the 
removal fund committee to devote this money to the building 
and equipment of an appropriate department of the new 
hospital shortly to be erected at Denmark-hill, this depart¬ 
ment to be named after him and to bear an inscription 
recording his 35 years’ work at King's College Hospital. 


A DEPILATORY FOR USE BEFORE SURGICAL 
OPERATIONS. 

In the Journal de Medecine et do Chirurgie Pratiques a 

formula is given for preparing a depilatory for use before 
operations. It consists of sodium monosulphide, 1 part ; 
calcium oxide, 1 part; starch, 2 parts ; and sufficient water 
to form a stiff paste. The longer hairs are removed with 
scissors and then, after washing the patient thoroughly, the 
paste is spread in a uniform layer with a spatula. After five 
minutes the paste is removed by means of a sterile swab of 
cotton and the skin is washed freely with sterile water to 
remove the alkali. 


THE LOCKING OF MILK CHURNS. 

The proposal of the London County Council in a clause in 
its General Powers Bill to examine samples of milk at 
railway stations in its area is to be petitioned against by 
the East Sussex County Council. The London authority is 
anxious to trace the origin of any unwholesome milk that 
may arrive in the metropolis but the rural authority objects 
to the proposed power on the score of the possible hardship 
to the farmer. Many hours frequently elapse from the time 
when the farmer places the milk In a train at a country rail¬ 
way station and its process of being doled out at one of the 
London termini. Is the farmer to be responsible for the milk 
in the interim 1 The East Sussex County Council at its 
meeting on Feb. 11th replied in the negative. It asks that 
the particular clause may be amended by providing that the 
person producing or consigning the milk shall not be liable if 
he can prove that the milk contained no matter rendering it 
unwholesome or unfit for the food of man when so produced 
or consigned. To some extent the object of the farmer 
could be surmounted by the lids of the churns being 
locked during transit. This would prevent any possible 
tampering either during the railway journey or on the plat¬ 
form at any station, except by some authorised person. The 
general practice, as was pointed out over and over again in a 
series of articles which appeared last year in our columns 
dealing with the subject of the railway transport of milk to 


! London, is not to lock up the churns : the contents are 
accessible to anyone—and anything that comes along. Of 
course, locking the churns would not obviate the harm that 
may occur through delay in transit, but it would stop much 
gross defilement. _ 

“ CAMPTODACTYLIA." 

In a clinical lecture delivered at the Charite Hospital in 
1885 and in an article which appeared in the Presse Medicate 
of April 21st, 1906, Professor Landouzy has described under 
the name of “ camptodactylie ” (xa/iurris, bent, and MktDXos, 
finger) a condition of permanent and irreducible inflexi¬ 
bility of one or several fingers which develops gradually 
without pain or inflammation and affects only the inter- 
phalangeal joints, never the metacarpo-phalangeal. The 
palmar fascia is intact and the ends of the bones do not 
present nodosities. At a meeting of the Socifitfi Medicale 
des llupitaux of Paris on Jan. 10th M. Ch. Lesieur read an 
important paper on camptodactylia which, he said, might be 
unilateral or bilateral. When unilateral the right hand is the 
more frequently affected ; when bilateral the condition most 
frequently commences in this hand and predominates there. 
Usually only one finger is affected, even in the bilateral form, 
and that finger is nearly always the little one. When more 
than one finger are affected the fingers involved are the little 
and ring, sometimes the little, ring, and middle fingers ; 
the index participates only exceptionally. When several 
fingers are involved the little finger is always the most 
affected, the ring finger less, and the middle finger least. 
Each affected finger may be inflexible at one interphalangeal 
joint or at both joints. In the first case the deformity forms 
a more or less obtuse angle ; in the second the finger has the 
aspect of a hook formed by a line broken at two points cor¬ 
responding to the joints. It also may happen that the 
second phalanx is flexed on the first and the third 
extended on the second. A pathognomonic characteristic 
of camptodactylia is its irreducibility: extension of 
the finger is limited by the degree of the deformity and 
the impression is given of tension of the flexor tendon. On 
the other hand, there is no obstacle to flexion, and in some 
cases this movement shows adhesion of the retracted tendon 
to the overlying skin. Even when marked, camptodactylia 
does not interfere with the use of the hand. Professor 
Landouzy regards camptodactylia as a stigma of “ neuro- 
arthritism ” and due to some functional disturbance at the 
confines of the cervical and dorsal region of the spinal cord. 
But M. Lesieur thinks that the condition has some causal 
relation to tuberculosis for the following reasons : Campto¬ 
dactylia resembles the retraction of the tendo Achillis which 
has been observed in tuberculous ulcers of the leg. In the 
condition termed by French writers “ tuberculous abarticular 
rheumatism ” fibrous tissue is involved. Finally, campto¬ 
dactylia clinically resembles contraction of the palmar 
fascia, which some French writers regard as tuberculous. 
M. Lesieur therefore investigated 100 cases of campto¬ 
dactylia. In these 87 of the patients were averredly tuber¬ 
culous, seven probably tuberculous, and six appeared to be 
free from the disease. But of the last group several 
gave a family history of tuberculosis and the greater number 
showed slight lesions, such as acrocyanosis which is regarded 
as a tuberculide. In the 87 cases of averred tuberculosis the 
lungs were affected in 78, the lymphatic glands in 28, and 
the bones in seven. In most of the tuberculous cases the 
lesions were of attenuated virulence, with a tendency to 
sclerosis, progressing for the most part towards cure or even 
already cured. Thus camptodactylia is of great use both in 
diagnosis and prognosis of tuberculosis. It is possible to say 
that a patient is tuberculous simply by examination of his 
fingers, for camptodactylia is a stigma of tuberculosis. In 
prognosis it is equally useful; it shows that the tuberculosis 



580 Thb Lanoht,] DEAR BUTTER.—KING EDWARD’S HOSPITAL FUND FOR LONDON. [Feb. 22. 1908. 


is of the sclerous type, i.e., of slow evolution and compatible 
with prolonged survival. In the words of Professor Landouzy, 
"The little finger of a patient tells his past, shows his 
temperament, and foretells his future. ” 


PLAGUE ON THE GOLD COAST. 

In another column of this issue there will be found an 
advertisement from the Colonial Office stating that six 
medical men are wanted for plague duty on the Gold Coast. 
The terms as tersely put in the advertisement are, ‘‘six 
months’ engagement, free passages to and fro, tra¬ 
velling expenses paid, camp equipment and tents pro¬ 
vided ; pay £50 a month," while experience in plague 
duty is naturally desired. The forms of application 
may be obtained before March 7th from the Assistant 
Private Secretary, Colonial Office, Downing-street, S.W. 
The decision of the Government to send extra medical help 
to the Gold Coast must not be taken to indicate that 
the outbreak has reached alarming dimensions. On the 
contrary, with the exception of a few cases at a small 
coast town called Brewa, the disease is still confined to 
Accra where it began early in January. The latest 
reports give a mortality of one, two, and three a day, 
and since the beginning the mortality has never exceeded 
six in one day. As has been already announced in our 
columns, Professor W. J. R. Simpson, M.D., was despatched 
to Accra with an assistant at the beginning of the year, and 
very energetic measures have been taken ; but the available 
medical staff is felt not to be sufficient to enable a close 
watch to be kept over the various towns on the coBst which 
are at present free from infection, but where, as a measure 
of precaution, it is very desirable to have competent 
observers stationed so as to detect at the outset any cases 
or suspected cases of plague. Hence the demand for 
special officers is a valuable preventive measure, and we trust 
that the Government will have no difficulty in obtaining 
what is sought. _ 

DEAR BUTTER. 

The substantial advance in the price of pure butter will 
come as a hardship to many families. Accounts are more or 
less conflicting as to the causes which have led to the 
increased price, but two factors have been mentioned as re¬ 
sponsible, one of which is a shortage in the supply, and 
the other fresh legislation in regard to the sale of butter 
substitutes. We are inclined to attribute the rise in price 
entirely to the new Butter and Margarine Act which came 
into force on the first day of this year. If we are right in 
this view, then the conclusion is inevitable that enormous 
quantities of foreign fat have been sold in the past as 
genuine butter. The new Act, in short, is the death-blow 
to this dealing, and the fact that the supply of genuine 
butter has become short is significant. The effect should be 
a great stimulus to the genuine butter industry and we 
have little doubt that the demand for genuine butter will 
be more than adequately met as the position is accepted. 
Meanwhile the public need not suffer any shortage in regard 
to that most important element in diet, namely, fat. It may 
be true that genuine butter fat is the moBt digestible of all 
fats, but there can be little doubt that many of the sub¬ 
stitutes are nearly if not quite as good in this respect. 
Margarine, cotton-seed and other vegetable oils, and dripping 
are perfectly wholesome and palatable substances and afford 
good human food. It is no argument against their use 
for dietetic purposes that certain of them have been 
employed wherewith to adulterate butter. The question 
never has been that these substitutes were injurious 
or unfit for food ; it was purely one of misrepresentation. 
They were sold entirely or in part as butter when they 
were not butter, and that fact alone has created a 


prejudice against them as articles of food—a prejudice 
which we hope will disappear now that the sale of the 
genuine article has been placed on a satisfactory basis. We 
welcome this new Act because it is an Act calculated to 
make things what they seem, and the present dear price of 
genuine butter will, we are inclined to think, be only 
temporary. ___ 

KING EDWARD’S HOSPITAL FUND FOR LONDON. 

H.R.H. the Prince of Wales, at the suggestion of the 
Executive Committee of King Edward’s Hospital Fund for 
London, has decided to appoint a committee to inquire into 
the system prevailing in the London voluntary hospitals with 
regard to the admission of ont-patients. We learn this fact 
with pleasure, for provided that the committee be well chosen 
its pronouncement upon the best way of dealing with tbe 
acknowledged troubles of hospital abuse might be regarded 
in some sort as authoritative. The evils of hospital abuse 
are many and are not apparently on the decrease, but 
great difference of opinion exists, even among those who 
have studied the problems most closely, as to the direction 
in which remedy should be sought, this difference being 
equally present whether tbe right of the sick poor or the 
wrongs of the exploited medical profession are under con. 
sideration. We are informed that in view of the fact that 
some portion of the subject of inquiry by such a committee 
would probably fall within the subjects to be reported upon 
by tbe Royal Commission on the Poor-laws the committee 
will not be appointed until that Commission has reported. 


The Department of Public Health of Queensland, in a 
bulletin dated Jan. 11th, states that no case of plague in man 
has occurred since Jan. 1st. The Acting Governor of the 
Gold Coast, in a telegram received at the Colonial Office on 
Feb. 13th, states that the total number of deaths from plague 
at Accra for tbe three days ending Feb. 12th were 5. The 
new cases numbered 6. Further telegrams received re¬ 
spectively on Feb. 14th and 15th state that 1 death ooourred 
from plague at Accra on Feb. 13tb and 1 on Feb. 14tb. No 
fresh cases had been notified. 


As we have already announced, the 135th anniversary 
dinner of tbe Medical Society of London will take place 
at the Whitehall Rooms, Hotel M4tropole, London, on 
March 11th, under the chairmanship of the President of the 
society, Dr. J. Kingston Fowler. Applications for tickets 
should be made to the honorary secretaries, Dr. F. J. 
Poynton and Mr. T. H. Kellock, 11, Chandos-street, Cavendish- 
square, W. _ 

Favoured for the greater part of his short visit with good 
weather for the time of year, His Majesty the King derived 
great benefit from his week’s stay at Brighton. His Majesty’s 
personal assurance that he had benefited by his stay has been 
made public, as well as his hope to pay another visit to 
Brighton. _ 

Mr. Charters J. Symonds delivered the second Lettsomian 
Lecture for 1908 before the Medical Society of London on 
Feb. 17th, the President, Dr. J. K. Fowler, being in the chair. 
This lecture will be published in The Lancet in a future 
issue. 


Crematorium for St. Petersburg. — The 

president of the sanitary committee has submitted his report 
to the St. Petersburg town conncil in favour of the establish¬ 
ment of a crematorium in the town to be used with due 
regard to the interests of justice and in fulfilment only of the 
testamentary instructions of such deceased persons aa may 
have decided to be cremated. 





The Lancet,] REPORT FOR 1906 OF THE ADMINISTRATIVE COUNTY OF LONDON. [Feb. 22, 1908. 581 


ANNUAL REPORT FOR 1906 OF THE 
MEDICAL OFFICER OF HEALTH OF 
THE ADMINISTRATIVE COUNTY 
OF LONDON. 1 


III. 

Ip justification were required of the policy of the London 
County Council in combining under one authority the 
administrative functions of public health and elementary 
education, it is difficult to conceive how this could have been 
more completely accomplished than by the publication of the 
comprehensive and instructive report that lies before us. 

The second appendix to this report is from the pen of Dr. 
James Kerr, the Council's medical officer for education. This 
report shows that, as regards the metropolis, a good 
beginning has been made to give effect to some of the chief 
recommendations of the Duke of Devonshire's Committee on 
Physical Deterioration. It will be remembered that one of the 
most important of these recommendations was that a medical 
examination should be made as to the mental and physical 
condition of every child on admission to an elementary 
school. Even a cursory reading of this report will suffice to 
indicate that a very serious amount of mental as well as of 
physical defect has been discovered among children in attend¬ 
ance at those of the London schools which have already been 
medically examined. To some of these we propose very 
briefly to allude. 

It will surprise no one to bear that supreme importance 
is attached by the education authority to the medical 
inspection of the very youngest children—the “infants,” as 
they are technically classed. It is at the earliest ages that 
slight defects or diseases have a profoundly modifying 
influence on the future ; and it is of special importance that 
children of from three to five years should be examined in 
order that the beginnings of tuberculous bone and joint 
diseases amongst others may be detected, and thus permanent 
crippling may in all probability be avoided. With the staff 
at present at the department's disposal detailed examination 
is impracticable, but an attempt has been made by sampling 
to ascertain what medical inspection of infants really means 
and what it is likely eventually to lead to when effectually 
carried out. For this purpose examination was made by 
Dr. E. M. Niall of 14 schools, varying from the slum 
areas of Vauxhall, through the artizan areas of Lambeth, 
to the better class districts of Brixton and Norwood. 
The effect of environment appears at once from the fact 
that the survivors of the slum children at the age of 
five are as a rule sturdier and quicker than the more 
carefully nurtured cihldren who have not been exposed to 
hard climatic conditions, but who on the other hand appear 
to present larger numbers of dull and backward children with 
anromia, nasal obstruction, and glandular troubles. Two 
neighbouring schools, Lollard-street and Walnut Tree Walk, 
presented respectively the highest and the lowest number of 
defectives. Lollard-street, the school with the highest pro¬ 
portion (27 per cent.), is in a poor district abounding in fried- 
fish shops. Many of the mothers are wage-earners, return¬ 
ing home late at night too tired to look after the children. 
As might have been anticipated, semi-starvation and home 
neglect are factors in these unhealthy surroundings. The 
high percentage of defectives in this school was due in part 
to the presence of large numbers of children below the 
average in mental ability in one of the classes—a dullards’ 
class containing 47 per cent, of children with some obvious 
defect. It is for such a class as this more particularly that 
early medical inspection is imperatively necessary, for by 
this means many cases of corneal nlceration, marginal 
blepharitis, incipient ophthalmia, and otitis may be detected 
and presumably remedied. Very harmful are what are 
designated “dirt conditions,” especially in relation to the 
eyes, nose, and ears, ulceration of the corneal surface often 
leaving permanent damage. In many cases the parents will 
do nothing, even when asked by the teachers. These “dirt” 
inflammations in children of debilitated constitution are the 
chief conditions of slum schools. 

But Dr. Kerr is careful to remind us that general medical 
inspection must eventually lead to the establishment of 
“school clinics ” for treatment in ways which he takes pains 


\J?® vio,ls notices of this report appeared in Th* Laxcet of Jan. 25th, 
p. 250, and Feb. 8th, 1908, p. 446. 


to define. Without 6uch treatment mere medical inspection 
is, in his judgment, incomplete and generally means time and 
trouble wasted. Most of these cases are neglected. Some 
few are attended to at hospital, but generally this is unsatis¬ 
factory and of late very many cases have been refused 
treatment. 

If individual medical inspection of school children becomes 
general, we are warned that all the hospitals in London would 
not provide for the treatment of one-tenth of the children 
that would require treatment for diseases of the eyes, ears, 
and teeth alone. In order to cope with these cases Dr. Kerr 
suggests that the question of school clinics ought to become 
a subject of careful inquiry and as a question of elementary 
education should receive the early consideration of the 
County Council. To anyone fairly conversant with the 
untoward conditions normally obtaining among the infant 
denizens of our slum neighbourhoods it will occasion no 
surprise that of all the morbid conditions revealed by 
medical examination of school children by far the most 
important are those in which tuberculosis in one or other of 
its forms plays a prominent part. In the course of an 
investigation concerning the prevalence of tuberculosis in 
elementary schools Dr. Annie C. Gowdey reported on 
the condition of the spinal column of more than 400 young 
girls at Addison-gardens school. Of these girls, whose ages 
varied from six to 16 years, not less than 64 per cent, showed 
more or less abnormality. Very many of these girls had 
“ round backs,” whilst the scapulae of not fewer than half 
of them were reported to be “ growing out,” with or 
without some lateral curvature. Unless the state of 
matters at this school be exceptionally bad, and if 
the condition of the children there is typical of 
what obtains among school children of the same age 
elsewhere, it is obvious that further investigation is 
required with a view of obviating some of tbe incidents of 
school life which, at this school at any rate, appear to have 
produced deplorable results. Dr. Kerr comments on the 
excessive prevalence of deformity of the back among girls as 
compared with boys, and points out that this is due to some 
specific cause, such, e.g., as a want of regular development of 
the trunk muscles induced by various constrictions and supports 
in the way of binders and corsets. Meantime, he suggests 
the desirability of directing the attention of teachers who 
superintend drill to the many causes that have been assigned 
for this condition, suoh as the imperfect lighting of school¬ 
rooms, the habit of sitting cross-legged, and of standing with 
tbe weight of the body constantly resting on one leg. 

The examination of girls in the secondary schools has 
also been carried out on a limited scale during 1906. 
In so doing Dr. Janet M. Campbell found it possible to 
conduct inquiry respecting the general physique of the 
girls with more detail than was possible in the case of 
the elementary school children before referred to. Out 
of 604 girls examined, 138 showed definite lateral curva¬ 
ture. Definite osseous deformity, not admitting of correc¬ 
tion, was presented by seven of these girls, their ages 
being from IS to 22 years. In all the other cases the 
deformity could be made to disappear by changes of posture. 
These girls migrate, for the most part, from the elementary- 
schools, and their average standard of physique is not high. 
As they have all been previously examined medically, many 
defects had already been remedied. Of the 138 girls with 
spinal curvature, 10 were above and 37 were below the 
average in general physique. 

Exaggerated and even alarmist reports having appeared 
from time to time to the effect that pulmonary tuberculosis 
is excessively prevalent among children of school age, the 
medical officer has very usefully addressed himself to the 
task of ascertaining how far children at school age are really 
affected with pulmonary tuberculosis, and also how far they 
are likely to be a danger to others. It should be premised 
that in the metropolitan schools there has long existed the 
salutary regulation that whenever a child is supposed to be 
suffeting from consumption, and especially if be coughs and 
expectorates, he is forthwith excluded from Bchool. Teachers 
similarly affected are likewise excluded for at least 12 
months. The risks of infection from parsons obviously 
suffering from pulmonary tuberculosis are therefore believed 
to be small. In order to ascertain by careful medical 
inspection the extent to which children of school age are 
actually suffering from pulmonary tuberculosis, the boys and 
girls, 1670 in number, in attendance at two large schools 
situate in Latimer-road and Addison-gardens respectively, 
were examined and the results tabulated for tbe present report. 




582 Thb Lancet,] 


SANITARY REFORM IN INDIA. 


[Feb. 22, 1908. 


From thiB examination there were certain indirect results 
that are worthy of note. For instance, we learn that child¬ 
ren, not necessarily consumptive, were found to be suffering 
from physical defects which either interfered with school 
progress or were likely seriously to influence the future life 
of the children, and for these medical treatment was 
enjoined. Many cases of heart trouble, greatly enlarged 
tonsils or adenoids, and carious teeth were thus detected and 
placed under treatment. As to the actual returns respecting 
the two schools above specified, out of 1670 children 
examined, signs in the lungs that would justify a diagnosis 
of tuberculosis were found in eight cases only. In 14 other 
children slight signs were found—prolonged expiratory 
breath sounds, or dry flue crepitation at the margin of the 
lungs—which might possibly be due to tuberculous infection. 
Even if these are included as actual cases of tuberculous 
disease, the percentage of possible pulmonary tuberculosis 
reaches only 1'3 per cent. There is a further small pro¬ 
portion in which enlarged veins on the chest suggest the 
possibility of enlargement of bronchial glands due to 
tuberculous changes, but without any evident lung affection. 
Nearly three-fourths of the children examined presented 
enlargement of the cervical lymphatics and over 40 per cent, 
had enlarged tonsils. 

Within the administrative County of London there are at 
the present time 23 invalid schools containing about 1800 
physically defective children. These children are daily con¬ 
veyed to and from school in 35 ambulances and II omnibuses, 
and their conveyance to school as well as their care there 
are provided for by the employment of 24 nurses. The 
admission of an invalid or crippled child to these schools is 
permitted only after medical examination. In most cases 
the decision as to whether or not a child is fit for admission 
is an easy matter. But there is clearly an advantage in 
securing for special cases the opinion of an expert surgeon. 
It is necessary to have regard to the possible future of the 
child in each particular case. Some children would be the 
better for gentle exercise or work suited to their strength, 
whilst for others absolute rest is a necessity. During the 
past year Mr. R. C. Elmslie has carefully examined every 
case on admission to school with manifest advantage to the 
children under his care. He has examined more than a 
thousand children in 15 “ physically defective” centres, and 
has noted in each case the nature of the disease or defect, 
the prevalence of active disease or of deformity, and the 
efficiency of any treatment adopted. Of these cases in the 
aggregate 80 per cent, began before the age of seven years 
and 67 per cent, below five. Of the spinal cases 72 per 
cent, occurred before the fifth year of life, whilst of the 
hip cases 64 per cent, occurred between the ages of two years 
and six. In the large majority of cases of tuberculous disease 
of the spine the onset of the disease occurs quite early in 
life, somewhere between the second and the fifth year. 
Tuberculous disease of the hip-joint is evident at a some¬ 
what later age than spinal caries. The age distribution of 
tuberculous disease of the knee-joint is much more even than 
that of the two preceding forms of infection, the disease 
appearing for the most part about equally in each year of tht 
first nine. Of the 83 cases observed two were bilateral, in 
27 of which the disease was active and in 54 inactive. Very 
interesting particulars are given of the results of tuberculous 
bone disease, as regards deformity, crippling, Sec., but for 
these reference must be made to the report itself. 


SANITARY REFORM IN INDIA. 


l. 

An important letter has been recently addressed by the 
Secretary to the Government of India, Home Department, 
to all local governments and administrations upon the 
subject of sanitary reform. We reproduce it verbatim and 
hope that our readers will appreciate the fact that a grand 
effort is now being made to improve the public health of our 
enormous Eastern Empire :— 

1 . I am directed to address you on the important subject of 
the improvement of the sanitary services in India and the 
development of the present establishment on lines which 
will bring it abreast of modem requirements. 

2. The history of sanitary administration in India was 
reviewed in the Home Department Resolution of Sept. 8th, 
1904, in which the appointment of a Sanitary Commissioner 


with the Government of India was announced. That resolu¬ 
tion concluded with the expression of a hope that, with the 
assistance of the Sanitary Commissioner’s advice and in con¬ 
sultation with local governments, substantial progress might 
in the course of time be made towards a complete reorganisa¬ 
tion of the Sanitary Department. The Governor-General 
in Council is of the opinion that the time has come when an 
endeavour may be made to realise expectations and I am 
accordingly directed to offer for consideration the following 
suggestions regarding the nature and direction of the advance 
which should now be made. 

3. The administrative machinery of the sanitary depart¬ 
ment is already, in most respects, fairly complete and 
efficient. Additional deputy sanitary commissioners are 
probably needed in some provinces, and I am desired to 
request that the question of increasing their numbers may be 
borne in mind. These officers are at present recruited solely 
from the Indian Medical Service, and though that arrange¬ 
ment must probably continue for some little time, the 
Government of India are disposed to think that the appoint¬ 
ment should not be reserved exclusively for officers of that 
service, but should be open also to the medical officers of 
health referred to below. And they are further of the opinion 
that no officer of the Indian Medical Service should be 
appointed a deputy sanitary commissioner, unless he is of less 
than seven years’ service and has secured a degree or diploma 
in public health. The latter condition would be applied to 
all candidates whether members of the Indian Medical 
Service or not. 

Sanitary Boards. 

4. Another part of the administrative machinery which 
has been developed in different degrees and has attained 
positions of varying usefulness in different provinces is the 
Sanitary Board. The Government of India believe that 
these boards are beneficial in emphasising the importance of 
the subject of sanitation, in correlating sanitary schemes 
with administrative exigencies, and in securing direct dis¬ 
cussion between sanitary experts and those who are in a 
position to appreciate and represent the attitude of the 
general population. They are disposed to think that the 
Board should consist of from three to five members, including 
a senior officer of the Civil Service, who is in close touch 
with the local administration, the sanitary commissioner, and 
the sanitary engineer as expertB, and one or two natives of 
India, preferably non-officials. If the chief engineer and the 
head of the Provincial Medical Service are placed on the 
board the local government is deprived of the independent 
expert advice which it requires when dealing with the 
board’s recommendations. The functions of these boards 
have hitherto been mainly advisory, but it is possible 
that they might be so constituted as to be able to 
relieve local governments of much work of minor import¬ 
ance. I am directed to suggest that the question of the 
constitution and powers of the sanitary board should be 
examined and to request that the Government of India 
may be favoured with your opinion and proposals upon 
this question. 

Medical Officers of Health. 

5. Turning now to the executive establishment the first 
defect that forces itself upon the attention is the inadequacy 
of the staff of medical officers of health. The Presidency towns 
and a few other cities have such officers, but speaking gene¬ 
rally the civil surgeon is the only health officer of the towns 
in a district. It is often difficult for him to give sufficient 
attention to the sanitary requirements even of the head¬ 
quarters town. It is quite impossible for him to do more 
than make an occasional inspection of other towns. A com¬ 
plete and qualified staff of sanitary experts is a necessary 
preliminary to any substantial improvement of sanitation. 
If reforms are to be planned on right lines and carried out 
with efficiency and economy (tie work cannot be left in the 
bandB of officers who have only a general knowledge of the 
subject and whose time is largely occupied by other duties. 

6 . The Indian Plague Commission of 1900 recommended 
that a special European medical officer of health should be 
attached to every town which contains a population of 
100,000 inhabitants, and that one European assistant health 
officer should be provided for each additional 100,000 
inhabitants. The Government of India consider that the 
standard of population suggested is reasonable and moderate. 
They are of opinion, however, that it is unnecessary and 
even inexpedient to require that all these health officers 
should be Europeans. A sanitary service offers a suitable and 



The Lancet,] 


SANITARY REFORM IN INDIA. 


[Feb.'22, 1908. 583 


congenial career for educated natives of the country, and by 
fully utilising this source of supply the Government will 
avoid the expense of materially enlarging the Indian Medical 
Service or of importing specially trained officers from England 
for the present. At least it will be necessary to insist upon a 
training in Europe as a qualification for employment, as the 
experience gained thereby would be wider and more valuable 
than could as yet be obtained in India. A health officer who has 
undergone Buch a training and is at the same time possessed 
of an intimate acquaintance with the customs and prejudices 
of the people would be singularly well equipped for the 
difficult and delicate duties connected with sanitation in 
India. He would on the one hand have the best scientific 
knowledge available, and be would on the other be able to 
avoid arousing that opposition which the application of 
Western sanitary science to Eastern conditions too often 
excites. The Governor-General in Council does not suggest 
that the combination of these qualities is not found in 
European officers or that it will always be found in natives of 
India. He knows that the contrary is the case. He pro¬ 
poses, therefore, that the new appointments shall be open to 
both classes alike, but on grounds of economy preference 
would naturally be given to Indian candidates when men 
with the necessary qualifications are forthcoming. 

7. For towns with a population between 20,000 and 100,000 
a medical officer of health will also ordinarily be necessary, 
but financial considerations will render it compulsory to 
accept a somewhat lower standard of scientific attainments 
than that prescribed for the larger cities. These appoint¬ 
ments may, the Government of India think, be recruited 
from natives of India of the civil assistant surgeon class, who 
on the completion of their medical training have taken a 
special course in public health at one of the medical colleges. 
The appointment of such an officer may not be necessary for 
every town of the class referred to, and where the head¬ 
quarters town of a district is small it will probably be 
possible to combine the appointment of health officer with 
the medical charge of the district. In that case it will 
probably be desirable that the civil surgeon should be chair¬ 
man of the sanitary subcommittee where there is one. 

8 . The Government of India are advised that it should be 
laid down as an inviolable rule that a medical officer of 
health should not be allowed to undertake private practice. 
Although a small amount of such medical work might not 
interfere with the performance of the health officer’s proper 
duties, yet if private practice is once allowed it is impossible 
to put a limit to it and it is, therefore, best to forbid it alto¬ 
gether. This restriction will necessitate the salaries of 
health officers being fixed on a more liberal scale than would 
otherwise be required, but tbe advantage of securing the 
officers’ whole time and undivided energies far outweighs the 
somewhat problematical economy that might be effected by 
permitting private practice. 

Sanitary Inspectors. 

9. The subordinate supervising staff of the Conservancy 
Establishment also calls urgently for improvement. In 
most towns there is an official whose functions resemble 
those performed by an inspector of nuisances in England. 
Except in the presidency towns, however, and in the Madras 
municipalities, it is very rare to find in this position a man 
who has any technical knowledge of his subject. The 
Government of India are assured that one of the most crying 
needs of municipal sanitation in India is a body of men fit 
to undertake the duties of sanitary supervision, which arc 
performed by inspectors of nuisances in Great Britain. It is 
urged that medical officers of health will not and cannot be 
expected to undertake work of this subordinate character and 
that the existing establishments of untrained supervisors and 
overseers are not able to give the health officer the assistance 
which he has a right to demand. If this assistance is denied, 
many petty and irksome duties will be imposed on the health 
officer, and suitable men will not be obtained for that office. 
Just a a trained subordinate acts as a link between the 
executive engineer and the working labourer, so a trained 
subordinate is required by the executive sanitary officer. It 
is imperative, therefore, that measures should be taken with¬ 
out delay to remedy this defect in the administration. The 
strength of the establishment' required will depend not on 
the population alone but on other local circumstances also. 
In the large cities a trained inspector will probably be 
needed for each sanitary division, with perhaps a chief 
inspector in addition. For other towns the number of in¬ 
spectors required will vary with the population, the area, 


and sanitary condition. In many a single officer will 
ordinarily prove sufficient. 

10. Tbe training of these sanitary inspectors is a question 
which will require very careful consideration. The standard 
required should be that prescribed by the Royal Sanitary 
Institute, with whom arrangements could no doubt be made 
for the issue of certificates to successful candidates. If that 
is thought desirable the course of instruction should embrace 
lectures in elementary physics, physiology, general hygiene, 
and minor sanitary engineering. Admission to the courses 
of instruction Bhould be confined to candidates who have 
passed some examination not lower than the school final or 
the university matriculation examination and are of good 
physique, satisfactory character, and suitable caste and 
social status, the consideration to be borne in mind in fixing 
this last qualification being that a sanitary inspector must 
be able to move freely among all classes of the population. 
To attract men of the right stamp it will be necessary to 
offer good pay. A scale of salaries rising from Rs. 50 to 
Ks. 150 will probably prove suitable in most provinces. 

Advantages of Certainty of Tenure. 

11. There remains the important question whether the 
medical officers of health and sanitary inspectors should be 
formed into a regular provincial sanitary service, or whether 
each local authority should be allowed to recruit its own 
staff independently. The objections urged against the latter 
course are : (1) that a career which is limited to employ¬ 
ment by local authorities on uncertain terms and without 
prospect of pension will not attract candidates of the right 
stamp if, indeed, it attracts candidates at all; and (2) that 
the insecurity of tenure of appointments under local 
authorities will tend to deter young men from qualifying 
themselves for such appointments. The duties of a sanitary 
officer will of necessity often bring him into conflict with 
members of the local authority or their relatives, and if he 
is merely the servant of the board or council he will either 
neglect his duty in such cases or perform it at the risk of 
losing his post. On the other hand, it is argued that the 
creation of a provincial service of sanitary officers will con¬ 
flict with one of the main principles of local self-government 
and it is urged that in no branch of local administration 
is local control so necessary as in matters connected with 
sanitation. The Government of India could not agree to any 
proposal which did not leave to the local authority the 
control of its executive officers, whether of the sanitary or 
any other establishment. On the other hand, they are con¬ 
vinced that in the case of the sanitary officers certainty of 
tenure during good conduct mu6t be assured. How this can 
best be secured is a question upon which the Governor- 
General in Council would like to have the opinions of local 
governments. It is not necessary to insist upon uniformity 
of treatment and arrangements which are expedient in one 
province may not be so suitable in another. The creation of 
a provincial service offers one solution, and for the purpose 
of attracting candidates this is probably the best solution. 
When a member of such a service held a post under a local 
authority he would be in a position corresponding to that of 
a member of the subordinate medical service in the employ 
of the municipal or district board. An alternative to 
the creation of a provincial service is for the Govern¬ 
ment to prescribe : (1) the minimum number of sanitary 
appointments for each local authority; (2) the minimum 
salary to be given to the incumbent of such appointments ; 
and (3) the professional qualifications to be required of 
incumbents. This would possibly afford a prospect of 
employment sufficiently good to induce candidates to undergo 
the qualifying course of instruction. To secure fixity of 
tenure it would be necessary to provide that no medical 
officer of health or sanitary inspector should be removeable 
from office without the sanction of the local Government in 
the case of the former or of the Sanitary Commissioner or 
perhaps the Sanitary Board in the case of the latter. 
Regulations somewhat similar to these exist in England and 
Scotland and are necessary to secure the employment of 
properly qualified men and to guarantee protection against 
arbitrary treatment in retaliation for the fearless and efficient 
performance of duty. 

12. The Government of India do not propose to discuss at 
present the thorny question of sanitation in rural areas. 
Assistant health officers are probably necessary in some 
districts and trained inspectors would often, no doubt, be 
useful to local boards to undertake special Inspections or to 
provide sanitary measures on special occasions, such as fairs 





584 The Lancet,] 


ROYAL COLLEGE OF SURGEONS OF ENGLAND. 


[Feb. 22, 1908. 


and festivals. Their services would further be valuable in 
connexion with measures against plague and other epidemics. 
If a supply of trained men is brought into existence local 
bodies should be encouraged to avail themselves of it for 
services of this nature, but in most provinces it is probably 
undesirable to go farther than to require that where sanitary 
inspectors are employed none but trained men should be 
appointed. 

Sanitary Engineers. 

13. The question of providing an efficient staff of sanitary 
engineers has been engaging the attention of the Government 
of India for some time and the conclusions at which they 
have arrived will be announced in a separate communication. 
The matter is mentioned here only in order to give an 
assurance that its great importance in connexion with the 
subject of sanitary advancement has not been overlooked. 

14. I am directed, in conclusion, to request that the various 
suggestions which have been put forward in this letter may 
be considered and that after consulting such official and non¬ 
official opinion as may seem desirable you will favour the 
Government of India with an expression of your views upon 
the whole subject. The Government of India would like at 
the same time to learn what specific action you propose to 
take in order to give effect to the accepted policy of sanitary 
improvement. 

Postscript (to Madras only).—The Governor-General in 
Council is aware that there already exists in Madras a body 
of trained sanitary inspectors and that rules regarding their 
employment and remuneration have been issued by the local 
Government. Much of the foregoing discussion of this 
subject is, therefore, inapplicable to the circumstances of 
that Presidency. On the other hand, the experience gained 
there will be valuable in dealing with the questions under 
consideration and the Government of India hope that the 
Governor in Council will favour them with an account of the 
Madras system, together with his opinion on the value of the 
results obtained and the direction in which amendment may 
be desirable. 


ROYAL COLLEGE OF SURGEONS OF 
ENGLAND. 


An ordinary meeting of the Council was held on Feb. 13th, 
Mr. Henry Morris, the President, being in the chair. 

The Secretary reported the death of Mr. William 
Allingham, past member of the Council. The following 
motion was carried :— 

That the Council hereby express their sincere regret at the death of 
Mr. William Allingham and their sympathy with the members of his 
family. The Council do also record their appreciation of Mr. 
Allingham's services to the College whilo Member of Council and 
their regard for the skill and ability which won for him a prominent 
position among the surgeons of the time. 

It was resolved to issue diplomas of Membership to 66 
successful candidates. It was also resolved bo issue, in 
conjunction with the Royal College of Physicians of London, 
diplomas in Public Health to 12 successful candidates. 

The Council then proceeded to the election of the Con¬ 
servator of the Museum, and from the candidates, all of 
whom were zoologists, the Council selected Mr. Arthur 
Keith, M.D. Aberd., F.R.C.S. Eng., lecturer on anatomy 
and Curator of the Museum at the London Hospital Medical 
School. 

At the last annual meeting of Fellows and Members the 
following motion was carried :— 

That the President and Council of the Royal College of Surgeons be 
asked to use their moral influence with hospital authorities to 
recognise Members of the College (who are also in almost all cases 
Licentiates of the Royal College of Physicians) as having equal rights 
with Provincial, Scotch, and Irish graduates to become candidates for 
hospital appointments. 

In accordance with the report of the committee which had 
been considering this resolution the Council decided to send 
the following memorandum to the hospitals in England and 
Wales:— 

Attention having been called to a regulation in force at some hos¬ 
pitals, under which the ordinary pass degree of any British University 
is accepted as qualifying for appointments on the staff, whereas the 
diplomas of M.B.C.S. Eng. amt L.B.C.P. Lend, are not so accepted, 
the Council ot the Royal College of Surgeons of Eugland desire 
to point out the injustice of this regulation to Diplomates of the two 
Royal Colleges. In the first place the Council would call attention to 
the fact that since the introduction of the live years’ curriculum the 
course of professional study required at the universities has not been 
longer than that required by the Colleges. Moreover, statistics recently 


compiled by a committee of the General Medical Council show that the 
average course of study in England is longer than that in Scotland or 
Ireland, and the inference is drawn by the committee that this differ¬ 
ence Is due to the regulation of the lioyal Colleges in England which 
guarantees for the subjects of the final examination an uninterrupted 
period of study of two yoare from the date of the completion of the 
intermediate examination. 

With regard to the standard of examination, the Council maintain 
that the examinations in professional subjects, which candidates for the 
diplomas of the Royal Colleges in England are required to pass, are not 
leas exacting than those required for the pass degrees of most uni¬ 
versities. In support of this contention the Council would point to 
the marked success of the diplomates of the Royal Colleges in England 
at the examinations for the Royal Navy Medical Service, the Royal 
Army Medical Corps, and the Indian Medical Service. (See below.) 

The Council believe that, in many eases, the regulation in question 
was made at a time when there were not more than four universities In 
England, and when the conditions for obtaining the degrees of those 
universities were in some respects more exacting than those 
imposed upon candidates for the diplomas of the two Royal 
Colleges ; but, having regard to existing conditions, they are of opinion 
that, in all cases in which those holding only the pass degree of a 
university are accepted as eligible i'or staff appointments, the same 
privilege should be accorded to those who hold the diplomas of 
M.R.C S. Eng. and L.R.C.P. Lond. 

The Council therefore trust that the authorities ot hospitals in 
England and Wales, who make this distinction between diplomates 
ami graduates, will see their way to modify a regulation which affects 
unjustly many who have studied and qualified in London, whore the 
clinical advantages for medical and surgical education are unsurpassed 
and places them at a disadvantage with those who have graduated in 
Scotland, Ireland, and elsewhere. 

Analysis oj Return* as to the Examination* lor the Medical Department 
of the Royal Nary, the Royal Army Medical Corps and the Indian 
Medical service during die live years lua.i-07, compiled Jrom Tables 
presented to the General Medical Council. 



Passed. 

Re¬ 

jected. 

Per¬ 

centage 

passed. 

M.R.C.S. Eng. 1 

L.R.C.P. Lond. S . 

. 344 

.. 20 

.. 94-5 

English University Graduates ... 

. 133 

.. 12 

.. 89 5 

Irish University Graduates 

. 153 

.. 25 

.. 859 

Scottish University Graduates ... 

. 162 

.. 40 

.. 80-1 

L.S.A. Loud. 

. 14 

.. 5 

.. 73-6 

Indian and Colonial University Graduates 16 

.. 9 

.. 640 

Irish Con joint Diplomates. 

. 76 

.. 46 

.. 62-2 

Scottish Conjoint Diplomates ... 

. 50 

.. 42 

.. 54*3 


The foregoing statistics are compiled from the results of 27 exa¬ 
minations, and the high position in order of merit obtained by the 
diplomates of the two English Itoyal Colleges is Bhown by the following 
table:— 

First place gained by-j K C V Lond ^ times in 27 examinations 


Second 

Third 

Fourth 

Fifth 


20 

14 

15 

16 


It was resolved that the Royal College of Physicians be 
informed that the Council is preparing to issue a circular to 
Fellows and Members of the Royal College of Surgeons of 
England asking their opinion as to whether or not it is de¬ 
sirable that women should be admitted to examination for 
the diplomas of the College, and that pending the result of 
this inquiry it is not proposed by the Council to take any 
further steps with regard to the petition from the London 
School of Medicine for Women. The following is the circular 
to the Fellows and Members :— 


Royal College of Surgeons of England. 


Dear Sir,—T he Council, although they have decided that it is 
desirable to admit women to examination for the Diploma of Member, 
and although they have power to act upon this opinion, are anxious, 
in accordance with a resolution passed at a meeting of the Council 
on May 9th, 1907. to obtain the views of the Fellows and Members on 
the matter. 

In regard to the corporate position of women if the diplomas of the 
College be granted to them, the Council have taken legnl opinion and 
are advised that, while under the Medical Act of 1876 (39 A 40 Viet. 
Ch. 41) women can be admitted as Members or as Fellows, no woman 
so admitted would thereby be entitled to take any part in the govern¬ 
ment, management, or proceedings of the College. 

It is hoped t hat you will answer the questions on the accompanj-ing 
post card, and return the card at your early convenience. In order to 
give time for the arrival of replies from the colonies and other 
distant localities, the poll will be kept open until the day 

of , 1903. 

Voting Card. 


Answer. 


A. In your opinion is it desirable that women should 
he admitted by examination as Members of 
the College. 


B. In your opinion is it desirable that women, after t 
admission to the Membership, should be ad- (_ 
mitted by examination as Fellows of the i’ 
College. ) 

(Please answer Yes or No.) 


Dr. J. Ward Cousins was reappointed the representative of 
the College on the Central Midwives Board. 




The Lancet,] 


THK MEDICAL INSPECTION OF SCHOOL CHILDREN. 


[Feb. 22, 1908. 585 


A letter was read from the President of the General 
Medical Council stating that a committee of the Council had 
been appointed to prepare a fresh edition of the British 
Pharmacopceia, and inviting the College to send to the com¬ 
mittee before April 30th next any recommendations or 
suggestions. A committee was appointed to consider the 
matter. 

A letter was read from the President and secretaries of the 
Geological Society of London thanking the Council for the 
address presented to the society at the celebration of the 
centenary in September last. 

The President reported that he had chosen Mr. W. Watson 
Cheyne as Bradshaw lecturer for the ensuing collegiate year. 

The President reported that the vacancy on the Board of 
Examiners in Dental Surgery, occasioned by the expiration 
of the period of office of Mr. W. A. Maggs, would be filled 
up after the ordinary Council meeting in March. Mr. Maggs 
is eligible for re-election. 

Upon the suggestion of the President, a small committee 
was appointed to keep the Council informed as to what is 
being done from time to time regarding the medical inspec¬ 
tion of school children and the arrangements for teaching 
elementary hygiene in training colleges and schools. 


THE MEDICAL INSPECTION OF SCHOOL 
CHILDREN. 


The following circular containing a schedule of medical 
inspection has been issued by the Board of Education to local 
education authorities. The schedule has been drawn up in 
response to requests which the Board of Education has 
received for further and more definite guidance as regards 
the details of the work of medical inspection. 8ir Robert 
Morant writes as follows to the local education authorities: — 

The Board have l>oen pressed by many local education authorities to 
issue a complete Bet of forms for use in carrying out the work directly 
or incidentally Involved in the performance of these new duties. Any 
forms which experience of the working of the Act may show to be 
necessary or desirable will be issued in due course, but for the present 
the Board think it expedient to leave considerable latitude, subject to 
the considerations hereinafter set out, in regard to the particular 
forms or schedules to be used in different, cases or circumstances. The 
chief difficulties to be considered are administrative rather than educa¬ 
tional or scientific. There is comparatively little dispute as to the end in 
view or as to the means which, from the technical standpoint of medical 
science and practice, should be adopted for its complete attainment. 
But the existing resources of local education authorities are (for 
practical purDoses, at all events) not unlimited, the feelings and 
prejudices of parents have to be considered, and a new element has 
to be introduced into school life and organisation with the least 
possible disturbance and inconvenience. Moreover, in this case two 
departments of looal public administration are brought for the first 
time into organic connexion—those of public health and of public 
education. 

The Board are fully aware of these difficulties, and in preparing their 
Memorandum and Regulations it was necessary for them to consider 
what system would best reconcile the theoretical and practical con¬ 
siderations, and overcome the divergence between the ultimate end and 
the end immediately attainable, or between the methods which are 
scientifically desirable and those which can bo applied in existing 
circumstances at the initiation of the work under the Act. 

In the accompanying schedule the Board indicate the particulars, 
attention to which they regard as constituting the minimum of 
efficient medical inspection, and they consider that at least these par¬ 
ticulars should be included in any other schedule which the local 
education authority may authorise for use in their schools. It 
deliberately excludes many points of anthropometric or statistical 
interest which are worthy of attention, and which it is hoped may 
receive attention In suitable districts. Nor does it profess to lay down 
the lines of a clinical study or of a scientifically complete medical 
examination. It is intended to indicate the methods which, in the 
Board’s opinion, should lie followed and the particulars which should 
be attended to for the purpose of determining the fitness of the in¬ 
dividual child for school life, to guide the authority in adapting educa¬ 
tion to the peculiarities or abnormalities of the child and to prepare the 
way for measures for the amelioration of defects in the child or its 
environment. A more elaborate and complete form could readily be 
devised, but the Board's knowledge of the circumstances in which the 
work is to be done leads them to believe that greater elaboration would 
in the majority of cases defeat its own end. 

If this schedule is properly used, few cases of serious physical weak¬ 
ness or defect will escape detection. Where the ordinary inspection 
shows the need of further and more searching medical examination a 
supplementary blank form should be used in which particular defects 
or diseases should be fully recorded. It may facilitate inspection if the 
schedule is printed on cards (8" by b ' or 10" by 6"). The notes are 
included in the attached form for the convenience of the school medical 
officer, and should not be reprinted on the cards. Of course it is not 
necessary that negative findings on all the points mentioned in the 
notes should be recorded. It will be noticed that a space is reserved in 
the schedule for *• General Observations"; this may conveniently be 
used to record a general summary of the condition of the child, and any 
information which may be available as to the home environment, or 
other conditions affecting its health. It is considered that the inspec¬ 
tion of each child should not occupy on the average more than a few 


minutes, and that the child need only, as a rule, have its clothes 
loosened or be partially undressed. Time may be saved in the actual 
inspection by the medical officer if the entries in some of the spaces are 
tilled in by the school authorities before his visit. The four columns In 
the schedule are designed for the four inspections required during 
school life. With regard to items 17 to 24 or the schedule, while 
it is necessary that all indications of diseased or unsound conditions 
should be thoroughly investigated, needless medical examination of 
healthy children should, for obvious reasons, be avoided. 

Where children are found to belong to that class of *• defectives " 
for whose education special provision is or ought to be made under 
the Statutes relating to such children, such cases should be made 
the subject of a special report to the local education authority. 

All entries of the remits of inspection in each individual case must 
be regarded as confidential. 

With this circular specimen cards were inclosed which we 
have already noticed in The Lancet, bnt cards will not be 
supplied with the copies of the circular which are placed on 
sale. 

The following is the schedule accompanying Sir Robert 
Morant’s circular letter to local education authorities 

Schedule of Medical Inspection. 

I. —Name ... Date of Birth 1 . 

Address .. School . . 

II. —Personal History : 

(a) Previous Illnesses of Child (before admission). 


Measles Whooping- 

Chicken- ; 

Scarlet 

1 

Diph- 

Other 

| cough. 

pox. t 

lever. 

■ theria. 

l illnesses. 3 


(6) Family Medical History (if exceptional).3 


- 

, | 

III. 

IV. 

1. Date of inspection . 

2. Standard and regularity of attendance 4 

3. Age of child *. 

4. Clothing and footgear • .. 

[III.— General conditions.] 

5. Height r . 

6. Weight 8 . 

7. Nutrition 9 . 

8. Cleanliness and condition of skin 10 

Head . 

Body . . 

[IV .—Special conditions.] 

9. Teeth u . 

10. Nose and throat 13 . 

Tonsils . 

Adenoids .. ... . 

Submax. and cervical glands. 

11. External eye disease i 3 . 

12. Vision ii . 

R. 

L. 

13. Ear disease 15 . 

14. Hearing l(i . 

15. Speech 17 . 

16. Mental condition 18 .. 

[V.— Disease or Deformity. ] ,9 

17. Heart and circulation 20 . 

18- Lungs 31 . 

19. Nervous system 22 ... ... . 

20. Tuberculosis 33 ... ... ... . 

21. Bickets 24 .. ... . 

22. Deformities, spinal disease, &e. 25 . 

23. Infectious or contagious disease 24 . 

24. Other disease or defect 27 . 

Medical officer's initials . 

1 






General observations. 

Directions to Parent or Teacher. 


NOTES FOR INSPECTING OFFICER. 

1. Date of birth to be stated exactly, date of month and year. 

2 “ Other illnesses ” should include any other fierious disorder which 
must be taken into account as affecting, directly or indirectly, the 
health of the child in after-life, e.g., rheumatism, tuberculosis. 

















586 Thb Lancet,] 


CENTRAL MIDWIVES BOARD. 


[Kim 22,19:8. 


congenital syphilis, small-pox, enteric fever, meningitis, fits, mumps, 
Ac. The effects of these, it still traceable, should be recorded. 

3. State if any case of, or death from, phthisis, Ac., in family. 

4. Note backwardness. 

5. Age to be stated in years and months, thus 5iV* 

6. Insufficiency, need of repair, and uncleanliness should be recorded 
(good, average, bad). 

7. Without boots, standing erect with feet together, and the weight 
thrown on heels and not on toes or outside of feet. 

8. Without boots, otherwise ordinary indoor clothes. 

Height and weight may be recorded in English measures if preferred. 

n annual report, however, the final averages should be recorded in 
both English and metric measures. 

9. General nutrition as distinct from muscular development or 
physique as such. State whether good, normal, below normal, or bad. 
Under-nourishment is the point to determine. Appearance of skin and 
hair, expression, and redness or pallor of mucous membrane are among 
the indications. 

10. Cleanliness may be stated generally as clean, somewhat dirty, 
dirty. It must be judged for head and body separately. The skin 
of the body should be examined for cleanliness, vermin, Ac.; and the 
hair for scurf, nits, vermin, or sores. At the same time ringworm and 
other skin diseases should be looked for. 

11. General condition and cleanliness of temporary and permanent 
teeth, and amount of decay. Exceptional features, such as 
Hutchinsouian teeth, should be noted. Oral sepsis. 

12. The presence or absence of obstruction in the naso-pharynx is 
the chief point to note. Observation should include mouth-breathing; 
inflammation, enlargement, or suppuration of tonsils; probable or 
obvious presence of adenoids, polypi; specific or other nasal discharge, 
catarrh, malformation (palate), Ac. 

13. Including blepharitis, conjunctivitis, diseases of cornea and lens, 1 
muscular defects (squints, nystagmus, twitchiugs), Ac. 

14. To bo tested by Snellen’s test types at 20 feet distance 
(= 6 metres). Kesult to be recorded in the usual way—e g., 
normal V. = J. Examination of each oyo (K. and L.) should, as a rule, 
be undertaken separately. If the V. be worse than £. or if there be 
signs of eye strain or headache, fuller examination Bbould be made 
subsequently. Omit vision testing of children under six years of age. 

15. Including suppuration, obstruction, Ac. 

16. If hearing be abnormal or such as interferes with class work, 
subsequent examination of each car should be undertaken separately. 
Apply tests only in general vxiy in case of children under six years of age. 

17. Including defects of articulation, lisping, stammering, Ac. 

18. Including attention, response, signs of overstrain, Ac. The 
general intelligence may be recorded under the following heads : (a) 
bright, fair, dull, backward; (0) mentally defective; (c) imbecile. 
Omit testing mental capacity oj children under six years of age. 

19. Under the following headings should be inserted particulars of 
diseased conditions actually present or signs of incipient disease. The 
extent of this part of the inspection will largely depend upon the find¬ 
ings under previous headings. 

20. Include heart sounds, position of apex beat, amcmis, Ac., in case 
of anything abnormal or requiring modification of Bchool conditions or 
exercises. 

21. Including physical and clinical signs and symptoms. 

22. Including chorea, epilepsy, paralyses, and nervous strains and 
disorders. 

23. Glandular, osseous, pulmonary, or other forms. 

24. State particular form, especially in younger children. 

25. Including defects and deformit ies of head, trunk, limbs. Spinal 
curvature, bone disease, deformed chest, shortened limbs, Ac. 

26. Including any present infectious, parasitical, or contagioiiB 
disease, or any sequela* existing. At each inspection the occurrence of 
any such diseases siuce last inspection should be noted. 

27. Any weakness, defect, or disease not included above (e.g., 
ruptures) specially unfitting child for ordinary school life or physical 
drill, or requiring either exemption from special branches of instruc¬ 
tion, or particular supervision. 


CENTRAL MIDWIVES BOARD. 


A meeting of the Central Midwives Board was held at 
Caxton House, Westminster, on Feb 13th, Dr. F. H. 
Champneys being in the chair. 

Medical Men v. Midrvives. 

The Standing Committee reported that a letter from the 
clerk of the Council transmitting a copy of a letter from the 
Local Government Board inclosing a letter from the executive 
committee of the Rural Mid wives Association in regard to 
the question of the training of midwives, and the possibility 
of the grant of 8tate aid in respect thereof, had been 
further considered. A letter from the clerk of the Council 
transmitting a copy of a memorandum addressed to the 
Secretary of State for the Home Department by Canon 
Dobell on the subject of the supply of midwives in rural 
districts was further considered at the same time. The 
committee reported that it had considered and settled 
a reply drafted by the chairman, and recommended that 
the same be sent to the Privy Council. The Board 
considered the letter which was discussed without 
being read in extenso. Dr. Champneys, in the course 
of his remarks, observed that there had been tension 
between medical practitioners and midwives in many parts 
of the country for some years. That condition of things 
must be recognised and a remedy must be found. If prac¬ 
titioners liked to cooperate with midwives more than they 


did there would be a modus vivendi found. Dr. Champneys 
also said he was not proud of the attitude of a large 
number of the members of the medical profession in the 
matter and quoted from a nursing journal some remarks 
alleged to have been made by a medical practitioner 
whose name Miss R. Paget said she could produce. 
Mr. E. Parker Young stoutly maintained that it should be 
widely known that the Midwives Act was unworkable. 
The medical profession bad on all sides and by all manner 
of means shown that the Act was unworkable. The remedy 
was to pay medical men an adequate sum when they were 
called in on the advice of midwives. The Government 
must be put in full possession of all the facts of the case. 
If the Government was going to do any good it must take 
action in the matter. The Government was greatly to 
blame for not grappling with the difficulty. 

The Board decided to send the letter to the Privy Council 
and the following is a copy kindly supplied for publication 
by the Board :— 

Central Midwives Board. 

Caxton House, Westminster. London, S.W., 
Feb. 15th, 1908. 

Sib,—I am directed to advert to your letter of the 12th December, 
1907, transmitting a copy of a letter from the Local Government 
Board inclosing a letter from the exeentive committee of the Rural 
Midwives Association in regard to the question of the training of 
midwives and the possibility of the grant, of State aid towards the 
coBt of such training. These matters have now received the careful 
consideration of the Board and I ain to forward to you for the informa¬ 
tion of the Lord President the observations of the Board on the 
questions raised in your letter. 

With regard to “ the number of midwives likely to be available on 
April 1st, 1910, their distribution in urban and rural districts, to what 
extent the supply will probably fall short of the requirements, and 
how the deficiency is to be made good,’’ the Central Mid wives Board 
has not hitherto considered that these questions fall within the scope 
of the Act, “ to secure the better training of midwives and to regulate 
their practice,” although many of its members who are interested in 
the larger question of the care of the poor mothers of England and 
their infants have taken part in movements with that object. 
The Board is, however, glad to do what it can towards the 
solution of the difficulties, and is earnestly considering the 
subject with a view to making recommendations at an early date. 
The returns of the local supervising authorities under Section 8 (5) 
of the Midwives Act. 1902. are the only data from which the Board can 
ascertain the approximate number of practising raidwives and their 
distribution in the urban and rural districts. These returns are now 
coming in, and it is hoped that by March the Board will be in possession 
of tolerably complete information as to the number of midwives 
practising in England and Wales at the present time. But in taking 
these figures as the basis of an estimate of the number likely to be 
available on April 1st, 1910, it must be remembered that undoubtedly 
a large number of uncertified womea still practise as midwives. There 
are no means available of ascertaining to what extent the total number 
of practising mid wives will be aflected by the fact that these un¬ 
certified women will be debarred from legitimate practice after 
March 31st, 1910. 

As regards the opinion of Mrs. Hobhouse quoted in your letter, 
but not otherwise within the knowledge of the Board, it may be 
well to inform the Lord President that that lady no doubt refers 
to the action of the Board in removing the Cottage Nurses' Home, 
Kings wood, Bristol, from the list of recognised training schools. 
This institution has neither a visiting nor a resident medical 
staff and its work is purely extern. It is situated about 
three miles from Bristol, in which city the Board recognises two 
training schools, the Royal Infirmary and the General Hospital. 
Mrs. Hobhouse was interested in the Kingswood Nurses’ Home 
and warmly supported its application for approval as a training 
school. After considerable discussion the Board granted its ap¬ 
proval in March, 1905. Dr. James McMurray was appointed lecturer 
to the pupil midwives and training was carried on under these 
conditions until June, 1906. Dr. McMurray then resigned his post 
and the pupil midwives received their theoretical training from 
Dr. W. C. Swayne, professor of midwifery at University College, 
Bristol. This course met with the approval of the Board, but as Dr. 
Swayne was a recognised teacher there was no longer any necessity 
for the recognition of the Kingswood Nurses’Home in order to enable 
training to be carried on there. The Board accordingly, on the revision 
of the list of training schools in April, 1907, removed the name of 
Kingswood Nurses' Home. This in no way interferes w ith the training 
at the home, which continues under precisely the same conditions as 
before the name was removed from the list. 21 candidates were sent 
up from the home while it wrs a recognised training school. Of these, 
13 passed and 8 failei. Since the change was made the number of 
candidates has beon 13, with 11 successes and 2 failures, the jierceiitage 
of failure falling from 38 to 15. 

The opinion as quoted alleges that the Board (a) haB “ raised the 
standard of examination,” \b) has " lengthened the syllabus,” (c> has 
•* refused to recognise several old-established training schools.” Ab 
regards the first, (a), the standard aimed at by the Board has always been 
strictly limited to such knowledge as it would be dangerous for a mid¬ 
wife to lack. It must be remembered that imperfect instruction is one of 
the objections alleged against midwives, especially by members of the 
medical profession. The Board has always endeavoured to restrict the 
scope of its examinations to this standard, and these are visited by 
many members of the Board, including the chairman, who makes a 
rule of being present if possible at every examination. To require loss 
than 1 b now required would not, in the opinion of the Board, be sale. 
As regard the second, (5), "lengthening the syllabus.” the Board does 
not quite understand the meaning of the phrase, as there has been no 
•* syllabus ” in existence to lengthen. But possibly it may mean much 
the same as (a), and, in such case, the answer of'the Board would be 




The Lancet,] 


IMPRESSIONS OF THE FINAL STAGE OF CHRONIC GLAUCOMA. [Feb. 22, 1908. 587 


practically the same. As regards the third, (c). “ refusing to recognise 
several old-established training schools," the Board has, of course, to 
exercise its discrimination in this matter, and to refuse to recognise 
institutions which are in its opinion unsuited for this purpose. But, 
as there appears to be much misunderstanding on this question, it 
would point out that recognising an institution is not the only way in 
which an institution can be utilised for training midwives. The prac¬ 
tice of the Board baa been to approve an institution as a recognised 
school of training only when its status is such that it may be taken 
for granted that none but competent officers of all kinds would be 
appointed to it. 

In the case of an institution, such as one of the great lying-in 
hospitals, for instance, the Board has taken it for granted that it 
would be properly officered and its officials are recognised as such for 
the purpose of signing Forms III. and IV. Thus, although officials 
change, the officials for the time being are recognised; when their 
connexion with the institution ceases their recognition lapses. On the 
other hand, in the case of an institution less fully equipped the Board 
has frequently refused to accept it as a *• recognised institution," but 
has approved its medical officer and midwife for the purposes of 
training midwives and signing Forms III. and IV. Such an institu¬ 
tion, though it lacks the prestige of a " recognised institution," has 
exactly the same opportunities of training midwives as if its request 
had been granted. In this case theapprovalof the medical practitioner 
and midwife are personal. The Board has not received any explana¬ 
tion of the statement that its policy as regards (a), ( b ). and (c) “ has 
resulted in an increase in the training fees, and a consequential diffi¬ 
culty in obtaining suitable candidates.” It is far from its wish to 
produce any such result, but it feels that the standard on which It has 
so far Insisted cannot be lowered with safety to the community. 

It must be remembered that nothing but the three months' course of 
training, with the attendance on 20 labours and puerperia, stands 
between what may be absolute ignorance and responsibility of the 
very gravest and most vital character. Only those who have had. on 
the one hand, to deal with the raw material, and on the other 
hand with the same material after training and in face of one 
of the grave complications of childbirth can fully appreciate 
the extreme importance of making such training, though strictly 
limited in scope, as thorough and practical as It cAn possibly 
be made. To place upon the roll women whose training had In 
any way been scamped would be to produce a state of things far 
worse than that which the Act was framed to abolish ; for, w hereas 
before the passing of the Act. the name of midwife carried no official 
weight, since the passing of the Act the name “ certified midwife" 
carries with it the authority of Parliament and implies that its holder 
has either been adequately trained, or (in the case of a bond-tide 
midwife) has at least avoided conviction for malpraxis and removal 
from the roll. The Board therefore feels that its present requirements 
cannot be safely reduced. 

The question of subsidising midwives is one of extreme difficulty'. 
It is certain that in some districts midwives are a necessity, yet it is in 
these very localities that it Is difficult for them to earn a living. It is 
obviously a matter of great delicacy to subsidise a class of persons who 
are alleged to be In competition" with medical practitioners. The 
Board considers that it must necessarily take some time before an 
antagonistic attitude can be expected to disappear. In the meanwhile 
it is of the utmost importance that amicable relations should be 
encouraged by every possible means, and the Board thinks that this 
difficulty would be greatly reduced by a Bcheme by which medical 
practitioners summoned on the advice of midwives, according to 
the rules of the Board, could be adequately remunerated. The 
relations of medical practitioners to midwives vary in different 
districts; in some they are frankly hostile, the medical practi¬ 
tioners stating that they intend to make it impossible for 
midwives to practise in their neighbourhood. The Board is 
not aware of any district in which medical practitioners 
and midwives cooperate amicably; such districts may, how¬ 
ever, exist. It must be remembe-ed that the Board docB not 
receive reports officially on these subjects, and is not In a position to 
speak with authority. It is possible that a conference could be held 
with advantage on the subject; If such a conference were held, It would 
be necessary that it should be thoroughly representative of all interests 
and that the medical (and especially the rural medical) practitioners 
should be represented by persons having full authority to speak in 
their name. The hope ot a better understanding must necessarily be 

receded by a conviction that. “ midwives are a necessity ” (Report of 

elect Committee of House of Commons, 1893), and also that midwives, 
under proper regulation, would act as cobperators and not as opponents. 
No good would result from such a conference if such delegates were 
only authorised to demand the abolition of midwives—which might 
quite possibly be the case. 

I am, Sir, your obedient 8ervant, 

G. W. Duncan, Secretary. 

To the Clerk of the Council. Privy Council Office, 

Whitehall, S.W. 

A letter from Miss B. M. Worrall, honorary secretary of 
the Mid wives Defence Association, as to the action of the 
local supervising authority for the County of London in 
regard to Rule E 26, was further considered. This rule is 
as follows ;— 

The proper designation of r certified midwife is “ certified midwife,” 
thus, e g., Mary Smith, certified midwife. No abbreviation in the form 
of initial letters is permitted, nor any other description of the 
qualification. 

Memorials on the subject from the Midwives Institute, and 
from the committee of the British Lying-in Hospital, the 
City of London Lying-in Hospital, the General Lying-in 
Hospital, and Queen Charlotte’s Lying-in Hospital were con¬ 
sidered at the same time, as well as a letter from Dr. H. 
Scurfield. The Board decided that the Privy Council should 
be asked to approve the addition of the following words to 
Rule E 26 :— 

Provided that a midwife whose name has been admitted to the roll In 
virtue of having passed the examination of the Central Midwives 


Board, or in virtue of a qualification under 8ection 2 of the Midwives 
Act, 1902, acquired by passing an examination in midwifery, may add 
the words “by examination" after the words “ certified midwife.” 

Letters were considered from the Master and the honorary 
secretary of the Coombe Hospital, Dublin, submitting for the 
observations of the Board certain rules and regulations 
adopted by the board of the hospital with respect to the 
training of pupil midwives. The Board decided that the 
board of the Coombe Hospital should be referred to the 
public press for the results of the Board’s examinations and 
that subject to the foregoing the Board expresses general 
approval of the rules. 


IMPRESSIONS OF THE FINAL STAGE OF 
CHRONIC GLAUCOMA. 

By One Who Has Suffered It. 

SOME six years ago 1 I was privileged to give a patient's 
account in these columns ol the exceedingly difficult eye 
disease known as chronic glaucoma, or grey atrophy, so far as 
a two years’ endurance of it would allow. Having now 
reached what the doctors consider, and what I also believe, 
its final stages I venture to give such fuller impressions as 
my nearly completed experience permits. 

At the period in which the article referred to was written 
it became necessary to make a special maintenance effort, 
and I accordingly devised a scheme in which two attain¬ 
ments successfully employed in earlier days were included 
together with my business as a journalist and advertising 
expert. As a result an engagement was given me by two or 
three food manufacturing firms, during which I walked some 
1200 miles, visiting the principal towns in Lancashire and 
Cheshire, delivering in places of entertainment, colleges, 
and schools lectures on the advantages of blindness and of 
the foods alluded to. The walk was accomplished in July, 
August, and September, my 12-years-old son acting aB guide. 
On most days the evening lecture obliged me to walk in 
evening dreBS and a high hat, as there was seldom much time 
after the day’s journey to get ready for the platform. On the 
whole, the long outdoor exercise seemed to benefit my general 
health, but it was certainly a considerable strain to grope 
through unknown buildings and np strange stairways to 
finally attempt the still more difficult task of interesting an 
unseen audience, and, if possible, make them laugh. At 
the conclusion of the expedition there was, in addition to a 
slight financial gain, an apparent increase in bodily strength, 
while the gout and nerve pains long suffered appeared to 
have been got rid of entirely. 

A year afterwards, however, the atrophy began to extend 
over the body, and in January of last year while in the 
streets I found myself at a full stop owiDg to a contraction of 
the leg muscles and had to be carried home to the bed from 
which I now write. Dr. E. Annacker of Manchester and Dr. 
J. G. Christie of Longsight attended me and watched the pro¬ 
gress of the malady with the skilled practitioner’s, and also 
perhaps the student’s, eye. The loss of vitality is apparent 
in all parts of the body and the nerve pains have returned. 
Dr. Christie has probed the legs, arms, chest, &c., with a 
lancet to what he knows would be pain-point in a person of 
ordinary sensitiveness and has pinched the neck muscles 
with full force without causing the slightest feeling of pain. 
Somewhat restless sleep and an appetite apparently ravenous 
but quickly satisfied, inability to use the legs, and a curious 
sinking of the nerves as if one of the spasms of a shivering 
fit had been abnormally prolonged, are the chief peculiarities 
of my present condition. 

Concerning the eyes, there is an increasing in frequency of 
the phantasmagoria apparent from the first stage of the 
disease. When the eyes are closed and bandaged and the 
room is dark a red patch or stage sometimes slightly 
bordered with a dark blue appears before me. On this 
surface appear, always coming from the right side, figures, 
human as well as fanciful, which engage in a kind of kine- 
matograph action. These figures are now invariably speckled 
with snowflakes, which also cover part of the stage. It 
requires a strong will and a change of the position of the 
body to drive away the illusion, if such it be. In thinking 
the matter carefully out I account for the red stage by the 
red lining of the eyelid, for the blue fringe by the fact that 
this is the colour o f the eyes, and for the flakes by the 

i The Lancet, April 5th, 1902, p. 984. 




The Lancet,] 


LOOKING BACK.—VITAL STATISTICS. 


[Feb. 22, 1908. 58» 


half the cases suffering from some form of physical disease 
for which medical treatment was required. 25 of the cases 
admitted were over 60 years of age. One of the patients 
admitted was a woman who had pleaded guilty at her trial 
for the wilful murder of her two infant children and was 
sent to the asylnm under Section 15 of the Act 25 £ 26 Viet., 
cap. 51. The medical superintendent, in reference to this 
case, writes as follows: “ No opinion is expressed here as to 
the regularity of the legal procedure followed in this case, 
but a protest must be raised against what appears to be a 
growing tendency to make use of asylums as convenient houses 
of detention for dangerous criminals. The modern asylum is 
essentially a hospital; its arrangements are not designed to 
meet the requirements of a gaol, and, in so far as its condi¬ 
tions are made to resemble those of a prison, its efficiency as a 
hospital must suffer. It is most unfair that respectable 
members of a community sent to the institution for medical 
treatment should be forced into association with malefactors 
and murderers and the presence of such persons in the wards 
is keenly resented by the patients." 38 patients were dis¬ 
charged during the year, 26 (11 males and 15 females) as 
" recovered,” 11 (six males and five females,) as “relieved,” 
and one woman as ‘ • not improved. ” The recoveries as com¬ 
pared with the admissions give a proportion of 35 ■ 1 per cent. 
(23■ 4 males and 55'5 females). In 80 1 per cent, of the 
recoveries the mental disorder was of less than three months’ 
duration on the patient’s admission into the asylum. The 
number of deaths (38) is the highest recorded since the 
opening of the institution. The rate of mortality calculated 
on the average number on the register was 11 • 5 (10 ■ 2 males 
and 12 7 females), but l)r. Johnstone states that exa¬ 
mination shows that there is nothing alarming in the 
high figures, which must be regarded as purely acci¬ 
dental. Pulmonary tuberculosis was present in active form 
in 28'9 per cent, of the deaths. The medical superintendent 
draws attention once more to the fact that the legislature has 
not yet made any provision for the granting of retiring 
allowances to the staffs of the Scottish district and parochial 
asylums. Statutory power has been given to grant more or 
less adequate pensions to the officials of the English county 
and borough asylums, the Irish district asylums, and the 
Scottish Boyal asylums. Scottish asylum workers have 
exactly the same kind of duties to perform and they run the 
same risks as the employees in other asylums. They receive 
no compensation for the lack of pensions in the shape of 
higher wages and salaries or otherwise, their remuneration 
being such as to render it impossible for them to make 
adequate provision for old age or infirmity ; and it is well 
known that of all public employments asylum service is the 
most anxious and responsible and the most dangerous to the 
health of body and mind. The new female wing of the asylum 
was opened on Nov. 26th, 1906, and the Commissioner in 
Lunacy, Dr. J. Fraser, states in his report that it is of a highly 
satisfactory character and suitably and comfortably furnished. 
He farther draws attention in his report to the excellence of 
the two hospital sections for sick and infirm patients, and to 
the great advantage that the asylum derives from having four 
certificated hospital nurses, the matron, the deputy matron, 
the assistant matron on duty in the male sick ward, and the 
assistant matron who acts as night superintendent. The 
present rate of board for pauper patients is £29 per annum. 
The garden account shows a favourable balance of £189. 

Leicester Borough Asylum (.Annual Report, 190G-07 ).-— 
On Jan. 1st, 1906, there were 815 patients (350 males and 
465 females) on the registers of this asylum. The admissions 
during the year were 221 (85 males and 136 females). Dr. 
J. E. M. Finch, the medical superintendent, reports that the 
number of admissions from Leicester itself of both sexes, but 
especially of males, has been higher during 1906 than in any 
former year, the admission rate for the previous four years 
having been stationary. He further adds that should this 
increase continue more accommodation on the male side will 
be necessary, though there will be ample room on the female 
side for several years. Amongst those admitted, insane 
inheritance was found to be present in 50 instances, intem¬ 
perance in 21, domestic trouble in 18, congenital defects in 
nine, and senile decay in 13. During the year 122 patients 
(57 males and 65 females) were discharged and of these 
82 (32 males and 50 females) were considered “recovered,” 
21 (nine males and 12 females) “ relieved,”and 19 (16 males 
and three females) "not improved.” In the discharges the 
percentage of the recoveries on the admissions, excluding those 
cases transferred from other asylums, is found to be 38 • 1 
in the males and 47'6 in the females. The deaths during the 


same period were 74 (38 males and 36 females), which gives 
a rate of mortality estimated on the average number of 
patients resident in the asylum of 10 • 9 in the males and 
7'3 in the females. The chief causes of death were general 
paralysis in 13 cases, other cerebral lesions in 12, cancer 
in three, pulmonary tuberculosis in five, heart disease 
in 16, and senile decay in eight. Of the 840 patients 
remaining in the asylum at the end of the year 1906 
29 (12 males and 17 females) were deemed to be 
curable. The total number of epileptic patients under 
treatment was 128. There were several changes during 
the year in the staff of the asylum. Amongst the medical 
officers, the second assistant medical officer unfortunately 
met with a fatal accident while cycling, and Mr. C. H. 
Gibson Lyall has been appointed to take his place. Dr. 
Finch reports many changes among the members of the 
nursing staff, and the Commissioners note in their report 
that the duration of service, although as good as in many 
asylums, cannot be considered satisfactory in view of the 
fact that 27 per cent, have served less than one year. During 
the winter the usual lectures on ambulance and nursing have 
been given, 14 attendants and 19 nurses obtaining the 
certificate and two attendants and nine nurses the 
medallion. 


Hoohino Back. 


FROM 

THE LANCET, SATURDAY, Feb, 20th, 1830. 


M. CHABERT. 1 

The following note was received by the Editor on Monday 
last ; can any of our Correspondents suggest an appropriate 
reply ? If M. Chabert has no antidote for prussic acid, it i& 
quite evident that be has impudence enough for anything. 

"M. Chabert requests Mr. Wakley will give him that 
satisfaction which is due to a gentleman, for the recent 
unprovoked, malicious, and unjust attacks against his 
character.” 

Saturday noon, Thomas Street, 

Waterloo Road, Lambeth. 

T. Wakley, Esq., Bedford Square. 


1 Vide ” Looking Hark" in Tit a Laxcet of Jan. 18th, p. 17ff, 
Feb. 1st, p. 383, and Feb. 8th, 1908, p. 435. 


VITAL STATISTICS. 


HEALTH OF ENGLISH TOWNS. 

In 76 of the largest English towns 8648 births and 5798 
deaths were registered during the week ending Feb. 15th. 
The mean annual rate of mortality in these towns, which had 
been equal to 18 2 and 18'3 per 1000 in the two pre¬ 
ceding weeks, showed a further slight increase to 18 • 6 in the 
week under notice. Duiing the first seven weeks of the current 
quarter the annual death-rate in these towns averaged 18 ■ 5 
per 1000; the rate in London during the same period did 
not exceed 18'1. The lowest annual death-rates in the 76 
towns last week were 6 0 in King's Norton, 6 9 in Hastings, 
7/9 in Hornsey, and 10 2 in Grimsby ; the rates in the other 
towns ranged upwards to 25'5 in Stockton, 25 ■ 8 in Rochdale, 
26'3 in Merthyr Tydfil, and 31'4 in Yarmouth. The rate 
in London last week did not exceed 19 0. The 5798 
deaths registered in the 76 towns during the week under 
notice showed an increase of 106 upon the number in 
the previous week, and included 388 which were referred 
to the principal epidemic diseases, against 441 and 447 in 
the two previous weeks ; of these, 154 resulted from 
whoopiDg-cough, 78 from measles, 47 from diphtheria, 43 
from diarrhoea, 40 from scarlet fever, and 26 from “fever” 
(principally enteric), but Dot one from small-pox. The 
deaths from these epidemic diseases in the 76 towns were 
equal to an annual rate of 1 ■ 2 per 1000, the rate from 
the same diseases in London being 1-1. No death 
from any of these epidemic diseases was registered last 
week in Tottenham, St. Helens, Wigan, King’s Norton, 
or in eight other smaller towns ; the annual death-ratea 





590 The Lancet,] 


VITAL STATISTICS. 


[Feb. 22, 1908. 


from these diseases in the other towns ranged upwards, 
however, to 2'9 in Oldham, 3'1 in Hanley, 3'3 in 
Sunderland, and 4 7 in Merthyr Tydfil. The fatal cases of 
whooping-cough in the 76 towns, which bad been 190 and 192 
in the two preceding weeks, declined last week to 154 ; they 
caused annual death-rates, however, equal to 1 • 8 in Oldham, 
1-9 in Aston Manor, 21 in Ipswich, 2'5 in Rotherham, 
and 3 1 0 in Sunderland. The 78 deaths from measles exceeded 
the number in the previous week by seven ; the highest 
rates from this disease were 1 ■ 1 in Salford and in Swansea, 

1 '5 in Hanley, and 2'7 in Merthyr Tydfil. Of the 47 fatal 
cases of diphtheria, showing a considerable decrease from the 
numbers in recent weeks, 18 occurred in London and its 
suburban districts, five in Manchester and Salford, and three 
in Cardiff. The 40 deaths from scarlet fever included 16 in 
London, two in West Ham, three in Liverpool, and four in 
Manchester and Salford. The 26 deaths referred to 
“fever" showed a slight increase; the four fatal 
cases in Norwich were equal to an annual rate of 
1 7 per 1000. The number of scarlet fever patients 
under treatment in the Metropolitan Asylums and London 
Fever Hospitals, which had steadily declined in the ten 
preceding weeks from 5581 to 3867, had farther fallen 
to 3806 on Feb. 15th; during the week ending on that day 
473 new cases were, however, admitted to these hospitals, 
against 380, 405, and 433 in the three previous weeks. The 
deaths in London referred to pneumonia and other diseases 
of the respiratory organs, which had declined in the four 
preceding weeks from 499 to 395, rose again to 451 in the 
week under notice, and exceeded by 79 the corrected aver¬ 
age number in the corresponding week of the five years 
1903-07. The causes of 69, or 1-0 per cent., of the 
deaths registered in the 76 towns last week were 
not certified either by a registered medical practi¬ 
tioner or by a coroner. All the causes of death were 
duly certified in Leeds, Bristol, West Ham, Manchester, 
Salford, and in 44 other smaller towns. Ten uncertified 
causes of death were, however, registered in Birmingham 
and in Liverpool, and three each in Sheffield, Gateshead, and 
Tynemouth. _ 

HEALTH OF SCOTCH TOWNS. 

The annual rate of mortality in eight of the principal 
Scotch towns, which had been equal to 22 ■ 3 and 23 • 5 
per 1000 in the two preceding weeks, declined to 21 ■ 4 in 
the week ending Feb. 15th, but exceeded by 2 • 8 the mean 
rate during the same week in the 76 English towns. 
Among the eight Scotch towns the death-rates ranged from 
14-3 and 17 • 4 in Aberdeen and Greenock, to 22 9 in 
Glasgow and 29 ■ 6 in Perth. The 755 deaths in these eight 
towns showed a decline of 72 from the high number returned 
in the previous week, and included 114 which were referred 
to the principal epidemic diseases, against 142,123, and 132 in 
the three preceding weeks ; of these, 55 resulted from measles, 
18 from whooping-cough, 18 from diarrhoea, eight from 
“ fever,” eight from diphtheria, seven from scarlet fever, 
hut not one from small-pox. These 114 deaths were equal 
to an annual rate of 3'2 per 1000, which exceeded by no 
less than 2'0 the mean rate last week from the same 
diseases in the 76 English towns. The 55 fatal cases 
of measles showed a decline of nine from the number re¬ 
turned in each of the two previous weeks, and included 
47 in Glasgow and three in Edinburgh and in Aber¬ 
deen. Of the 18 deaths from whooping-cough, fewer 
by 14 than those in the previous week, 11 were returned 
Glasgow and two both in Edinburgh and in Leith. 
The 18 deaths attributed to diarrhoea exoeeded the 
numbers in recent weeks ; 11 occurred in Glasgow, 

two in Dundee, and two in Leith. Of the eight deaths 
referred to “fever,* seven were certified as cerebro-spinal 
meningitis and one as enteric fever; these eight deaths 
included five in Glasgow, two in Paisley, and one in Edin¬ 
burgh. Five of the eight fatal cases of diphtheria were 
returned in Glasgow ; and the seven deaths from scarlet 
fever included three in Glasgow and two in Paisley. The 
deaths referred to diseases of the respiratory organs in 
these eight towns, which had been 179 and 171 in the 
two preceding weeks, rose again to 176 in the week under 
notice, and exceeded by seven the number from the same 
diseases in the corresponding week of last year. The 
causes of 28, or 3'7 per cent., of the deaths in these 
towns last week were not certified or not stated ; in the 
76 English towns the proportion of these uncertified deaths 
last week did not exceed 1 0 per cent. 


HEALTH OF DUBLIN. 

The annual rate of mortality in Dublin, which had declined 
in the four preceding weeks from 31 • 2 to 22 ■ 3 per 1000, rose 
again to 24 7 in the week ending Feb. 15th. DurlDg the 
first seven weeks of the current quarter the death-rate in the 
city averaged 26 ■ 4 per 1000, whereas the mean rate during 
the same period did not exceed 18'1 in London and 19 ■ 7 in 
Edinburgh. The 187 deaths of Dublin residents registered 
last week showed an increase of 18 upon the number in the 
previous week, and included three which were referred to the 
principal epidemic diseases, against nine, six, and four in the 
three preceding weeks ; these three deaths included one each 
from measles, diphtheria, and whooping-cough, nodeath being 
registered either from scarlet fever, “fever,” diarrbcea, or 
small-pox. These three deaths from epidemic diseases were 
equal to an annual death-rate of but 0 4 per 1000, the 
death-rate from the same diseases last week being 1" 1 
in London and 1'3 in Edinburgh. The 187 deaths from 
all causes in the city last week included 30 of infants 
under one year of age and 60 of persons aged upwards of 
60 years; the deaths of infants showed an increase, while 
those of elderly persons were fewer than in any recent 
week. Four inquest caseB and four deaths from violence 
were registered during the week, and 76, or 40'6 per cent., 
of the deaths occurred in public institutions. The causes 
of six, or 3'2 per cent., of the deaths in the city last 
week were not certified ; in London the causes of all 
but two of the 1752 deaths last week were duly certified, 
while in Edinburgh the proportion of uncertified deaths 
was 3'6 per cent. _ 

VITAL STATISTICS OF LONDON DURING JANUARY, 1908. 

In the accompanying table will be found summarised 
complete statistics relating to sickness and mortality in the 
Oity of London and in each of the metropolitan boroughs. 
With regard to the notified cases of infectious disease it 
appears that the number of persons reported to be suffering 
from one or other of the nine diseases specified in the 
table was equal to an annual rate of 8'4 per 1000 of 
the population, estimated at 4,795,757 persons in the 
middle of the year ; in the three preceding months the rates 
were 13 ■ 6, 11 ■ 4, and 9 • 1 per 1000 respectively. The lowest 
rates last month were recorded in Paddington, Kensington, 
Chelsea, the City of Westminster, St. Marylebone, Hampstead, 
and the City of London ; the highest rates were Hackney, 
Bethnal Green, Stepney, Poplar, Bermondsey, and Deptford. 
The prevalence of scarlet fever again showed a marked 
decline last month ; among the various boroughs this 
disease was proportionally most prevalent in Hackney, 
Bethnal Green, Stepney, Poplar, Bermondsey, Camberwell, 
and Deptford. The Metropolitan Asylums hospitals con¬ 
tained 3866 scarlet fever patients at the end of last 
month, against 5395, 5600, and 4956 at the end of the 
three preceding months ; the weekly admissions averaged 
423, against 773, 621, and 458 in the three preceding 
months. The prevalence of diphtheria showed no variation 
from that recorded in the previous month ; this disease was 
proportionally most prevalent in Stoke Newington, Hackney, 
Bethnal Green, Wandsworth, Greenwich, Lewisham, and 
Woolwich. The number of diphtheria patients remaining 
under treatment in the Metropolitan Asylums hospitals at 
the end of last month was 1135, against 1252, 1277, and 
1168 at the end of the three preceding months ; the 
weekly admissions averaged 150, against 199, 179, and 
155 in the three preceding months. Enteric fever 
was considerably less prevalent than it bad been in any 
of the four preceding months; the greatest proportional 
prevalence of this disease was recorded in Hammersmith, 
Chelsea, Holborn, Bethnal Green, Poplar, and Bermondsey. 
There were 96 enteric fever patients under treatment in 
the Metropolitan Asylums hospitals at the end of last month, 
against 123, 128, and 119 at the end of the three preceding 
months; the weekly admissions averaged 12, against 

18 in each of the two preceding months. Erysipelas 
wa6 proportionally most prevalent in Fulham, Hackney, 
Bethnal Green, Stepney, Poplar, and Bermondsey. The 

19 cases of puerperal fever notified during the month 
included two in Bethnal Green and three each in Shore¬ 
ditch, Stepney, and Wandsworth. Ten cases of cerebro¬ 
spinal meningitis were notified, of which two belonged to 
Hackney, two to Lambeth, and one each to St. Marylebone, 
Islington, Stoke Newington, Finsbury, Poplar, and South¬ 
wark. 

The mortality statistics in the table relate to the deaths 



ANALYSIS OF SICKNESS AND MORTALITY STATISTICS IN LONDON DURING JANUARY, 1908 

(Specially compiled for The Lancet.) 


The Lancet,] 


VITAL STATISTICS OF LONDON DURING JANUARY, 1908. 


[Feb. 22, 1908. 591 


0001 

s 

a s s s a a 

io -< tf io in o 

CD CJ PO r-. sc CM 

P- CM © 

CO CM O 

OJ CO CM PO 

CM CM r-t PO 

sssassasss 

i 

»juxjuj ,o eqi«9Q 








'XUIAJI 

0001 Md eisj-qinaa 

*9 

C— 

r*4 

PO OJ rH N ip C— 
t> P- Cl CO T 

CO rrt P-Q TT O O 

00 r—4 OJ UD 03 00 

ri fp P- 

<r r-t 

CM CM CM 

>T ■O' N OO 

CM •—* d> O 

CM CM r« CM 

rrqjcMiOr-*OJp-tocnr-t 

6 ii(fl«ibirpijpbtr 

r—t CM r—' r—t r—t r—. 1 —1 r—I r-l 

i 

'Bosnia 

H« tuoj; sq;«9Q 

O 

CO 

o 

oo 

^ y) t« iO IO 

in - co « w <r 

OO rO CM CM r. IM 

§ a 1 § s s 

CO MP O 

CM cm vr 
n CM 

CO OJ r-t CM 

CO t- ST 

CM CM tO PO 

391 

269 

500 

291 

420 

399 

199 

152 

2C9 

178 

i 


S)U 1 A |1 

auosjad 0001 

Jed [«nuuy 

cm 

H 

tt oi m w « (p 

O O +■* o 

CM rp O 00 00 

O O rrt r —1 O f —1 

OJ CO r-t 

PO P- OJ r-l 

H i H cM 

rOCOP-ipoiCTJOJrOP-p 

r—t r—1 C3 r-4 r-t O O t^4 r—4 r4 

i 

s 

i 

5 

WOi 

c- 

s 

g (O (O H ® o 

OJ CM O CM rr O 
rc m 

O to CM 

h 3 S 2 

POHPM«tO<T®PO 
iMCMCMCMPOCMnriCMt—' 

i 

"vaoqjjMfQ 

o 

oo 

H H N K) CO ro 

r-4 | f-4 LO j to 

1 " 1 

<cr r-» oo 

OJ<»tOPOtOi-rpOCMr-4 | 

i 

S 

o 

BJ9A9J 

panuijuoo uaq^o 


II 1 1 1 1 

1 1 1 II 1 

1 1 1 

1 1 rt 1 

1 1 1 1 1 1 1 1 1 1 

i 

8 

w 

K 

* 

•aaAaj aijaqug 

to 

1 1 1 " 1 " 

1 1 ~ N 1 1 

r-l CM | 

1 11 

I r | | 1 r | | | r 

i 

i- 

Ct 

H4 

-I 9 AQJ snq<l£x 

1 1 1 1 1 1 1 1 1 1 1 1 1 III 1 1 1 1 1 1 1 II 1 1 1 1 1 1 


•qflnoo 

- 8 ujdooq^ 

o 

- 1 1 ” w ~ 

to | O CM CM to 

PO PO | 

t-4 CM CM O 

pinNONPICCOlOU 

i 

a 

o 

£ 

.'»H 8 TWlia 

00 

H 

to | CM | CM 

ro n PO | OJ 

^ ^ 

n rr P- PO 

P-POrOPOCOP-nCMCMaJ 

i 

so 

a 

t* 

3 

•J0A9J ^dlJMOg 

a 

CM j CM «T CM | 

1 |-. |» 

1 - 1 

m co o to 

CM m W tt 4p P | CM CM r-4 

i 

O 

‘ H 8 [ 8 U 8 J\[ 

o> 

04 

H 

CM O CM 00 r-4 CM 

| H » CO CM 00 

CM CM r-4 

ro p- m oo 

CM CM CM CO r-4 r-4 | | UO CM 

i 


•xod-ipnng 

1 1 1 1 1 1 1 1 1 1 1 1 1 III 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 


-Euiau 
inosjBd OOOT 
aod q*«j pmuuy 

7* 

00 

V » « C- N OO 

r- OJ *r 

OJ t>- OO CO CM 00 

po v i in i h 

® O PO 

ib co tp 

CM O CO o 
t> ■b h « 

np pvporoioinpropo 
cbriODCOOOOrHP-OOaj 

i 


*m<>i 

a 

a 

2 a 5 3 s s 

CO CM to cn CM CO 

oi 5i po ic 

*-• CM CM 

O) v co 

CM c— 

O « H H 
UJ to tO PO 
r—1 PO OJ 

O^TOJtOtOP-ri,— 


S 

w 

■sj^iHumaiu 

Ivuidfl-oaqaJdQ 

o 

r-4 

1 1 II II 

- | | 1 1 « 

1 - 1 

III" 

- r I i i I i i i 

i 

Q 

00 

p 

■B«iad}B^JS 

a 

Tfi 

00 OJ O tO o 

r-l CM r-4 

CM po po n- pp 

r-t r-t rO PO 

PO r-t r* 

(C P P P 

ro cm 

ssssaass”” 

i 

i 

1 

N 

O 

•J 8 A 9 j jiuadaenj 

o> 

1 1 ”* 1 1 1 

1 1 " ~ 1 

1 1 1 

PO 00 PO r-4 

i i - i m - i i i " 

i 

•SJ9A0J 

panuj^uoo aaq^o 

w-t 

1 1 1 1 1 1 

1 1 1 1 1 1 

1 1 1 

1 1 - 1 

i i i i i i M i i 

i 

$ 

5 

o 

-JOAdj opaquja 

CO 

H 

H 

■M- PO r-l r-l PO CM 
ri 

| CM CO to 

PO CM | 

CM CM OJ 

CO CO PO CM O PO rt lO t —i 

i 

p 

W 

s 

■J0A9J snqd^j, 

1 1 1 1 1 1 1 1 1 1 1 1 1 III 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 

§ 

65 

.'«H»qwd,a 

to 

H 

OJ 

2 § 2 S h 2 

H ^ ? S H S 

CO "3- PO 

Cl CO O CM 
r-t ro c— ro 

P-«fP-CMiOPOOr-tC>-4 

NMlOtCP^MPOntf 

- 


•40A9; lepvog 

cj 

o 

eo 

<M 

« h co h oo 
ro CM lO OJ r-t «T 

P- PO O CM tO 

r-t ro OJ CM n CD 

C* CO ra¬ 
ft «3- 

CM —r PO 

in p gj to 

CD rO r-t CM PO PO CM P— r—4 CM 
P-GJCTJCOP^tiJajrOCOtO 

i 


' 'XOd-IlStUg 

H 

1 1 1 1 1 1 

1 1 - 1 1 1 

1 1 1 

i i i i 

II 1 1 1 1 1 1 1 1 

i 

■8061 

jo Oipppn 8 q*j u\ 
aoftii[ndod pequuinsH 

O 

t- 

Sf 

t— 

<«r 

150,923 

182,752 

124,012 

171,562 

75,049 

170,545 

126,867 

92,654 

237,075 

349,091 

54,015 

235,253 

(D N M 

w o in 

V O M 
tt" tO OJ - 
to OJ r-t 

115,227 

131,066 

310,706 

171,516 

210,442 

127,910 

321,344 

183,873 

289,506 

280,022 

117,539 

109,110 

156.627 

131,346 

■ 



i 

:::::: 


55 ; 

: s • • 


: 


00 

w 

© 

p 

o 

« 

o 

« 

p 

K 

a 

g 

5 

, : 

s 

65 

O 

Q 

65 

O 

•0 ***** • 
o ..... . 

■ss h 

5- • • ■ =2 

•0 ; • J • 5 

S' •s • ! a 

flag • : 8 

a® oe a> a 

G n fl » S 

-- *b H «8 a ° 

S a 5 5 • >? 

2 O a o X3 *2 

Ph « H c*. o o 

Forth Districts. 

St. Marylebone . 

Hampstead . ... 

St. Pancraa . 

Islington.. ... 

Stoke Newington. 

Hackney... 

Central Districts. 

Hoi bom .. ... ... ... 

Finsbury. .. 

City of London . 

East Districts. 

Shoreditch . 

Bethnal Green .. ... 

Stepney . .. .. 

Poplar .. ... .. 

1 : • : : 5 : : : : : 
| i 

S - . : .. : 

sSfltjSS&aiJ? 

COOkJD^OQOhl^ 

: 

a 

o 

1 

3, 

o 

i 


Including membraooai croup. 









592 Thu Lancet,] THE LONDON COUNTS’ COUNOIL & THE TREATMENT OF SCHOOL CHILDREN. [Feb. 22,1908. 


of persons actually belonging to the various boroughs, 
the deaths occurring in institutions having been distri¬ 
buted among the several boroughs in which the deceased 
had previously resided. During the five weeks ending 
Feb. 1st the deathB of 8030 persons belonging to London 
•were registered, equal to an annual rate of 17'5 per 1000 ; 
in the three preceding months the rates were 13 • 5, 14 5, 
and 15'2 per 1000 respectively. The lowest death-rates last 
month were 11 1 in Hampstead, 13'9 in Lewisham, 14 1 1 
in Woolwich, 14 2 in Fulham, 14 5 in Greenwich, and 
14 -7 in the City of Westminster; the highest rates were 
20'8 in Poplar, 21 4 in Bethnal Green, 21 7 in the City of 
London, 21 ■ 9 in Bermondsey, 22'4 in Shoreditch, 24 1 in 
Holborn, and 24 • 3 in Finsbury. The 8030 deaths from all 
causes included 567 which were referred to the principal 
infectious diseases; of these, 129 resulted from measles, 
83 from scarlet fever, 118 from diphtheria, 140 from 
whooping-cough, 16 from enteric fever, one from ill- 
defined pyrexia, and 80 from diarrhoea. The lowest death- 
rates last month from these diseases were recorded 
in Hammersmith, the City of Westminster, Hampstead, 
8 t. Marylebone, Stoke Newington, and Lambeth; and the 
highest rates in Hackney, Holborn, Finsbury, Bethnal Green, 
Stepney, Poplar, Bermondsey, and Lewisham. The 129 deaths 
from measles were 54 below the corrected average number 
in the corresponding periods of the five preceding years ; 
this disease was proportionally most fatal last month in 
Paddington, Kensington, Fulham, St. Pancras, Stepney, and 
Poplar. The 83 fatal cases of scarlet fever were 34 
in excess of the corrected average number; among the 
•various boroughs this disease showed the greatest pro¬ 
portional mortality in Hackney, Shoreditch, Bethnal Green, 
Poplar, and Bermondsey. The 118 deaths from diph¬ 
theria were 41 above the corrected average number in the 
first five weeks of the years 1903-07 ; this disease was pro¬ 
portionally most fatal in Hackney, Holborn, Finsbury, the 
City of London, and Lewisham. The 140 fatal cases of 
whooping-cough were 65 fewer than the corrected average 
Dumber; among the various boroughs the highest death-rates 
from this disease were recorded in Chelsea, St. Pancras, 
Holborn, Stepney, Poplar, Battersea, Wandsworth, Deptford, 
and Greenwich. The 17 deaths referred to “ fever" were 13 
below the corrected average number ; of these 17 deaths two 
belonged to the City of Westminster, two to Islington, two 
to Finsbury, two to Stepney, and one to each of nine 
other boroughs. The 80 fatal cases of diarrhoea corre¬ 
sponded with the average number; this disease was pro¬ 
portionally most fatal in Finsbury, Shoreditch, Poplar, 
Southwark, and Bermondsey. In conclusion, it may be stated 
that the aggregate mortality in London last month from 
the principal infections diseases was 9 per cent, below the 
average. 

Infant mortality, measured by the proportion of deaths 
among children under one year of age to registered births, was 
equal to 115 per 1000. The lowest rates of infant mortality 
were recorded in St. Marylebone, Stoke Newington, Holborn, 
Lambeth, Wandsworth, Camberwell, Lewisham, and Wool¬ 
wich ; and the highest rates in Kensington, Hammer¬ 
smith, Fulham, St. Pancras, Poplar, and-Bermondsey, 


THE SERVICES. 


Royal Navy Medical Service. 

In accordance with the provisions of Her late Majesty's 
Order in Council of April 1st, 1881, Surgeon Francis Edwin 
McCune has been placed on the retired list (dated Jan. 23rd, 
1908). 

The following appointments are notified Fleet Surgeon 
F. J. A. Dalton, to the President, additional, for R.F.A. 
Maine: Staff Surgeon E. S. Reid, to the President , additional, 
for R.F.A. Maine: Surgeon C. T. Baxter, to the President, 
additional, for R.F.A. Maine. 

Army Medical Service. 

Lieutenant-Colonel Fitzroy B. Maclean, from the Royal 
Army Medical Corps, to be Colonel, vice J. F. Williamson, 
C.B., C.M.G., retired (dated Feb. 6th, 1908). 

Royal Army Medical Corps. 

Major F. M. Maugin has been posted to the Connaught Hoe- 
p’.tal, North Camp, Aldershot for duty. Captain W. L. Baker 
has joined at Aldershot and been posted to the Connaught 


Hospital for duty. Lieutenant M. J. Cromie has been trans¬ 
ferred from Mhow to Jubbulpore for permanent duty. 

Army Medical Reserve of Officers. 

Surgeon-Captain Arthur H. Vernon to be Surgeon-Major 
(dated Feb. 1st, 1908). 

Imperial Yeomanry. 

Lancashire Hussars : Surgeon-Lieutenant J. T. Nisbe to 
be Surgeon-Captain (dated Jan. 24th, 1908). 

• Volunteer Corps. 

Hayol Garrison Artillery (Volunteers'): 1st Berwickshire: 
Irvine Kempt Hermon to be Surgeon-Lieutenant (dated 
Jan. 17th, 1908). 1st Durham ; William George Thompson 
to be Surgeon-Lieutenant (dated Jan. 1st, 1908). Frank 
Wilfred Burn to be Surgeon-Lieutenant (dated Jan. 3rd, 
1908). 

Hide : 2nd Volunteer Battalion, The Prince Albert's 
(Somersetshire Light Infantry) : Arthur Norman Haig to be 
Surgeon-Lieutenant (dated Jan. 14th, 1908). 2nd Volunteer 
Battalion, The Welsh Regiment : Surgeon-Major J. A. Jones 
to be Surgeon-Lieutenant-Colonel (dated Jan. 29th, 1908). 
13th Middlesex (Queen's Westminster) Volunteer Rifle Corps: 
Surgeon-Major and Honorary Surgeon Lieutenant-Colonel 
P. P. Whitcombe to be Surgeon-Lieutenant Colonel (dated 
August 7th, 1907). 

Royal Army Medical Corps (Volunteers). 

Western Command: Manchester Companies: Thomas 
Carnwath to be Lieutenant (dated Jan. 28th, 1908). 

Tuberculosis in thf. Army. 

In the House of Commons on Feb. 18th, in reply to a ques¬ 
tion by Mr. Summerbell regarding the action which the 
Secretary of State for War proposed to take with reference 
to soldiers suffering from tuberculosis, in view of the findings 
of the Select Committee appointed to go into the matter, 
Mr. Haldane said that the recommendations of the Select 
Committee had been recently considered by the Government. 
The decision was that, however desirable the special provision 
recommended by the Committee in the case of soldiers dis¬ 
charged from the army because of tuberculosis, it was 
impossible to justify the assumption of this new kind of 
obligation by the State unless it is extended to other services 
as well as the army, and possibly more widely still. 


Comspottbmc. 


"Audi alteram partem.” 


THE LONDON COUNTY COUNCIL AND 
THE TREATMENT OF SCHOOL 
CHILDREN. 

To the Editor of The Lancet. 

Sir,—Y ou are doubtless aware that the London County 
Council has caused its Education Committee to appoint a 
special subcommittee consisting of members of the Council 
and representatives of outside institutions to inquire into the 
whole question of the medical treatment of children attending 
public elementary schools. This subcommittee has been formed 
and it may be stated at once that the London hospitals, in¬ 
cluding the Hospitals for Sick Children, are wholly inade¬ 
quately represented upon it. Under the Education (Admini¬ 
strative Provisions) Act, 1907, the Council has powers to 
make such arrangements as may be sanctioned by the Board 
of Education for attending to the health and physical con¬ 
dition of these children. The Education Committee of the 
Council has issued to the London hospitals a series of ques¬ 
tions which indicate the extensive natnre of its investiga¬ 
tion, the diseases including those of the eye, ear, skin, 
teetb, malnutrition, &c. There is considerable danger that 
these qnestions may be answered without due appreciation 
of the far-reaching effects of any scheme which may be 
instituted. It need only he mentioned that school clinics 
cannot be established without enormous expense and 
without injury to the hospital clinics; or, if the addi¬ 
tional work is thrown upon the hospitals, they will have 
to bear the increased expense. In the former case, and 
in the latter also, if the hospitals are subsidised (of 
which there is no suggestion) the ratepayers will have to 




Th» Lancet,] 


PLEURAL EFFUSION AND ITS TREATMENT. 


[Fbb. 22, 1908. 595 


bear the harden. Judging by the examination of sohool 
children for diseases of the eye, which is already in force, no 
attempt will be made to ascertain whether the parents are in 
a position to pay, however inadequately, for advice. If the 
scheme is extended to include diseases of the Bkin, general 
debility, &;c., general medical practitioners must inevitably 
suffer severely. 

I have been led to trouble you with this letter more 
particularly on account of the false analogy which is likely 
to be made between special diseases, such as diseases of the 
eye and other complaints. It has already been pointed out 
in your columns that the work cow done by the County 
Council oculists might equally well be done by teachers after 
a short course of instruction, and you have advocated that 
the oculists should correct the refractions which at present 
they are occupied in discovering. 1 am in complete agree¬ 
ment with this policy which would relieve hospital clinics 
of uninteresting drudgery and would entail no hardship 
upon general practitioners. It is a very different matter, 
however, to hand over to the County Council the treatment of 
other minor complaints and more serious diseases affecting 
school children, for this would be in the highest degree 
detrimental to hospital clinics and general practitioners, as 
well as entailing enormous expense. 

More than ever at the present time questions continually 
arise which demand coordinated action on the part of the 
medical staffs of the London hospitals. Lack of coordina¬ 
tion in matters such as that under consideration is likely to 
lead to schemes which fall short of the best which can be 
devised. In this manner the praiseworthy aims of the 
Connty Council and of the hospitals, which are alike working 
for the alleviation of suffering, are liable to be frustrated. 
The lay control of the London hospitals is in some con¬ 
siderable degree coordinated by the Council of King Edward’s 
Hospital Fund. I would suggest that a standing committee 
composed of representatives of the medical staffs of the 
London hospitals be formed to which matters of mutual 
interest might be referred with a view to coordinated action. 
The Central Hospital Council does not exactly meet the 
requirements of the case. 

I am, Sir, yours faithfully, 

Wimpole-streot, W., Feb. 16th, 1908. J. HERBERT PARSONS. 


DEVELOPMENT OF NODULES IN SUTURE 
SCARS AFTER OPERATIONS FOR 
THE REMOVAL OF CANCER. 

To the Editor of The Lancet. 

Sir,—I n The Lancet of Feb. 1st Mr. C. W. Mansell 
Moullin, in a paper on the above subject, draws attention to 
cancer nodules occurring in the cicatrices caused by the 
sutares used in closing the abdomen in a case of cancer of 
the pylorus which had been under his care. In referring to a 
publication of mine in The Lancet of Nov. 9tb, 1907, 
in which somewhat similar cases were reported, he considers 
that the appearance of nodules in his case suggests that 
the mode of conveying cancer infection to the suture 
tracks is not so simple as is generally believed. My 
paper referred to the danger of cancer infection and 
its importance in relation to the question of “ recurrence." 
I tried to demonstrate that the cancer cell is infective, and 
therefore if it be set free at the time of operation it is liable 
to be implanted by the surgeon or else implant itself in some 
part of the wound and thus give rise to a fresh cancerous 
outbreak. The cases of suture star nodules quoted were 
given as illustrations of how readily cancer cell implantation 
may occur and also as some of the possible ways in which 
implantation may be brought about. 

In the course of my experience I have come across a great 
many varieties of infection of the sutnre tracks: in some 
the infection was limited to the superficial and in others to 
the deeper layers of the skin ; and, again, it manifested 
itself as a nodule deeply in the tissues directly in the 
course of the sutures ; and I have also seen it occurring 
as infection of the entire track of the suture ; nevertheless, 
it is far from belief that these cancer “ recurrences ’’ were 
all due to infection haviDg been carried there on the needle 
or sutures. In Mr. Mansell Moullin’s case two sets of sutures 
were used in closing the wound, one of stout catgut, inter¬ 
rupted, passing through all the layers of the abdominal wall 
except the skin; the other of finer catgut, continuous, 
through the skin only. Practically all the sntnre points of 
the former series were infected; none of the latter. His 


explanation as to how the latter condition occurred 
appears to me to be a perfectly rational one, and I 
may add that a similar condition has come under my 
own observation. The fact that no nodnles appeared in 
the scars of the superficial stitches leads one to infer 
that there were no free cancer cells at the time 
of operation and that the infection in the tracks of 
the deeper sutures came from the abdomen. Cancer cells 
escaped where the sutures pierced the peritoneum, and 
finding their way along the tracks there they became lodged, 
and probably the tissues damaged by the suture proved 
themselves a ready site for implantation. Where the 
abdomen is closed by a single row of “through and through ’’ 
sutures the infection will sometimes spread along the whole 
suture track, and, in fact, in cases of tubercular disease of 
the peritoneum, tubercular infection spreads in a similar way 
along the suture. Doubtless Mr. Mansell Moullin's sugges¬ 
tion explains the occurrence of these phenomena. On the 
other hand, his explanation of the occurrence of canoer 
nodules in suture scars, after operations for mammary cancer, 
is a totally different one. lie suggests that cancer cells may 
be present in the tissues, and that the irritation of the 
sutures may cause these cellB to take on greater activity at 
the points of irritation, hence the subsequent development 
of suture scar nodules. Though I recognise the possibility of 
this, yet I very much doubt that it is a frequent occurrence. 

It is a recognised fact that the peripheral spread of 
mammary cancer is almost entirely by the lymphatics. 
Therefore, if cancer cells are present in the tissues of the 
fiaps it almost necessarily follows that infected lymphatics 
must have been divided at the time of operation, thus allow¬ 
ing the escape of cancer cells. From my experience these 
latter would very readily manifest themselves by setting up 
cancerous infection along the line of incision, if they did not 
even cause widespread infection of the whole wound. It is 
not so much that cancer cells are already present and that 
they take on activity owing to diminished resistance of the 
tissues as the result of irritation of the sutures, which is 
mainly the cause of suture scar “ recurrence.” Our own faulty 
technique is more frequently responsible. It permits the 
escape of free cancer cells, which readily implant them¬ 
selves in whatever part of the wound they may come to 
rest, or to whatever part of it they are carried by the 
surgeon, whether by suture or otherwise. This explains 
many of the cases of suture scar infection, but there are 
others, and Mr. Mansell Monllin’s interesting case is one of 
these, where the suture doeB not actually carry infection ; 
but, on the other hand, it encourages or permits of ready 
implantation. I am, 8ir. yours faithfully, 

Harley-street, tV., Feb. 11th, 1908. CHARLES KYALL. 


PLEURAL EFFUSION AND ITS 
TREATMENT. 

To the Editor of The Lancet. 

Sir,—I n my letter in The Lancet of to-day, p. 521, col. 1, 
second line, “ not elastic ” should be “ non-elastic ”; p. 522, 
col. 2, twentieth line, “ abstract quantity ” should be 
“ abstract quality.” I would not have troubled about these 
trivial mistakes only I am dealing with two toi-disant philo¬ 
sophers and I don’t wish even a printer’s error to creep into 
my letter. I am, Sir, yours faithfully, 

Liverpool, Feb. 15th, 1908. __. James Barr, 

To the Editor of Thr LANCET. 

Sir,—Y ou have been so generous with your space that I 
forbear to reply categorically to Sir James Barr’s last letter, 
the more so that a detailed reply would involve much 
repetition and probably weary your readers. That Sir James 
and I differ profoundly on the subject of pulmonary physics 
is becoming more and more obvious. Sir James now asserts 
that the tautness of the lungs does not exert traction, that 
the pulmonary tissue is not relaxed at the end of a full 
respiration, that the fibroid apices of the lungs in fibroid 
phthisis do not drag in the chest walls, and that, no matter 
how many of the pulmonary vessels are destroyed in this 
disease, if “taut lungs constantly maintained a negative 
intrathoracic pressure there could be no obstruction to the 
systemic venous circulation.” (Not even if all the pulmonary 
capillaries were reduced to a single one 1) In my opinion all 
these contentions are wrong. 

It seems to me, Sir, that the time has now come for the 




594 The Lancet,] 


PLEURAL EFFUSION AND ITS TREATMENT. 


[Feb. 22, 1908. 


jury to retire and consider the verdict. I have stated my 
case as simply as I could and am content to let it stand as 
it is—unamended and unqualified. 

I am, Sir, yours faithfully, 

Wlmpolcstreet, Feb. 16th, 1908. HARRY CAMPBELL. 


To the Editor of The LANCET. 

Sir,—I have carefully read and re-read the correspondence 
between Sir James Barr and Dr. Harry Campbell, and the 
conclusion I have come to is that it has been greatly confused 
through a lack of knowledge and precision on the part of the 
former in discussing the physical problems involved, and on 
the part of the latter through the use of unnecessarily com¬ 
plicated phraseology. 

The employment of the terms “ tautness ’’ and “ traction ” 
by Dr. Campbell is peculiarly unfortunate, as they, at 
least it appears so to me, could both have been so much 
more easily expressed by the word “ tension.” Tension is a 
state of strain, or the act of straining, and is a term per¬ 
fectly well understood. Pulmonary tautness is a pulmonary 
state of strain, or tension. Pulmonary traction is a 
pulmonary act of straining, or tension. The word “tension” 
implies both the condition and the act. The tension of a 
wire means that it is tight and that it pulls ; and it would be 
absurd to worry over its tautness and traction, as both are 
stated or implied when one speaks of its tension. 

Dr. Campbell says I “fail to make the necessary dis¬ 
tinction between tautness and elasticity.” 1 purposely 
avoided discussing the subject, but the distinction is obvious. 
There can be tension or tautness in a wire far beyond what 
its elasticity can produce or resist, or there may be tension 
or tautness less than what its elasticity can produce or 
resist, in which case the force of elastic recoil or tautness are 
equal. There can be tension or tautness in a fibroid lung as 
well as in an elastic one. I am quite at one with Dr. 
Campbell in distinguishing between tautness (or tension) and 
elasticity : where I differ is when he says that the negative 
intrapleural pressure when the thorax and respiratory 
muscles are at rest “ is due to the tantness of the pulmonary 
tissue pure and simple, and that the factor of elasticity, or 
elastic recoil, has nothing to do with it." Dr. Campbell, like 
so many people who discover a truth, fails to see its limita¬ 
tions. 

Suppose there be a large pneumothorax ; the lung recedes 
far from the body wall and rests contracted. Gradually, by 
vital processes, the air is absorbed, and as the chest walls 
cannot fall in so readily as the lungs can stretch, the latter 
expand and presently again fill the thorax. What stretched 
the lungs 1 Dr. Campbell says “ the stretched condition of 
the pulmonary tissue is effected by the Inspiratory muscles.” 
I maintain that the cell action, or other vital processes 
which actively absorbed the air from the pleural sac, lowered 
the pressure in it and cleared the space for the lung to 
expand into, primarily caused its expansion, by decreasing 
the opposition to the action of the intrapulmonary air 
pressure. Likewise though at birth the lung is stretched 
by the thoracic expansion, the lung at, say, ten years of 
age is another lung, and I can conceive of no other way in 
which the new elastic tissue has kept on the stretch than by 
supposing it has been laid down on the stretch, or has con¬ 
tracted afterwards. In this way the elastic tension pro¬ 
ducing the intrapleural negative pressure, when the thorax 
and respiratory muscles are at rest, is generated within the 
lung, and in time would pull the visceral and parietal pleurae 
apart if their lining cells would allow air or liquid to 
accumulate there and permit their separation. When the 
inspiratory muscles expand the thorax beyond the position 
of rest then it is that they obviously operate in lowering the 
intrapleural pressure. 

In addition to his employment of the words “tautness” 
and “ traction ” Dr. Campbell also seems to me unfortunate 
in his use of the word ‘‘suction.” He does not use it as 
indicating a force decreasing the resistance to another force, 
as Sir James Barr rightly contends he should, but as though it 
were the force directly producing the effects observed. These 
are minor matters; the great principle for which Dr. 
Campbell has so earnestly contended—viz., the much over¬ 
looked importance of the action of the inspiratory movements 
in their effects within the chest, and the nature of these 
effects—he has done much to elucidate and establish, and I 
personally feel much indebted to him for what I have learned 
at his hands. 

In regard to Sir James Barr's criticisms, it seems to 
me, after bis letter of Jan. 25th, there is little to 


be gained by discussing physics with him. He there 
gives from the “ Century Dictionary ” a definition 
of “elastic” in which it is stated, “A body is 
perfectly elastic when it has the property of resisting a 

given deformation equally .,” and he remarks: “The 

Campbell physicist says it is a mere property of a certain 
form of matter, by which it has the power of recovering its 
original form after being stretched, but I prefer the other 
authority who say9 that it also signifies a retistan.ee to 
stretching or other deformation.” Now the other authority 
which Sir James Barr quotes and prefers does not say it 
“signifies a resistance to stretching or other deformation." 
The words are, “it has the property of resisting,” and it is 
this idea of a property which Dr. Campbell and I want Sir 
James Barr to admit. Surely it would he better if Sir James 
would “ prefer ” the definition of elasticity given by the 
authority from which he quotes, the “Century Dictionary,” 
rather than his own misquotation from that authority. 

Sir James Barr shortly after proceeds in his letter to what 
he calls “prick the bubble” blown by Dr. Campbell, and he 
compares the uses of a “ non-elastic chain ” and what he 
terms “a hawser made of highly elastic hemp.” He says: 
“ The elastic rope offers resistance to being stretched and 
when the tug of the ship ceases the elasticity gradually pulls 
the vessel back to its former position.” Sir James Barr 
should know that a hawser is made on the twist, and it 
stretches, not because hemp is what he styles “highly 
elastic,” but because the component fibres and twists 
straighten out under tension, taking a direction more along 
the length of the rope than before and less across it, while 
at the same time mutually compressing one another. If 
Sir James twists a piece of string he will see that it shortens 
and will then lengthen when pulled upon more than before. 
The recoil in the hawser is due to the recovery of the parts 
from mutual compression and has nothing at all to do with 
elasticity in hemp. Moreover, if Sir James considers hemp 
highly elastic, why does he immediately speak of “non¬ 
elastic fibroid lungs”? By what mental process does he 
make hemp highly elastic and fibroid lungs non-elastic ? 

Later in his letter Sir James tells how he was selected by 
the Home Office to “devise a method of estimating the 
elasticity of any rope,” and he modestly says, “I did not 
retire to my study and work out the coefficient of elasticity, 
and what should, but probably would not, happen. I deter¬ 
mined the vis viva or energy which I considered necessary, 
and then under a strain of a given number of foot pounds I 
determined the stretch, and I had no difficulty in devising a 
method of measuring the length of unstretched rope which 
would allow of a given energy.” Fancy speaking of the 
length of unstretched rope which would allow of a given 
energy! Energy is the “capacity for doing work,” and is 
measured by the amount of work a body having energy can 
be made to do. What capacity for doing work is inherent in 
a piece of unstretched rope. Would it allow of boiling a 
kettle or climbing a hill ! It would have been far better if 
Sir James Barr had retired to his disparaged study and 
learned the elements of physics as taught before hastily 
experimenting. He might then have started with ideas of 
energy, elasticity, ice., which were physically precise. 

Sir James Barr’s criticism in your last issue of my letter 
of Jan. 25th calls for little comment. He Beems to hold me 
responsible for the consequences of the physical definition 
of elasticity. He says: “Let us see how his definition 
works out.” It is nothing to me how my definition works 
out and what confusion or sadness it produces in the mind of 
Sir James. If he discusses physics as a physicist he must 
take the consequences, however they work out; if as the 
“ man in the street ” he may call hemp highly elastic, rubber 
more elastic, and gas most elastic, but be must pose in future 
as the “ man in the street "and not as a physicist. I will 
leave my last letter and Sir Jame9 Barr’s criticism of it to 
the impartial judgment of your readers as this communica¬ 
tion is already too long, but I hope more particularly that 
Dr. Campbell’s suggestive views may have the attention 
which I think they deserve. 

I am, Sir, yours faithfully, 

Mentone, Feb. 17th, 1908. D. W. SAMWAY8. 

*,* The various parties to this correspondence have had 
ample space in which to expound their views, and none of 
them can complain of the undue vigour of their opponents’ 
language, for none of them has failed to reply with equal 
vigour. As they cannot all have the last word we supply it. 
This Interesting discussion must now cease.—E d. L. 






The Lancet,] 


THE SITUATION AT THE HAMPSTEAD GENERAL HOSPITAL. [Feb. 22, 1908. 595 


TOMB OF AN ANCIENT EGYPTIAN 
PHYSICIAN. 

To the Editor of The Lancet. 

Sin,—In The Lancet of Jan. 11th in your annotation on 
“ The Burial Customs of Ancient Egypt ” by Professor John 
Garstang yon mention the following in connexion with the 
deceased physician’s tomb—viz., that “various and many as 
were the objects deposited beside hiB body only two of 
these can in any way be considered as connected with his 
vocation - namely, a set of writing implements, consisting of 
a writing tablet and a pen-box” ; also that “unfortunately 
no written notes survive upon the palette.” The significance 
of the pen box and tablet in or upon the tomb seems to be 
misunderstood. They are not scarce in any of the bigger 
towns of India and Arabia. Those who have visited the well- 
known tombs of the Moghul Emperors, Akbar and Sbah- 
Jehan, and their wives, must have noticed the carved pen 
box and the adjacent tablet, these being purely symbolic, the 
pen for the man—the active agent and doer of things ; the 
unwritten slate representing the woman—i.e., the passive 
agent, the slave and complement of the man. 

I am, Sir, yours faithfully, 

L. Jones, M.R.C.B. Eng., L.R.C.P. Lond. 

Sialkote, India. 


THE SITUATION AT THE HAMPSTEAD 
GENERAL HOSPITAL. 

To the Editor of The Lancet. 

Sir,—I think the time has come when an attempt should 
be made to remove the impression that this hospital has been 
guilty of some crime against society in general or the 
medical profession of Hampstead in particular, and in order 
to do this I beg the hospitality of your columns, although 
in telling the story I am largely repeating what has already 
appeared editorially in your columns. 

The Hampstead Hospital was started in 1882 with a few 
beds for patients able to contribute a little towards their 
support, and was most successfully officered by certain 
general practitioners in its neighbourhood. It is misleading, 
however, to describe it as a “ cottage hospital.” The free 
beds, which have existed since 1894, have always been in 
charge of the regular medical staff; only the “ contributory 
beds ” have been available to other practitioners. In the new 
hospital there is no intention of taking away this privilege 
from the local members of the profession. 

As a result of increased demands the first portion of the 
new hospital was erected two years ago with 64 beds, and in 
these excellent quarters the hospital has continued to receive 
the willing and able services of the same staff of general 
practitioners. At the opening ceremony it was announced 
that a sum of £10,000 was required to free the hospital from 
debt and that a further sum of £15,000 would complete the 
scheme to provide a total of 110 beds. An immediate 
response was received, Sir Henry Harben announcing that he 
was authorised by an anonymous donor to say that £20,000 
would be forthcoming if the remaining £5000 require i were 
obtained. To avoid diverting support from the general funds 
of the hospital by an appeal for this sum the council laid the 
conditions of this special offer before King Edward’s Hospital 
Fund and received a promise from them to provide the sum 
of £5000. At the same time the King's Fund suggested that 
the growing importance of the hospital made it desirable for 
it to adopt a similar constitution for its medical staff to that 
of all other general hospitals in London. 

At a later date the King's Fund having had its attention 
drawn to the condition of the North-West London Hospital, 
the buildings of which were considered unfit for continued 
treatment of in-patients, and the committee of that institu¬ 
tion being unable to see its way to obtain an adequate 
sum for rebuilding, suggested that an amalgamation of that 
hospital with the Hampstead General Hospital might be 
arrived at, an out-patient department being maintained solely 
in Kentish Town and all in-patients being received at the 
Hampstead Hospital. The King's Fund decided that as it 
was proposed that the Hampstead General Hospital should 
henceforth be reckoned, as was the North-West London 
Hospital, amongst the Metropolitan hospitals, it should be 
a condition of the amalgamation that the Hampstead 
General Hospital should be officered by physicians and 
surgeons of recognised consulting rank. In a canvass on 
this proposal, by means of a series of questions issued to 


the members of the local profession, the opinions expressed 
for and against the change were almost equal, but the 
result was distinctly unfavourable to the scheme of a mixed 
staff of general practitioners and physicians and surgeons 
in consulting practice. It was eventually resolved by the 
council of the hospital to make the change to a staff con¬ 
sisting of physicians and surgeons in consulting practice, 
with definite provision for a term of continued service in the 
case of members of the existing staff of general practi¬ 
tioners. These terms mere accepted as satisfactory by the 
members of the existing staff, except as regards the decision, 
arrived at later under the amalgamation scheme, that the 
two junior members in charge of out-patients (being in 
general practice), who were entitled to further service of 13 
years each, should not be eligible for promotion to in-patient 
posts. 

As regards the amalgamation proposals, I may say that on 
April 10th, 1907, a committee of the local medical profes¬ 
sion and the medical staffs of the Hampstead and North- 
West London Hospitals reported to a meeting of the British 
Medical Association (Hampstead division) that the proposed 
amalgamation with the North-West London Hospital was 
desirable from the public point of view (on certain conditions). 
On the amalgamation being decided upon, the medical staff 
placed themselves in line with the local practitioners who 
were opposed to the changes. Since then, as your readers 
are aware, a canvass of local practitioners has been made by 
the Hampstead division of the British Medical Association, 
resulting in a vote which in their view justified their sending 
a “ warning notice ” to the British Medical Journal which 
was accepted. 

I may say that the council of the hospital appreciate most 
highly the valuable services of the present acting medical 
staff and also their generosity in consenting to act until suc¬ 
cessors could be appointed ; but the council nevertheless 
much regret that when arrangements had been made for the 
retention of these gentlemen on the staff, on a plan but 
slightly modified from that which had been approved by 
them, they should suddenly have changed their mind and 
joined nith others in a scheme for prevent ing their place being 
filled by such persons as the King's Fund suggested, and 
financial reasons had compelled the council to accept, The 
hospital cannot get the promise of the necessary financial 
support in Hampstead—it will need three times as large an 
income as that which it has been able to count on—and it 
has no alternative but to accept the substantial and welcome 
help offered by the King’s Fund, and at the same to submit 
to its conditions which, after all, in a place like London, are 
not unreasonable. 

In conclusion, I would say that the council of the hospital 
have no quarrel with the medical profession in Hampstead, 
nor. on the other hand, have they any fear, doubt, or 
hesitation in adopting the course which the successful evolu¬ 
tion of the hospital has thrust upon them. 

I am, Sir, yours faithfully, 

Ernest Collins, 

Chairman of the Council, Hampstead General 

Hampstead, Feb. 19th, 1908. Hospital. 


THE PRESENT PROSPECTS OF THE 
MEDICAL PROFESSION. 

To the Editor of The Lancet. 

yuj,_Continuing on the ethical lines which we as a 

profession have been following the answer to the heading 
of this correspondence would be, “Not much.” The 
letter of “ Yirtutem Sequor ” contains much which can 
be agreed with, particularly that part in which he deals 
with so-called “ specialists.” Some while ago you headed 
a correspondence, "What is a specialist?” To this 
question you had replies but no definition. I will, with 
your kind permission, essay that needed definition. “ A 
specialist in a department of the healing art is one who, 
knowing thoroughly the entire human body and its ailments, 
is able to devote bis attention to that department for 
which hiB skill and dexterity are most suited.” Instead 
of the above, "specialism,” as now practised, should 
be defined as follows: “A ‘specialist’ is a person whose 
knowledge needs increasing and skill perfecting in that 
department in which he exclusively practises, presuming 
upon a superficial knowledge of the human body and its 
ailments generally.” The contrast is as striking as true. 
The letter of “ Half-and-Half ” centres the “ bull's-eye ” and 



596 The Lancet,] 


THE INACCURATE DOSAGE OF MEDICINES. 


[Feb. 22, 1908. 


will meet with the endorsement of every one who has been 
a general practitioner and has kept himself abreast of the 
times and is striving to rise, and with his rise improve the 
status and prospects of the profession. The first and true 
definition of a specialist applies to the risen general practi¬ 
tioner, the latter definition applies to the 11 bospital-appoint- 
ment-made-specialist ” who yet has his knowledge to gain, 
who has no skill, yet who professes to sell that which he does 
not possess. From the above you can see that the prospects 
for those who have worked hard as general practitioners is 
certainly “not mnch.” Your late most honourable campaign 
in the Law Courts in defence of the rights of the public and 
of those of us who have to work hard for our daily bread was 
partly due to the condition of affairs dealt with by both 
“ Virtutem Sequor”and “ Half-and-Half.” 

Did general practitioners keep themselves abreast of the 
times, and were “ specialists” (?) more really “specialists ” 
and less “ exclusivists ” (learning their “one horse-shay 
racket”), there would be no lay advertisers of this and that 
“ specific ” for one disease and another. Is not “specialism ” 
as now practised a species of quackery ? A good “general 
practitioner” is a true “specialist in many departments,” 
a modern “ specialist ” is a one-string fiddler in an orchestra 
who does not know his notes. Let me ask “Virtutem 
Sequor” one question. Is it worse to advertise rather than 
starve and become a financial defaulter following an un¬ 
written law which no one really cares a straw about, or is it 
worse to be ethical (with your mouth only), the while doing 
all you can to hinder and ruin the prospects of your fellow 
man and brother (?) as is practised in London at hospital 
elections ? Which of the two pictures will show painted the 
blacker sheep? The frank, open advertiser, according the 
same to his fellow man, or the hypoorite who does 
all he can to damn the career of a general practi¬ 
tioner and pitchforks a young “specialist” (?) into a 
post to keep out the other fellow ? All those things 
of which “Half-and-Half” ably writes have I done, 
and more. I will therefore finish iwhat he has left unsaid. 
He says, “ It is, 1 think, forgotten by many that each patient 
sent by them to a “ specialist ” means the loss to them, only 
too frequently, not only of that patient but of all that 
patient’s friends who have, or think they have, any disease 
affecting that particular region of the body.” Let us now 
continue (in my own words), “and of those who have not, 
but have ailments of other parts, will that ‘ specialist ’ send 
on direct to his brother ‘ specialists ’ in accordance with their 
custom of mutual 1 back-scratching,’ and so on, till soon there 
is no practice left for the general practitioner who sent the 
first case.” If it is borne in mind that these so-called 
“specialists” are daily engaged in cutting the throats of 
the lesser general practitioners in the out-patient depart¬ 
ments of hospitals, besides distributing their richer patients 
amongst themselves, we must repeat “ -V ot much." In a recent 
issue you printed an article showing the existence of a 
decided schism in the Liverpool district between general 
practitioners and hospital practitioners who are advertised 
by their (?) hospital and I make bold to say that the London 
general practitioner is a greater fool than I take him for if 
the same does not occur soon in London. 

Strangely enough, a letter by “ F.K.C.S.” entitled "The 
Responsibility for the Anaesthetic ” shows up another phase 
of the “ prospects of the profession,” Why does the general 
practitioner asked to be allowed to give the anassthetic ? As 
one who has been a general practitioner let me answer. To 
be able to retain a hold on his patient, as a patient, and not 
to be entirely cut out of that which his honesty has put into 
the hands of “ F.R C.8.” A general practitioner nowadays 
is a tout (at his own expense), paying his rent, rates, taxes, 
and keeping up a position, purely in order to find cases with 
fat fees for the “specialist.” The “ specialist ” comes in, 
whisks the patient off to a nursing home, and out goes the 
poor wretch of the general practitioner to his debts; those 
that he owes and those that are owed to him. In nine cases 
out of ten, the general practitioner has money owing to him 
by the patient for present and past illnesses, the “specialist” 
comes in, and the patient begs, borrows, or steals the where¬ 
withal to pay the fee demanded. Off goes the specialist with 
the “ready” and the general practitioner has only debts 
owing to him, and a useless patientfor some time to come, till 
the money borrowed to pay the “ specialist ” is repaid. “ I 
have had some ” and got heartily sick of it. The more 
fair and equitable rule is the one which I now follow, and 
perhaps “ F.R.C.S ’’ will please note and practise it. When 
the case needs operation my practice is as follows : refuse 


the request except the general practitioner be a skilled 
anaesthetist, but ask the general practitioner to assist at the 
operation and undertake the major part of the after attend¬ 
ance, and for his services give him “ down on the nail " one- 
third of the fee agreed upon for the operation, for he has 
earned it. So that “F.R.C.S." can still have his skilled 
anesthetist and at the same time feel that the general 
practitioner gets something for his wife and children and is 
not left, as he often is, a “skinned eel ” with an “invitation 
to dinner.” More often than not that third part of the 
operation fee will be the only money the general practi¬ 
tioner will ever see out of the case. Let this plan be adopted 
universally and there will then, at any rate, be some prospects 
for both general practitioner and specialist. Mutual help 
and support should be the watchword, not selfish hindrance 
and throat-cutting, grasping greed. 

I am. Sir, yours faithfully, 

F. W. Fohbes-Ross, M.D.Edin., F.R.C.S. Eng. 

Harley-street, Fob. 16th, 1906. 


To the Editor of The Lancet. 

Sib,—S o far as the general public is concerned “ Virtutem 
Sequor ” raises a very important issue in his remarks re con¬ 
sultants. What constitutes a consultant, and to what fees 
is he entitled ? A friend of mine afflicted with failing eye¬ 
sight had occasion to go to an optician who advised him to 
go to a certain oculist. This latter gentleman examined the 
eyes, prescribed glasses, and charged £2 2a. On subsequently 
referring to the Medical Directory it was found that the 
doctor consulted had merely ordinary qualifications and was 
not, nor ever had been, attached to any ophthalmic hospital. 

Now, Sir, sis a mere layman, what I want to know is, how 
can the public be protected from this kind of thing t The 
general impression amongst us is that a consultant is a 
gentleman of the highest qualifications (e.g., F.R.C.S.) and 
who has a hospital appointment. I appeal to you, Sir, for an 
ex cathedra pronouncement on the matter. 

I am, Sir, yours faithfully, 

Feb. 14th, 1908. Walter Carter. 


THE INACCURATE DOSAGE OF 

medicines: 

1 o the Editor of The Lancet. 

Sir, —Your remarks in an annotation in your issue 
of Feb. 16th, p. 512. on “The Inaccurate Dosage of 
Medicines,” due to the different sizes of bottles sup¬ 
posed to be two, four, six, and eight ounces, are most 
appropriate, but there is also, I think, a still greater reform 
required, that all tinctures should be so prepared that 
the same quantity of each should represent an adult dose, 
say one drachm. Infusions might be one ounce, wines one 
drachm, and so on, with spirits, pills, powders, &c. Surely 
wholesale druggists could arrange this, and so reduce the 
dangers and difficulties in dispensing medicines. There is 
often some uncertainty in remembering the correot doses of 
drugs other than those habitually used, and a desirable 
preparation may be omitted from the prescription through 
this cause. I am, Sir, yours faithfully, 

Dorney, Windsor, Feb. 16th, 1908. J. H. WATERS. 


RECEPTION HOUSE FOR RECENT CASES 
OF INSANITY. 

To the Editor of The Lancet. 

Sir, —Through the medium of your valuable columns and 
the columns of your less specialised contemporary the 
Sunday Cnronicle, I have recently learnt that some striking 
“ advances ” have been made in the treatment of mental 
diseases in Scotland—namely, (1) through the medium of a 
structure of corrugated iron and ‘ 4 oompo ” boarding, &c., and 
(2 ’ some open air. 

I regret that (owing possibly to a defeot within myself), 
having carefully read all the details mentioned in Dr. H. C. 
Marr’s paper in your issue of Feb. 8th, I entirely fail to see, on 
analysis, any difference in the practice adopted at Woodilee 
to that in use here (in the southern portion of England) for 
many years, or in probably 90 per cent, of other asylums in 
England, with the exception that: 1, Only few asylums have 
female nurses in the male wards, and this may, or may not, 
be an important factor, though I personally have yet to feel 
that yearning desire to add one to the female staff. 2. That 




The Lancet,] ANAESTHESIA AND ITS MORTALITY.— THE SITE OF A SANATORIUM. [Feb. 22,1908. 597 


no day nurse has keys, <fco. If this be so important and so 
satisfactory a factor, why should it be limited to the day¬ 
time ? But doubtless this point must be considered with the 
recovery-rate, which, be it noted, is at Woodilee, according 
to published statistics, about the lowest in Great Britain. 

1 trust this is due to the large number of cases of dementia 
admitted, which should also explain the absence of keys, 
&c. ; surely it cannot be due to the elaborate intermingling 
of corrugated iron, “ compo ” boarding, open air, and female 
nurses. I do not throw doubt for a moment upon Dr. 
Marr’s great ability, nor the entirely excellent organisation 
and administration of the asylum over which he to zealously 
presides ; this, however, has nothing to do with the subject 
at issue. I am, Sir, yours faithfully, 

Medical Superintendent, 
Feb. 6th, 1908. County Asylum (England). 


ANAESTHESIA AND ITS MORTALITY. 

To the Editor of The Lancet. 

Sir,—A discussion on “deaths under chloroform ” at the 
Medico-Legal Society is reported in the lay press. Dr. F. W. 
Hewitt is there stated to have recommended a higher system 
of tuition as to the administration of anmsthetics. It would 
bs interesting further to strengthen such a recommendation, 
by an inquiry as to why, at provincial, Scotch, and Irish 
hospitals, the percentage of deaths connected with the 
administration of anaesthetics is so small as compared with 
the London statistics. I am told that at Edinburgh the 
specially instructed students often administer the anaesthetic, 
and, in chloroform anaesthesia, only use a towel. So I am 
told. Is the special instruction there more thorough than 
here ? Dr. Hewitt generally has good reason for his 
opinions. I am, Sir, yours faithfully, 

Feb. 12th, 1908. G. H. R. D. 


THE SITE OF A SANATORIUM. 

To the Editor of The Lancet. 

Sir,—As I am interested in the efforts of the medical pro¬ 
fession to minimise the ravages of consumption, perhaps you 
will give me a few particulars as to the nature of the soil on 
which a sanatorium should be built. The Cork Conjoint 
Hospital Board has been offered, as a free gift, land on 
which to erect a public sanatorium. The proposed site has 
been described as a bog over which snipe have been shot; 
bulrushes grow on it; the surface earth to the depth of 
6 or 12 inches is peat mould, under which is a deep stratum of 
yellow clay ; there are several small ponds or holes, from 8 to 
12 feet in diameter, containing stagnant water ; and in other 
places surface water lies on the ground. Would this be a 
suitable or unsuitable site? Would it be a good or particularly 
good site, a bad or particularly bad site ! As I know your 
journal focusses medical opinion on such subjects perhaps 
you will excuse me for venturing to address you. 

I am, Sir, yours faithfully, 

Feb. 13th, 1908. VALETUDINARIAN. 


THE MEDICAL INSPECTION OF SCHOOL 
CHILDREN. 

To the Editor of The LANCET. 

Sir,—A great many opinions are finding expression as to 
how the work of medical inspection of school children shall 
be carried out, and it seems doubtful whether the uncertainty 
at this moment exhibited can be in any degree edifying to 
the powers that be, or to the public who are acting the part 
of lookers-on. 

The last memorandum of the Board of Education issued 
upon the subject states that the difficulties to be encountered 
are chiefly administrative. Precisely so, but the Board of 
Education do not do much to diminish these difficulties. 
The few suggestions which they have made in this behalf are 
sufficiently confusing. That they are desirous of Unking up 
this public health work with the other public health work is 
evident and that the medical officer of health, who is the 
chief public health officer, must take a prominent part in the 
business is equally manifest, but having given a hint of their 
desire in this direction, they have left it to the local 
education committees to make all appointments, and these 
committees are to do the work as well as they can, 


or as badly as they will. The Board of Education have said 
in their memorandum that the sanitary authorities should 
instruct their medical officers of health to go in and advise 
the education committees. This is rather cool of the Board 
of Education, who have nothing to do with the sanitary 
authorities or their medical officers of health. And here lies 
difficulty Mo. 1—that is, the complication of having 
the public health work of the country managed by two 
different sets of committees, the public health committees 
proper and the education committees. Unless a free hand 
be allowed the superintending officer to conduct the work 
without interference from the education committee, whose 
members are likely to think themselves quite capable of 
“ directing ” the work of medical inspection, the result must 
be confusion worse confounded. There is no direction in the 
memorandum of the Board of Education as to how these 
committees are to treat and pay their medical officers, but 
we know that these officers will be expected to subscribe to 
the farce that it is the committee and not the officer that 
does the work and is the responsible party. And what is the 
Local Government Board doing that they allow officers that 
erstwhile were under their own sovereign control to become 
the fags of a peregrine department 1 

As to difficulty No 2, the Board of Education’s memo¬ 
randum alludes to the medical officer of health as if the 
office of that person were perfectly satisfactorily estab¬ 
lished and as if the public health department of every town 
of 20,000 inhabitants, and of every county in tbe land, were 
efficient, whereas we know it to be far otherwise. We know 
that three parts of the public health service that is being 
called upon to undertake this tremendous accession of work 
is hopelessly inefficient and incapable of its performance. 
And yet this work cannot be divorced from the public health 
office ; it is public health work. The medical examination 
of the children, which mast be itself deputed to the general 
practitioner, must nevertheless be directed and supervised 
from the public health department, and this general direc¬ 
tion is only a part of the work that will fall to the public 
health officer, for much more will ensue as tbe result of the 
examinations and in connexion with them. Yet with the 
public health service in tbe condition it is, what a putting of 
the cart before the horse is this business. Would it not be 
better for Parliament in the present session to pass a re¬ 
pealing Act, or the Boaid of Education to send round a 
notice postponing all action until we have the needed reform 
in the public health service ? 

The various and bewildered propositions as to the way the 
medical inspection of school children shall be carried ont 
which are emanating from the education committees as the 
result of deliberations guided by competent or incompetent 
medical officers of health, or unguided altogether by any 
medical officer, only further serve to exemplify the ridiculous 
condition of our public health administration, and of the 
absurdity of supposing that a work of such special character 
and national effect as that In question can be accomplished 
nationally by the independent ungoverned action of hundreds 
of different committees, or, for that matter, by as many 
medical officers of health acting without any general 
governance, constraint, or co-relation. 

I am, Sir, yours faithfully, 

Feb. 17th, 1908. M.D., D.P.H., M.O.H. 


THE UNIVERSITY OF LONDON AND 
PROVINCIAL STUDENTS. 

To the Editor of The Lancet. 

Silt,—May I, in the name of the numerous external 
students of the University of London, protest against the 
absurd length of time they are made to stay in town when 
sitting for the final M.B. examination If a candidate takes 
all the subjects at one time he is kept up for three weeks. 
He has a good deal of his time wasted and in many instances 
his concluding tests are given to him after students residing 
in London have received theirs. In the case of a candidate 
only taking half the examination at a time the evil is much 
worse, for there is then an interval of eight or nine days of 
idleness provided for him. He has oither to remain in 
London at considerable expense, or make two or more 
journeys to the provinces, which may be equally expensive. 
I consider that the authorities can, if they choose, remedy 
this state of affairs. 1 am, Sir, yours faithfully, 

Fob. 18th, 1908. PROVINCIAL. 




598 The Lancet,] 


BIRMINGHAM.—MANCHESTER. 


[Feb. 22, 1908. 


BIRMINGHAM. 

(From our own Correspondent.) 


The University. 

The report of the Principal to the governors of the 
University, which waB presented at the annual meeting on 
Feb. 20th, shows a large increase in numbers in the Faculties 
of Arts and Science, and as satisfactory a condition as could 
be expected in the other faculties. Medicine and com¬ 
merce remain comparatively stationary, and the numbers 
in the Medical Faculty are not likely to increase till the 
rush into engineering declines and the public recognise that, 
for the money and time spent, the medical profession offers 
as good a return as, if not a better average return both 
as regards money and position than, any other profession. 
In medicine as in other professions it is true that there is 
always plenty of room at the top, but it is more true of 
medicine than perhaps of any other profession that the 
licentiate or graduate from the moment of obtaining his 
qualification or degree can make a respectable liviDg. This 
simple fact is not generally understood and until it filters 
into the minds of parents and guardians the number of 
entries in the Medical Faculty is not likely to increase 
largely. As regards the University as a whole the Principal’s 
report shows that its work is proceeding satisfactorily and 
advances are being made, but further extension and develop¬ 
ment are hampered by want of funds. This is a condition 
which afflicts most of the universities of England but it is 
particularly felt in Birmingham where the advances have 
been so rapid and great in a comparatively short time. 
Money is urgently needed and it is to be hoped that before 
long it will be obtained, so that the excellent work going on 
may proceed steadily and without hindrance. 

Mr. J. Hall-Ednards. 

Every member of the medical profession, as well as his 
own immediate friends, will sympathise with Mr. J. Hall- 
Edwards, whose left hand was amputated at the beginning of 
the week. Mr. Hall-Edwards was an enthusiastic pioneer of 
x ray work and his hand is a sacrifice to the advance of 
medical science, for, prosecuting research in the new avenue 
of work before the dangers were understood, he exposed 
himself fearlessly to the rays and, unfortunately, his hands 
were attacked with x ray dermatitis. Treatment failed in 
the case of the left hand and as the condition was proceeding 
from bad to worse it became necessary to amputate, but it is 
hoped that the right hand will respond to treatment and that 
no further operation will be necessary. 

The University Company of the 1st V.B. Royal Warwickshire 
Reyimtnt. 

The annual dinner and prize distribution in connexion with 
the above company, which took place on Feb. 14th, was, in a 
certain sense, not devoid of gloom, for there was a fear which 
expressed itself, even through words of hope to the contrary, 
that the members might be taking their last annual dinner 
together as a university company. What is to happen to 
university companies under the new scheme of re¬ 
organisation is not yet known, for, as Mr. Neville 
Chamberlain said, the wheels of the Government move 
slowly in this matter, but it is clear that unless some sDecial 
provision is made the days of university companies are 
numbered. They cannot form part of a local battalion 
because the terms of enlistment, fcc , are not compatible with 
university duties. It is possible that they may be affiliated 
with a local battalion and therein lies the hope of many, 
but it is feared that they may be disbanded, in which case 
much valuable material will be lost. 

Medioal Inspection of Schools in West Brommoh. 

The report of the West Bromwich elementary education 
committee on the medical inspection of school children is 
interesting both as regards the estimate of the work to be 
done and the price it is proposed to pay for it. The com¬ 
mittee estimates that there will be 1500 children admitted 
since January 1st who will have reached the age of five 
years. These will have to undergo a thorough and searching 
examination, and there is to be a second examination of 1500 
children who will be leaving during the year. When the 
scheme is in full working order there will be in addition two 
intermediate examinations. The committee's report states 
that the medical officer estimates that 800 hours per year will 
be required for the examinations. Apparently, therefore, when 


the scheme is in full working order, 6000 children will be 
examined each year in 48,000 minutes, and it is clear that 
there will be no excess of time for thorough examination. 
The cost is estimated at £350 for the first year and it is 
suggested that a medical inspector should be appointed at a 
salary of £250, the remuneration to cover expenses and any 
extra personal assistance. 

The Notijical ion of Births Act. 

The Birmingham city council has adopted the Notification 
of Births Act (1907) and it is to come into force on 
March 1st next. In view of this fact the medical officer 
of health has sent a letter to all practitioners in the 
city area drawing their attention to the fact that on 
and after the date mentioned, in the case of all children 
born after the twenty-eighth week of pregnancy the birth 
must be notified either by the father or by the person 
in attendance upon the mother. The medical officer points 
out that all births must be notified irrespectively of class, but 
it is, of course, understood that the health visitors will only 
be sent to those cases where it appears that their services 
may be useful. Forms of notice have been printed and a 
supply of them can be obtained on application to the health 
department; they are, however, not essential, and a post¬ 
card or letter will serve the purpose equally well. 

The Health of the City. 

Coincidently with the period of sudden changes of tem¬ 
perature which came upon us last week the death-rate of the 
city has jumped up from 18’6 to 21-7. The inorease is 
almost entirely attributable to pulmonary alfections which 
are so liable to become serious under the conditions men¬ 
tioned. We are also suffering from an influenza epidemic, 
but though it is widespread it is, on the whole, a mild attack 
and so far has proved fatal only in a comparatively few cases. 
It is, however, proving a Berious trouble to many large busi¬ 
ness establishments whose stalls it has decimated severely. 

Health of Su tton Coldfield. 

Sutton Coldfield may almost be looked npon as a resi¬ 
dential part of Birmingham, for so many of those who spend 
their days in the city live during the remaining parts of their 
lives in this very healthy borough. In his annual report on 
the sanitary condition of the borough, Dr. A. Bostock Hill 
estimates that the population has increased by 1054 during 
the year and that it now totals 20,000. The birth-rate for the 
past year was only 19 ■ 71, the lowest recorded since 1898. and 
the death-rate was 8 ■ 97, which is the lo west for the last ten 
years. Being so easily reached and so healthy it cannot be a 
matter of surprise that so many people who make their 
livings in Birmingham choose to reside in Sutton Coldfield. 

Feb. 18th. _ 


MANCHESTER. 

(From our own Correspondent.) 


Meat-Traders' Conference. 

AN important gathering of delegates from all parts of the 
country met in Manchester last week to attend the annual 
meeting of the National Federation of Meat Traders’ Asso¬ 
ciations. In his presidential address the chairman men¬ 
tioned that the members of the trade were handicapped 
by laws and enactments administered by men ‘ • who had 
plenty of theory but no practical knowledge.” He spoke 
also of the confusion and want of uniformity with regard to 
the inspection of meat, scarcely two places being alike in 
this respect, so that meat may be passed as fit for con¬ 
sumption in one place while at another 30 miles away 
the same meat would be condemned. No doubt uni¬ 
formity is desirable and inspection should not be need¬ 
lessly vexatious, but it is necessary for the protection of 
the public that it should be thorough. On one matter meat- 
traders have always shown great sensitiveness and wrathful 
indignation—namely, on what the President called “ the 
exaggerated statements about private slaughter-houses.” He 
reproved the Manchester Guardian for calling them “ vile 
places, insanitary places, dirty places, and they were given a 
very bad character. ’’ On the other band, he said the ‘ ‘ owners 
of private slaughter-houses are animated by a love of cleanli¬ 
ness and sanitation, and are not afraid of the inspector’s 
visits, because they take a pride in their buildings and their 
trade.” This is no doubt true of large numbers of meat- 
slaughterers, let us hope of the majority, but the residuum has 
to be looked to, and that there is such a residuum the annals of 




The Lancet,] 


MANCHESTER—SCOTLAND. 


[Fkb, 22,1908. 599 


the “slink butchers” show. Even Sir James Crichton-Browne 
comes under animadversion as exaggerating the defects of 
private slaughter-houses, and the President boldly challenged 
a comparison between them and the public slaughter-houses. 
Another argument was that if these private slaughter-houses 
were abolished “it would be one of the greatest blows 
agriculture had ever received,” and very few would say in 
these days that our agriculture required any more blows. 
There was a strong feeling that as to the sale of meat which 
was diseased the butchers had just cauBe of complaint. For 
years the Federation had been fighting for compensation 
where tuberculous meat had been surrendered to the 
authorities for the public good. At present they are liable 
to penalties, and the relief they want is a warranty between 
the seller of the livestock and the meat-trader, “a full 
warranty throughout the United Kingdom.” There will 
occasionally, no doubt, be cases of hardship where beasts 
sold to the butcher as healthy are found on his stall 
diseased ; but as a rule he is acute enough to distinguish a 
diseased or doubtful beast. The system of inspection is 
objected to, as the butcher is not allowed to have an 
“independent expert” on his side. All these things and 
a few others no doubt take some of the glamour from the 
trade of butchering, but the health of the people is the 
paramount consideration. 

Annual Hceting of the Trustee! of the Royal Infirmary. 

At the annual meeting of the trustees of the Royal 
Infirmary on Feb. 14th Mr. Cobbitt, the chairman, said 
that they had every reason to expect that the building would 
be completed by July 31st; and there was an urgent 
need for the subscriptions of the general public to be in¬ 
creased. He used an ingenious argument to show that the 
‘ ‘ district served by the infirmary could well afford to maintain 
it at the high level necessary, especially considering that 
following the trade boom of the past few years there should 
now be accumulated profits at the disposal of the com¬ 
munity.” Mr. Nevill Clegg, vice-chairman, followed up this 
appeal by saying that, apart from trade fluctuation, there was 
wealth enough in the district “ to raise twice the sum of 
£7000 which was now contributed.” No doubt this is so, and 
very little sacrifice on the part of “the general public "would 
be required to put the infirmary into a sound and satisfactory 
financial position. At present those who have worked for it 
so long and strenuously cannot but feel anxious for the future, 
faced as they are with the certainty of largely increased 
expenditure and, it is to be feared, a diminished feeling 
of duty or inclination to give to old established medical 
charities. 

Early Notification of Births. 

The Medical Guild has expressed its strong objection to 
the Early Notification of Births Act in a letter from Dr. 
J. H. Taylor (the honorary secretary) to the Manchester 
papers. One objection is the disregard shown to what the 
medical profession holds as one of its most sacred duties— 
namely, “that it shall not divulge any facts learned in a 
professional capacity.” Also that “it so utterly scorns the 
rights of medical practitioners that they have been com¬ 
pletely alienated.” Dr. Taylor says it becomes more and 
more evident that the Act has little chance of proving a 
success in its present form, and that “ it is to the credit of 
'the Manchester council that it has recognised this fact.” 
At the annual meeting of the Guild the following motion 
wa s r arried 

That the Medical Guild notes with great pleasure the refusal 
of the Manchester city council to adopt the Early Notification of 
Births Act, but, recognising the advantage to be gained in many cases 
by early assistance being given to nursing mothers by the health 
authorities, would urge its members and the medical profession gene¬ 
rally to facilitate matters to the best of their ability by advising their 
patients in suitable cases to give early notification of births and to 
make application for any required assistance to the health department. 

Mrs. Hyland's Will. 

The provisions of Mrs. Ryland’s will have been so widely 
quoted in the lay press that detailed mention of them here 
is unnecessary. The bequests to medical charity are sub¬ 
stantial, and although the exclusion of the Royal Infirmary 
from benefit cannot fail to provoke comment the generosity 
displayed towards the Manchester Eye Hospital, the Dental 
Hospital, and the Hospital for Incurables is great. Medical 
men in Manchester also feel that they will have an intimate 
share in the good that will follow upon the bequest of 
£50,000 to the University. The largest legacy in the will, 
£200,000, was left for the up-keep of the John Ryland’s 
Library, Mrs. Ryland’s splendid gift to the city. 

Feb. 18th. 


SCOTLAND. 

(From our own Correspondents.) 

The Local Government Board in Scotland. 

The Commission recently appointed by the Local Govern¬ 
ment Board for Scotland to inquire into complaints made 
concerning the fever hospitals at Falkirk and Ruchill has led 
to comment that may be useful upon this important Govern¬ 
ment department. The Glasgow Herald, in commenting on 
the relation of the Local Government Board to the various 
hospitals for infectious diseases throughout the country, 
points out, what must be manifest to medical men, thatwhile 
it is the duty of the Board to inspect hospitals for infectious 
diseases and to compel local authorities to remove any 
existing defects the Board does not possets a staff 
adequate in numbers to undertake such work. The 
Local Government Board in England has one medical 
officer who is head of the medical department, one 
assistant medical officer, and 14 medical inspectors proper, 
besides two medical inspectors for Poor-law purposes. 
Ireland has one medical member on the Board and seven 
medical inspectors. The Local Government Board for 
Scotland, like the Irish Board, has one medical member but 
only one medical inspector and one part-time medical officer. 
Leaving England out of the question, it would appear that 
although Ireland and Scotland have roughly the same 
population the former has seven medical inspectors to the 
latter’s one. It has been urged that there should be a 
regular inspection of infectious hospitals but one medical 
inspector is quite unfit to undertake a continuous round of 
such systematic duties as he ought to be engaged in. In 
Scotland, also, there are 69 poorhouses which must contain 
in the aggregate a very large number of sick people but the 
inspection of these is entirely left in lay hands. There is 
surely some room for improvement here. 

Turner Memorial Hospital, Keith. 

The annual meeting of the directors of the above hospital 
was held in the institution in the end of January. A report 
was read showing that after careful consideration the com¬ 
mittee had come to the conclusion that the best use to which 
the improved finances of the hospital could be put was to 
make provision for the relief of patients suffering from con¬ 
sumption. A scheme was then approved for the erection of a 
sleeping shelter in the hospital grounds for the accommoda¬ 
tion of two patients, the estimated cost for construction being 
about £60. In the course of the year 67 patients have been 
treated in the hospital and of these 43 have recovered, seven 
improved, eight have died, and nine remained in hospital on 
Dec. 31st last. The financial report for the year was 
satisfactory. 

The Queen and Qlasgorv Maternity Hospital. 

The Secretary for Scotland has intimated that Her Majesty 
the Queen has been graciously pleased to accept the office of 
President of Glasgow Maternity Hospital. It is expected 
that the new hospital will be opened in April. 

St. Mungo's College, Glasgow. 

The Lord Provost of Glasgow, Sir William Biisland, who 
also occupies the position of chairman of the managers of 
the Royal Infirmary, visited Liverpool last week in con¬ 
nexion with the question which has arisen as to the future of' 
8t. Mungo’s College and its relation to the Royal Infirmary. 
In Liverpool similar difficulties arose regarding medical 
teaching and were amicably arranged, and it is hoped that 
the Lord Provost, after consultation with the Lord Mayor of 
Liverpool, who is a prominent medical man, may be able to 
suggest a scheme that will prove satisfactory to all parties. 

Cancer Research Appointment. 

Dr. Archibald Leitch, of the Cancer Research Laboratories, 
the Middlesex Hospital, London, has been appointed investi¬ 
gator at the Caird Cancer Pavilion of the Dundee Royal Infir¬ 
mary. Dr. Leitch is a graduate of the University of Glasgcw 
and during the last five years has been engaged in cam er 
investigation at the Cancer Hospital, London, and later at the 
Middlesex Hospital Cancer Research Laboratory. He is the 
author of several papers on the subject, and recently was 
sent to Paris to inquire into and report on particular methods 
of treatment there. The new appointment is made under a 
grant of £1000 a year for five years by Mr. J. K. Caird, 
Dundee, for cancer research. 

Aberdeen Royal Infirmary : Annual Report. 

The twenty-first annual report by the directors of the 




600 The Lancet,] 


IRELAND.—PARIS. 


[Feb. 22, 1908. 


Aberdeen Royal Infirmary along with the accounts, Ac., for 
the year ending Dec. 31st, 1907, has just been issued. The 
average number of beds in daily occupation was 226; 
average number of days in hospital of each patient, 26 ; 
operations performed, 1689 ; and death-rate, 6 9 per cent, in 
cases treated. The number of in-patients treated (3119) 
shows an increase of 281 over that of 1906. 15.792 out¬ 

patients (including 1606 treated in the electrical department) 
received advice and treatment. The average cost per 
occupied bed is £53 9s. 2 d. and of each in-patient £3 17s. 6W., 
as compared with £50 3s. 7 d. and £3 19s. Id. respectively 
for the year 1906. A gift which afforded much gratification 
was the cheque for £10,000 received from the Right Hon. 
Lord Mount-Stephen towards the endowment fund. A further 
addition to this fund was received in the form of a donation 
of £300 made by the trustees of the late Miss Helen Walker 
from the residue of her estate. The nursing staff consists 
of nine sisters and 60 nurses. The candidates for 
admission numbered 378. Under an arrangement with 
the governors of the Aberdeen Educational Trust the 
nurses have had the advantage of a coarse of instruc¬ 
tion in invalid cookery. The days for the admission 
of patients’ friends have been arranged as follows: (a) 
For residents in Aberdeen, Wednesdays and Saturdays from 
3 to 4 p.M., and Sundays from 4 to 5 p.m. ; and (A) for 
country visitors, every weekday from 3 to 4 p.m., and Sundays 
from 4 to 5 P M. At the convalescent hospital 206 cases 
were treated during the year, the average period of residence 
being 33 days. The income amounted to £445 and the 
expenditure to £6L2. Reference is made in the report to 
the death of Mr. William Carnie who for the long period of 
37 years—from 1861 to 1898—occupied the office of clerk and 
treasurer to the Royal Infirmary and the Royal Asylum, 

Feb. 17th. 

IRELAND. 

(From our own Correspondents.) 

Tuberculous Disease in Ireland. 

AS returned in the last quarterly return of the marriages, 
births, and deaths in Ireland the total number of deaths 
from all forms of tuberculous disease registered during the 
quarter was 2418, representing an annual rate of 2 21 per 
1000 of the population of Ireland, estimated to the middle of 
the year. The rates for each of the three preceding 
quarterly periods for deaths from all forms of tuberculous 
disease were 2-76, 2'97, and 2’24 per 1000. The above 
total—2418 -constitutes 13-4 per cent, of all deaths 
registered during the quarter. 

The Health of Belfast. 

For the week ended Feb. 8th the death-rate from all 
causes was the terribly high one of 27r 8 per 1000, and from 
the principal zymotic diseases 3 • 7. Daring the week there 
were notified two cases of typhus fever, four of typhoid fever, 
11 of scarlet fever, seven of diphtheria, and eight of cerebro¬ 
spinal meningitis. There were (on Feb. 19th) in Purdysburn 
fever hospital 76 patients. Of these, 21 were suffering from 
cerebro-spinal meningitis, which the city corporation has 
decided shall be a notifiable disease for one more year dating 
from Jan. 1st, 1908.—A deputation of ladies representing the 
executive of the Belfast branch of the Women’s National 
Health Association of Ireland appeared before the public 
health committee of Belfast in reference to the aid which 
they might give in the infantile mortality question. The 
health committee promised to supply report cards similar to 
those in use in the health department. 

Feb. 19th._ 


PARIS. 

(From our own Correspondent.) 


The Comparative Influence of Intestinal Juice upon Pepsin 
and Pancreatin. 

M. Leoper and M. Eimonet made a communication to the 
Society of Biology, at a meeting held on Feb. 1st, on 
the above subject. They had found by experiment that the 
activity of pepsin diminished by three-quarters under the 
influence of duodenal juice, by one-half under that of the 
juices of the ileum, and by a quarter under the influence of 
the juices of the colon. On the other hand, the activity of 


the Becretion of tho pancreas increases as regards the power 
of the trypsin, the steapsin, and the amylopsin in the same 
proportion for the various regions of the intestine. 

The Meal (barme) of Nctte. 

Various explorers have noted that the ‘ ‘ farinc de Nettc ” 
produced from the fruit of Parkia biglobusa is a form of 
nourishment much appreciated by the natives of tropical 
Africa; despite its name it is not a meal, for it contains no 
starch. It is, however, very rich in fat, in phosphates, and 
in sugar. At a meeting of the Academy of Sciences held 
on Jan. 27th M. Goris and M. Cidte communicated a paper 
in which they gave the results of some researches which 
they had made into the alimentary value of this foodstuff. 
Analysis showed that it was the richest in saccharose of any 
food which they had come across. Beetroot pulp, for 
instance, contains from 18 to 20 per cent, of saccharose, and 
sugar-cane an almost similar proportion, but the substance 
under investigation contains as much as 25 per cent. 

The Hygiene of Dwellings. 

Some years ago M. Juillerat, the chief of the Bureau of 
Hygiene of the Prefecture of the Seine, took up the question 
of the sanitary ’ arrangement of all the houses in Paris. A 
new campaign has just been entered upon by the “Ligue 
Sociale des Acheteurs.” This society, which formerly dealt 
with insanitary houses and the lodges of concierges , is now 
directing its attention to the conditions under which servants 
are housed. Its members bind themselves only to become 
tenants of those fiats where the rooms allotted to the 
servants are provided with windows affording proper venti¬ 
lation and light and where there is a proper apparatus for 
warming. A list of houses fulfilling these conditions will be 
drawn up and it will be open to public inspection. 

The Treatment of Disease of the Hip joint by Intra- 
artioular Injections. 

At a meeting of the Academy of Medicine held on 
Feb. 4th M. Calot discussed Hip Disease and held a brief 
for the great superiority of the method of treatment by 
injection over any catting operation or simple immobilisation. 
He claims that it shortens the length of time necessary for 
treatment by two-thirds and brings about a cure without 
lameness or even shortening the limb. The treatment is 
practically identical with that of a cold abscess. If there 
is no effusion iodoform injections may be used, or still 
better a solution of naphtholcamphor in glycerine. M. 
Calot has been using this method of treatment since 1893. 

The Thyroid Treatment of Chronic Rheumatism. 

At the same meeting of the Academy M. Leopold de L£vi 
and M. Henri de Rothschild communicated a paper dealing 
with 39 cases of chronic rheumatism in patients of both 
sexes, aged from 12 to 15 years. 10 of these cases were of 
generalised chronic rheumatism, while 9 showed the 
nodular form with ankylosis and persistent pain. Out of 
these 19 patients 14 improved greatly, while 2 could be 
considered as cured. Of the 20 remaining cases who showed 
the disease in a milder form, 18 improved or were cured. 
The treatment consisted in the administration of 10 centi¬ 
grammes of extract of sheep's thyroid from one to three 
times a day. The effects of the treatment must be carefully 
watched. 

The Poison of Koch's Bacillus Tuberculosis. 

At a meeting of the Academy of Sciences held on 
Feb. 10th Professor Armand Gautier brought forward some 
researches undertaken by Dr. Auclerc and Dr. Paris on Koch’s 
bacillus tuberculosis. These observers found three distinct 
poisons in the bacillus—namely, a tuberculin, lecithiD, and 
a special protoplasm poison. This last can be separated 
chemically and a quarter of a milligramme of it will slowly 
kill an average-sized guinea-pig by bringing about the same 
conditions in the lungs as does the bacillus itself. 

Arsenic in the Treatment of Syphilis. 

At a meeting of the Therapeutical Society held on 
Jan. 18th M. Bardet put in a strong plea for the use of 
arsenic in cases of syphilis where mercury is ill borne. He 
was anxious that the treatment should be tried in hospital, 
and as he considers that in some cases of syphilis arsenic 
has a specific action he said that it ought to be tried by itself 
and not in combination with mercury or the iodides. In the 
town he thought it would be better given by injectior, but 
in the country, where there might be a difficulty in the 



Thb Lancet,] 


COPENHAGEN.—VIENNA. 


[Feb. 22, 1908. 601 


patient going to the medical man or vice versa , it conld be 
given by the mouth in the ordinary manner. 

Obituary. 

Dr. Peyron, formerly Director of the Assistance Pablique 
and also of the department which dealt with deaf mates, 
died last week. He was Director of the Assistance for 14 
years, but latterly had retired to Marines in the department 
of Seine-et-Oise. 

Feb. 18th. _ 


COPENHAGEN. . 

(From our own Correspondent.) 


The Bacteriological Examination of Sputum and Urine. 

All pathologists know how difficult it often is to find 
tubercle bacilli in specimens where only a few are present, 
and those perhaps not uniformly distributed throughout the 
substance under examination. Ilesearches made by Dr. 
Ellermann and Dr. Erlandsen and communicated by them to 
the last meeting of the Copenhagen Medical Society have led 
to the adoption of a new method which increases the relative 
number of the bacilli from 10 to 20 times. Sputum is 
treated as follows : (1) 20 cubic centimetres of sputum are 
carefully mixed with 10 cubic centimetres of a 0 • 6 per cent, 
solution of carbonate of sodium and placed in the thermostat 
(37° C.) for 24 hours; (2) the sputum is centrifugalised ; 
(3) four parts of a 0 • 25 per cent, solution of caustic soda are 
added to the deposit, mixed carefully, and boiled for half a 
minute ; and (4) it is again centrifugalised. Urine is treated 
somewhat differently to begin with. First, the clear urine is 
poured off the sediment, which is subsequently centri¬ 
fugalised. To the resulting sediment four parts of a 0 • 25 
per cent, solution of carbonate of sodium are added with from 
25 to 50 centigrammes of pancreatin ; it is placed in the 
thermostat (37°) for 24 hours, and subsequently treated as 
sputum in directions (3) and (4) above. 

A Boycott of the Copenhagen Hospitals. 

Danish medical circles have been much interested in the 
struggle that has arisen between the municipality of Copen¬ 
hagen and the Association of Junior Medical Men. In order 
to explain to an English public the object of the conflict and 
its importance I must in a few words deal with the way in 
which hospitals are managed in Denmark, as on this point a 
great difference obtains from what is customary in England. 
In the first place, hospitals supported by private subscrip¬ 
tions are here practically unknown save some few minor 
institutions maintained by Koman Catholic religious orders. 
The Crown supports one (University) hospital with 300 
beds, which takes in such patients from the whole country 
as are considered suitable for the instruction of the medical 
students. All other hospitals are managed by the dif¬ 
ferent municipalities themselves, the expenses being chiefly 
defrayed out of the rates. Only a comparatively small 
amount is paid by the patients or by the sick clubs 
of which they are members. For a town like Copen¬ 
hagen this expense forms, of course, rather a heavy item. 
The municipality of Copenhagen has 440,000 inhabitants and 
supports ten hospitals with a total of 2900 beds, besides a 
lunatic asylum of 1400 beds. The total yearly outlay on the 
hospitals alone (the lunatic asylum not included) is somewhat 
below £200,000. Of this sum £150,000 a year are paid directly 
from the rates, the rest being paid by the patients, the clubs, 
the Crown, and so forth. The other point in which our 
hospital management differs from English ways is this, that 
our hospital staffs are not composed of honorary medical 
officers. Not only are the resident medical officers paid but 
so also are all the medical men who visit the hospitals. Of 
course, the salary is highly inadequate, and the Association 
of Junior Medical Men, which numbers amongst its members 
all Danish medical men not yet in actual practice as well as 
all junior medical officers of the hospital staffs, has 
therefore considered it highly important to try to obtain 
an improvement in the salaries. A year ago one party 
of the town council of Copenhagen had at last granted 
the very modest wishes of the association, but at the 
final discussion in the council one of the members—I am 
sorry to say it was a colleague of ours—saw fit to oppose the 
proposal, which was therefore only passed a lew days ago 
and in a badly modified form. The Association of Junior 
Medical Men at once resolved to act on the offensive and 
with the support of the Danish General Medical Association, 


which latter numbers amongst its members practically all 
medical men in practice, it has now invited all medical men 
in Denmark to abstain from applying for appointments in 
the Copenhagen municipal hospitals. As the profession in 
Denmark forms one compact body, outsiders being very 
scarce, and as a great number of appointments in the 
said hospitals will shortly become vacant, the pressure 
brought to act on the town council is very strong. 
In order to insure the proper care of the sick during 
the struggle the association is offering the munici¬ 
pality to procure any requisite number of locum-tenents, 
but of course their salary would be the ordinary rather high 
one paid by the medical men themselves. This boycott 
certainly smacks of trade unionism, but the time has finally 
come for the profession to see clearly that this is the only 
way in which it can maintain its position. It is confidently 
expected that this Btruegle will end in a victory for the pro¬ 
fession. The outcome of the struggle is all the more 
important in that very soon' the whole medical system of 
Denmark is to be discussed and altered by a Royal Commis¬ 
sion. Other important questions are also pending - e.g., 
that of the salary of sick club medical officers. If the pro¬ 
fession wins in the present straggle the result cannot fail to 
influence the solution of the other questions in a way favour¬ 
able to ourselves. « 

An Interesting Method of Raising Funds for Benevolent 
Institutions. 

Signs are not wanting to show that the Danish National 
League for Combating Tuberculosis is now nearing it sgoal 
as far as the establishment of a sufficient number of sana- 
toriums for the poorer classes of the population is concerned. 
But while this has been brought about by the work and 
contributions of a comparatively restricted number of 
persons throughout the country, the promoters of a scheme 
for a special children's sanatorium have succeeded in interest¬ 
ing all classes of the community, rich and poor alike, in 
their object and that in a practical manner. This has been 
attained by the issue of a special Christmas stamp which for 
the four last years has been sold at all post-offices (price 
one farthing) from a little before Christmas until New 
Year's Eve. Any letter posted in Denmark during that 
space of time carries besides the ordinary postage 
one or more of the Christmas stamps. The whole output of 
the sale of Christmas stamps goes towards the children’s 
sanatorium ; it has during the four years reached a total of 
£20,000, certainly a very good result considering the fact 
that Denmark only has 2,500,000 inhabitants. This plan 
might perhaps be adopted by other and greater countries for 
raising funds for benevolent institutions. The Crown suffers 
no loss from the scheme as the usual postage has to be paid 
in ordinary stamps. 

Feb.17th. _ 


VIENNA. 

(From our own Correspondent.) 

Special Charges for Dispensing Medicines at Eight. 

By an understanding arrived at recently between all the 
corporations concerned the Society of Apothecaries has given 
public notice that in future for all prescriptions, with one 
exception, an extra charge of about 6 d. will be made if 
they are dispensed at night time—i.e., after 9 p.m. and 
before 7 a.m. This extra 6 d. will be handed over to the 
fund for the old-age pensions of the apothecaries’ assistants. 
If, however, the medical man adds the letters “ E. N.” 
(expcditio noctuma ) to the prescription it will be free from 
the extra charge and this is expected in all urgent night 
cases. As a good many prescriptions and pharmaceutical 
preparations have been obtained by the public after the 
usual business hours, and as only the regularly constituted 
apothecaries are, in this country, allowed to make up pre¬ 
scriptions the abuse has grown very much during the last 
few years. The raising of the charges for dispensing is not 
without interest for the medical profession because those 
village practitioners who have dispensaries of their own 
attached to their consulting-rooms will also be obliged to 
charge the increased sum for dispensing at night. 

Death of Professor Friihmald. 

Professor Fruhwald, one of the best known Vienna 
specialists for children’s diseases, died recently. He was a 
pupil of Professor Widerhofer, from whom he learned the 





602 The Lancet,] 


VIENNA.- BUDAPEST. 


[Feb. 22, 1908. 


methods of acute observation and exact diagnosis. In h's 
work on the infectious diseases of childhood and in bis 
investigations on the treatment of riokets his knowledge of 
the complicated conditions of the growing organism is 
clearly illustrated. Profepsor Friihwald was director of the 
children's department of the Policlinic since 1891 and his 
lectures were attended by numbers of medical men from all 
countries, whilst his consulting-room was the meeting place 
of parents belonging to all classes of society. His health 
haa been giving cause for anxiety since last summer. He 
had an attack of urremia six months ago, and kidney trouble 
led on to cerebral bicmorrhage which finally proved fatal. 

Cholelithiatii in Children. 

At a recent meeting of the Medical Society Dr. Friedtiiuder 
showed a boy, six years of age, who had from bis Becond 
year suffered every few weeks from colic lasting for one or 
two days. When he passed solid motions these attacks 
ceased. Later a tumour was made out in the right bypo- 
chonlrium and as vomiting occurred cholelithiasis was 
suspected and an operation was performed. The gall¬ 
bladder was euormously distended but no reason for the 
distension was discovered. A year later laparotomy had to 
be performed again. This time a large calculus was found 
in the cystic duct. The gall-bladder was removed and the 
patient was now doing well (ten months after the operation). 
As regards the earliest age at which cholelithiasis has been 
known to occur, Dr. Friedjung said that he has seen a 
biliary calculus in an infant four weeks old, but the con¬ 
dition must be very rare in children, because a case is hardly 
ever seen in the post-mortem rooms. Professor Naunyn 
believed that biliary calculi were not uncommon at the age 
of six years. 

A Safe Method of Opening the Abdomen. 

At a meeting of the Gesellschaft der Aerzte Professor 
Libotzky explained a method of opening the abdomen which 
was new here although much in vogue in Germany and for 
which it was claimed that it gave an excellent functional 
result with a minimum of local disfigurement. It was called 
the suprasymp hjsic transverse section of the fasciae. The 
incision was from three to four inches long, slightly curved, 
and extending transversely over the pubes, dividing the skin, 
subcutaneous tissue, and fasciae. The latter were then 
detached from their base upwards and downwards so that the 
recti and pyramidales muscles were free. The recti muscles 
were then divided in a longitudinal direction so that they were 
held only by a thin layer of connective tissue and the trans¬ 
verse fascia and the peritoneum were subsequently incised. 
This method gave a very ample access to the abdominal and 
pelvic organs. Tumours reaching up to the umbilicus could be 
easily removed through the opening. All operations on the 
uterine adnexa as well as the total extirpation by Wertheim's 
method and the operative treatment of extra-uterine pregnancy 
could be easily performed. The closure of I he wound was 
effected in the following manner. The peritoneum and the 
recti muscles were sutured in the longitudinal direction and 
the fascia: and skin in the transverse direction. The sutured 
wound was covered with gauze, held down by two strips of 
adhesive plaster. After eight days the sutures in the skin 
were removed, after which the patient might be out of bed 
without any abdominal belt. The cosmetic defect of the 
scar was soon concealed by the hair growing over it, 
especially if the incision was not very large, whilst the trans¬ 
verse scar was not liable to become stretched with formation 
of ventral hernia. This functional superiority of the 
horizontal incision over the vertical one has been proved by 
many hundreds of cases in Germany and also in Austria. The 
method was also available for a bilateral Bissini operation if 
the angle of the incision was drawn well to the side by means 
of a blunt hook. 

Excision of a Pad of Fat from the Abdominal Wall. 

Professor Eiselsberg had recently under his care a man, 
25 years of age. a waiter, who was not able to sit down on 
account of the fat on bis abdominal wall. The patient's 
general conformation presented a juvenile type. All the 
epiphyses were in loose connexion with the diaphyses, the 
genital organs were infantile, and there was extensive 
lipomatosis. As the accumulation of fat was a hindrance to 
the patient in his occupation he was operated upon with a 
view of removing as much as possible of the superfluous 
tissue. Within 15 minutes six kilogrammes (13 pounds) of 
fat were removed and the patient had an uninterrupted 
recovery. This was the largest amount of fat intentionally 


excised of which there was a record where general lipoma¬ 
tosis was the indication, bnt in operations for hernia even 
larger quantities have been removed. 

Feb. 17th. 


BUDAPEST. 

(From our own Correspondent.) 


Industrial Accidents in 1907. 

Since the coming in force of the Workmen's Compensa¬ 
tion Act the necessity of exhaustive accident statistics 
is felt more and more. Francis Kossuth, Minister of Com¬ 
mercial Affairs, has endeavoured to fill this gap by publishing 
a detailed list of the industrial accidents in 1907. According 
to this list there were 18,962 accident cases notified in 
Hungary during that year, showing an excess of 407 in 
comparison with the previous year. Out of all accidents 
only 1170 befell women owing to the comparatively small 
number of working women in Hungary and to the fact that 
those occupied with work are mostly employed at home. 
While out of 1000 male workers 39 suffered from acci¬ 
dents, out of 1000 female workers only 17 were in the 
like case. More than four fifths of the injuries caused 
incapacity to work, lasting less than four weeks. Persistent 
partial incapacity was caused by 257 accidents. Persistent 
entire incapacity occurred in 19 cases. Fatal accidents 
were 225 in number. In more tnan four-fifths of the acci¬ 
dent cases the limbs were injured. In factory work there 
were ten times as many accidents as in small industries. 
The working days lost by the accidents amounted to some¬ 
thing over 300,000. 

A School for Mothers. 

To teach mothers how to preserve their children from 
infective diseases and how to nurse them when healthy or 
ill a school was opened in Budapest last year and has had 
an immense success. Every lecture (delivered by voluntary 
lecturers) was attended by audiences consisting of from 1200 
to 1300 mothers. The first lecture was delivered this year in 
the town-hall by Dr. F. Torday, chief physician of the 
State Foundling Home. The title of his lecture was : “The 
Preservation of the Health of the Future Generation ; the 
Prevention of Tuberculosis and Scrofulosis.” The entrance 
to these lectures is free and men are not admitted. The 
order of the lectures is as follows : Dr. Presich lectures 
on Rickets ; Dr. Wein on the Bodily Education of Children 
at Home ; Dr. Deloe on the Essentials of the Infective 
Diseases and their Prophylaxis; Dr. Berend on the 
Nutrition of Infants; and Dr. Schaffer on the Mental 
Training of Children. The good effect of this school 
is shown by the following declaration of the wife of a 
State official. “The frequenting of the lectures of the 
‘School for Mothers' is exceedingly useful for us. We 
learn there different things, amongst them one thing par¬ 
ticularly—in case of emergency not to ory and rub our 
bands bnt to send for the doctor immediately, and th»n 
such disaster as I was unfortunate enough to survive will 
be avoided. About two years ago my baby (aged one year) 
was attacked by cramps. His face became bluish and the 
eyes turned upwards. The instruction of the grandmother 
was of no use ; the child did not regain consciousness. 
The blue tint of the face changed to mortal paleness; the 
baby's glassy eyes showed that he was dead. We began to 
cry bitterly ; baby was really dead. Later I learned that 
a medical man might have saved him by applying artificial 
respiration. Such a mishap will never occur in a family 
where the mother has gained such useful information as we 
gathered in the School for Mothers.” 

Medical Men's Hours of Consultation. 

Dr. Lenard advises his confreres in the Orrosoh Lapja to 
quit the old custom of remaining at home to receive patients 
in the afternoon. This, he says, has many disadvantages 
for medical men. First and foremost the practitioner is 
occupied thus during the whole day. He sees his patients 
at that time (forenoon) when patients generally are at their 
easiest. Tne temperature is highest in the afternoon and 
lowest in the morning hours. By keeping office hours 
between 8 and 10 A M. he can execute all the calls which 
arrive during this time. Then making the out-door visitR 
till 2p.m (remembering that the severer cases should be 
left till after 12 noon) he sees his patients at the time when 
their temperature is rising. After 2 P.M. he is free and can 




The Lancet,] 


BUDAPEST.—CANADA. 


[Feb. 22. 1908. 603 


enj iy the rest of the day. This fact, particularly in summer 
time, is very valuable considering the possibility of making 
excursions and attending outdoor amusements. 

The Taxation of Secret Medioines and Cosmetics. 

Vilmos Szigethy, a financial expert, has submitted a pro¬ 
position to the Minister of Financial Affairs wherein he 
advises the taxation of all cosmetic and hygienic specialities. 
He shows that most of these substances are articles of 
luxury on which the manufacturers make immense profits, 
considering the fact that their production often costs less 
than the bottles and boxes wherein they are packed. The 
statistical returns of the last five years’ imports of these 
articles prove that during this time £500,000 worth of per¬ 
fumery and cosmetics and £800,000 worth of ready-made 
pharmaceutical preparations were imported into Hungary. 
The import increases from year to year. The demand is 
very large considering the fact that in Hungary itself 
cosmetics to the value of about £1,000,000 are manu¬ 
factured. Szigethy quotes sad instances showing how detri¬ 
mental these conditions are to the respectable druggists. 
He proposes to impose a tax on all cosmetics and secret 
medicines amounting to 25 per cent, of the sale price of the 
same. The proposal will be brought before the Legislature. 

Calomel in the Treatment of Tuberculosis. 

In a lecture delivered before a provincial medical society 
Dr. Bucfunyi said that calomel has an almost specific action 
on phlyctenular conjunctivitis and on lupus tubercles. As 
it has such a particularly good effect on local tuberculous 
affections he has used it also for pulmonary tuberculosis 
in the form of inhalations. The method of administration 
is as follows : above a spirit lamp he puts a sheet of tin, 
and strews over it from 1 to 2 grammes of calomel ( via 
humida par atom). In a few minutes tho calomel is con¬ 
verted into a white, odourless vapour which is inhaled by 
the patient. These inhalations may be carried on for several 
weeks without the least harm to the patient. Dr. Bncfanyi 
did not observe diarrhoea, salivation, or loss of appetite. 
He has applied this treatment in seven cases already and 
is satisfied with the results. 

Feb. 13th. 


CANADA. 

(From our own Correspondent.) 

United Statei and Canadian Methods of Health Inspection of 
Immigrants Compared. 

In a report recently issued by Dr. P. H. Bryce, of the 
Department of the Interior in the Cahadian Government, 
this officer, who has had charge of the inspection of immi¬ 
grants, states that the Canadian Act provides conditionally 
that otherwise desirable immigrants suffering from some 
curable disease may be detained for treatment, while the Act 
of the United States not only excludes persons suffering 
from loathsome and contagious diseases of a chronic type 
but further levies a fine upon the vessel carrying them if 
there is reasonable ground to suppose that the disease could 
have been detected before embarkation. In the case of Canada 
no immigrant shall be permitted to land in this country who 
is feeble-minded, an idiot or epileptic, or who is insane or 
has had an attack of insanity within four years. In this 
respect the United States Act is precisely the same. The 
chief difference in the laws of the two countries regarding 
the exclusion of undesirables is that the United States pro¬ 
hibits polygamists and anarchists from entering the country, 
while the immigration laws of Canada do not discriminate 
against these classes. The laws of Canada exclude the deaf, 
dumb, and bliod, unless the immigrant so affected belongs to 
a family which will give security for his permanent support. 
From the United States are debarred persons who are under¬ 
going a sentence for correction in their own country for 
crimes other than political, or whose sentence has been 
remitted conditional on their emigration. Canada is lax in 
this respect. The percentages of deportations in the two 
countries for the past nine years to the total immigrations 
show a higher ratio in the United States than in Canada. 
Of the British immigrants only 1 in 1003 is deported, while 
amongst those from the continent 1 in every 237 is deported 
from Canada. Of the latter the highest deportations are 
amongst Italians. 


Annual Report of the Royal Victoria Hospital , Montreal. 

There were admitted to the wards of the Royal Victoria 
Hospital during the year 1907 3398 patients, a decrease of 46 
from the previous year. Of these 1994 were Protestants, 1071 
were Roman Catholics, 290 were Hebrews, and 43 were of 
other faiths. The free patients numbered 1656 and the public 
ward patients 1280, and there were 462 private patients. Of 
the total number 2473 were residents of Montreal. The total 
days of hospital treatment aggregated 81,902, as against 
73,993 for the previous year. The average number of days’ 
stay in hospital per patient was 24 • 10, as against 22 • 04 for 
the previous year. On Jan. 1st, 1907, there were 224 patients 
in the hospital remaining from 1906 and during the year 3404 
were discharged, of whom 1897 were well, 1002 were im¬ 
proved, and 165 were not improved, while 123 were not treated 
and 217 died. There remained in the hospital on Dec. 31st, 
1907, 218 Of the 217 deaths 71 took place within 48 hours 
of admission. The death-rate for the year has been 6 ■ 81 
per cent., or, if those dying within 48 hours of their 
admission be deducted the rate would be 4'58 percent. In 
the 14 years during which the hospital has been in existence 
it has treated 36 524 patients. In the out-patient depart¬ 
ments during 1907 there were treated 4156 patients, the 
number of visits of these aggregating 27.399 consultations. 
The income for the year amounted to 8168.381, while the 
ordinary expenditure amounted to §146,610. The total cost 
per day per patient has been $1.79. 

Retirement of the Dean of the Laval Medical Faculty. 

Dr. Jean Philippe Rottot, for many years dean of the 
medical faculty of Laval University, Montreal, has retired 
from this honourable post. Dr. Rottot was born in 1825 and 
graduated from the old Victoria College, Montreal, and was 
admitted to the practice of medicine in 1847 In 1850 he 
was given the chair of botany at Victoria College, which he 
left in 1878 to enter Laval University. Two years after he 
succeeded Dr. Pierre Beaubien in the chair of pathology, and 
when the Notre Dame Hospital was founded he was made 
head of the clinical department. In 1891 Dr. Rottot was 
given the deanship of the medical faculty of Laval Univer¬ 
sity, which be has retained until the present time. His 
departure from the University is deeply regretted by both 
professors and students. 

British Association for the Advancement of Science in 
Winnipeg in 1909. 

Considerable progress has been already made with the 
arrangements for the meeting of the British Association for 
the Advancement of Science in Winnipeg in 1909. This 
will be the fourth time in 70 years that the Association 
has mot outside the British Isles. The first occasion was in 
1884 when the meeting took place in Montreal; the second in 
Toronto in 1897 ; and the third in South Africa in 1905. The 
Dominion Government has promised a grant of $25,000 
towards the expenses of the meeting and the local executive 
will collect $50,000 for the entertainment of the visitors. 
The meeting will probably be held on August 25th and 
following days. Professor M. A. Parker, University of 
Manitoba, Winnipeg, Manitoba, is the honorary local sec¬ 
retary. 

Violent and Sudden Deaths in Montreal in 1907. 

According to the official report of Coroner MacMahon of 
Montreal there were 785 deaths in that city due to violence 
in 1907. Altogether 83 persons were killed by railways, of 
which deaths 60 were due to Bteam railways and 23 to street 
cars. Fire was responsible for the deaths of 44 persons, 
including 17 children and one teacher in a school fire. There 
were 12 homicides, 27 suicides, and 53 drowning accidents. 
The sudden deaths were 217. An automobile was responsible, 
for one death. 

Feb. 6th. 


Royal Society of Medicine : Therapeutical 

and Pharmacological Section.— A conversazione of this 
section to which ladies are invited, will be held in the 
Apothecaries’ Hall, Blackfriars, E.C., on Tuesday, Feb. 25th, 
at 4.30 P.M. An address will be given by Dr. Harry 
Campbell on the Therapeutics of Diet; there will also be 
demonstrations of electrical apparatus, colour photography, 
and an exhibition of instruments, drugs, and foods. 
Admission will be by signature or card of a Fellow of the 
society or a member of the section. 






' 604 The Lancet,] 


OBITUARY. 


[Feb. 22, 1908. 



Sib JOHN DENIS MACDONALD. K.C.B., M.D.St. And., 
M.RC.S.Enc., F.R.S., 

INSPECTOB'GENERAL It N. (RETIREE). 

On Feb. 7th there passed away at Southsea, full of years 
aud honour, one of that distinguished band of men of science 
who notably advanced the study of biology during the middle 
of the last century by its eager pursuit in deep waters. Sir 
John Denis Macdonald’s services to science gained him the 
Fellowship of the Royal Society and his services to the navy 
won him a Knight Commandership of the Bath of the military 
division. He was born in 1826 aud was the son of Mr. James 
Macdonald, an artist of Cork, a parentage which in some 
measure shaped his own subsequent tastes. He was educated 
privately and subsequently entered the Cork School of 
Medicine ; his medical career, however, owed something to 
all three divisions of the British Isles, for he studied at 
King's College, London, and derived his M.D. in 1867 from 
St. Andrews. He qualified M.R.O.S. Eng. 18 years earlier 
and in the same year (1849) entered the Royal Navy as 
an assistant surgeon. His scientific tastes and faculty for 
classification at once gained him the post of curator to the 
Plymouth Hospital Museum and his bent also lay to the 
personal cultivation of the fine arts, a combination of tastes 
in a man of science as welcome as it is rare. Three years 
later II.M.S. Herald was commissioned for exploring and 
surveying work in the South Pacitio, and Macdonald was 
gazetted to assist in the second of the great British 
marine explorations of the last century, 20 years later 
than Darwin had made his historical voyage in the 
Beagle and 20 years before Wyville Thomson won another 
laurel for Bdtish science in the Challenger. It may 
fairly be said that Macdonald’s work ranks with that of 
those men and he pursued it unremittingly for seven years, 
bringing within the focus of his microscope many thousands 
of forms of marine life which had been netted and dredged. 
The value of his work was recognised in England and when 
he returned in 1859 at the early age of 33, he was made a 
Fellow of the Royal Society. In 1862 the sister society of 
Edinburgh awarded him the Macdougall-Brisbane medal, and 
gaining steady promotion in his service he was elected 
professor of naval hygiene at the NetleyBchool in 1866, a 
post which he held for nine years. In 1871 he obtained 
further distinction in the shape of the Sir Gilbert Blane 
medal. His next promotion was in 1875, when he became 
a deputy inspector-general of hospitals and fleets, and in 1883 
inspector general to the Royal Naval Hospital at Stonehouse. 
He only held this post for three years, as he retired from the 
service in 1886. His knighthood was conferred upon him in 
1902, and he has since lived in retirement. 

Macdonald’s contributions to literature included “An 
Analogy of Sound and Colour.” published in 1869; “Out¬ 
lines of Naval Hygiene” in 1881; “A Guide to the Micro¬ 
scopical Examination of Drinking Water” in 1883; the 
article on Yellow Fever in the first volume of Reynolds’s 
System of Medicine in 1866 ; and various papers on bio¬ 
logical matters in the Transactions of the Royal Societies 
of London and Edinburgh and of the Lineman Society. 
He maintained his interest in microscopy, music, and 
painting until the last. He was a man of distinguished 
appearance and fine culture and his death has removed 
another of the few remaining leaders of science of the 
nineteenth century. 

Sir John Macdonald was twice married, first in 1863 to 
Sarah Pboc-be, daughter of Sir. Ely Walker, of Stanary 
House, Stainland, Yorks; this lady died in 1885; and 
secondly to Erina, daughter of the Rev. William Archer, 
who also predeceased him. He leaves two sons and two 
daughters and had resided with one of the latter, who is 
married to Mr. W. R. Meyer of Hurstpierpoint in Sussex, 
for the last ten years. _ 


JOHN HENRY GALTON, M.D.Lond., M.R.C.S. Eng., 
L.S.A. 

We regret to announce the death of Dr. John Henry 
Galton, which took place at his residence, Ghunam, 
Upper Norwood, on Feb. 7ih. Ha was well known to several 
branches of the profession as a man who had always 
laboured to support its bast interests; indeel, his fatal illness 
was directly due to his unwisely aftendiog a meeting of the 


Council of the British Medical Association some ten days 
before he died, which was the occasion of his taking a chill 
resulting in a fatal bronchitis. For the last two years his 
heart and kidneyB had shown signs of failing and last 
summer, after a visit to Aix-les-Bains, he broke down 
badly, but with rest and careful treatment he was able to 
be about again, though not enough to satisfy a man of his 
active disposition. Dr. Galton was the son of Dr. Edmund 
John Galton of Brixton Rise and was born in 1840; he 
was educated at Chatham House School, Ramsgate, and 
entered Guy’s Hospital before he was 16 years old. He 
had a successful career as a student and in 1861 he 
obtained the qualifications of L.S.A. and M.R.C.S. Eng., and 
in the same year the degree of M.B. at the University of 
London, with the gold medal in midwifery, his M.D. following 
a year later. He served as house surgeon at his own hos¬ 
pital and then became resident medical officer at the Carey- 
street Dispensary. After these close years of London life he 
was attracted by the prospect of travel and obtained the 
surgeoncy of the Hudson Bay Company’s vessel the Prince 
Arthur. He only made one voyage in her, however, and 
then turned his steps to the EaBt, settling down in China, at 
Foochow, where he obtained the official medical appoint¬ 
ments to H.B.M. Consulate, the gaol, and H.I.M. Customs. 
These posts gave him an opportunity of acquiring a wide 
practical knowledge especially of surgery, to which he had 
been early attracted. He operated freely on cases of 
elephantiasis. He was not to spend his days in a foreign 
land, for in five years he decided to return to England, and 
shortly after he had done so he married and settled down at 
Anerley in partnership with Mr. J. Sidney Turner, a partner¬ 
ship which was only terminated at the end of last year. He 
became one of the leaders of the medical profession in bis 
district and in 1882 was largely interested in helping to found 
the Norwood Cottage Hospital, of which he was one of the 
original honorary surgeons, and to whioh he was appointed 
consulting surgeon on his retirement when bis health first 
began to give way. He was also surgeon to the Anerley Dis¬ 
pensary and Lying-in Charity and his interest in gynaecology 
is evidenced by several contributions whioh he made to our 
columns between 1884 and 1887 dealing with cases of 
Ciciarean section and ovariotomy. It has been mentioned 
that he was at the time of his death a member of the 
council of the British Medical Association, of which he was 
a prominent supporter, having held the post of President of 
its South-Eastern Branch. He was the originator of the 
movement in favour of admitting medical women to the 
Association, and the successful issue of that movement was 
largely due to his powerful advocacy. Another valuable 
medical institution to which he gave his whole-hearted 
labour and support was Epsom College, with which his 
official connexion began in 1885, when he was elected a 
member of the council, and his interest in its affairs has 
been actively maintained. Until within the past few 
months, when continued ill-health prevented him from 
attending at the office in Soho-square, he rarely failed 
to be present at council and committee meetings and 
he was specially devoted to the benevolent side of the 
institution. Many a widow and orphan will miss his kindly 
interest in their cases, for he took a genuine interest in 
assisting by his votes those candidates whom he knew 
personally to be deserving of support, especially when, 
as sometimes was the case, they were the relatives of an old 
professional friend. In 1902 he was elected a vice-president 
of the institution in recognition of his having collected a 
sum of over £1000 in aid of the foundation attached to the 
college, and subsequently he was elected chairman of the 
finance and works committee, which offices he had to 
resign within two years in consequence of persistent Ill- 
health. Whilst chairman of the works committee he took a 
leading part in the work of bringing the drainage system 
and the sanitary arrangements at the colleee to their 
present excellent condition at a total cost of £8000 and he 
paid frequent visits to the college as long as he was able to 
travel about. He originated the idea of providing the 
boys with the "Holman” art and reading room, which 
was erected out of contributions collected entirely by 
himself, to commemorate the services rendered to the 
college by his old friend Sir Constantine Holman, M.D., who 
then held the office of treasurer. These two were also 
closely associated in the work of the Surrey Medical Bene¬ 
volent Society for very many years. Sir Constantine Holman 
holding the office of president and Dr. Galton the office of 
treasurer. His death cannot but be felt keenly by all who are 



The Lancet,] 


OBITUARY.—MEDICAL NEWS. 


[Feb. 22,1908. 605 


interested in the welfare of Epsom College, which he did so 
much to promote. 

Dr. Galton leaves a widow and five daughters. The funeral 
took place at Shirley cemetery on Feb. lltb. The ceremony 
was largely attended by old friends and patients and many 
medical men from London and his neighbourhood, amongst 
those present being Mr. Edmund Owen, Mr. Frederic 
Durham. Dr. Henry Hetley, Mr. J. B. Lamb (secretary of 
Epsom College), Mr. G. 0. Parnell, Mr. J. Sidney Turner, and 
Mr. E. Reynolds Riy. _ 

Deaths of Eminent Foreign Medical Men. —The deaths 
of the following eminent foreign medical men are announced : 
—Dr. Martin Bloch, formerly assistant to the late Professor 
E. Mendel of Berlin, aged 41 years.—Dr. Ferdinand Albert 
Thierfelder, professor of general pathology and pathological 
anatomy in Rostock, aged 65 years.—Dr. Karl von Voit, pro¬ 
fessor of physiology in the University of Munich, at the 
age of 67 years. —Dr. A. Polotebnoff, formerly professor 
of dermatology in the St. Petersburg Military Medical 
Academy. —Dr. Adrian T. Woodward, formerly professor 
of gynaecology in the University of Vermont.—Dr. 
Sirus-Pirondi, formerly professor in the Marseilles Medical 
School.—Dr. Robert W. Taylor, formerly professor of 
the diseases of the urogenital organs in the New Yokr 
College of Physicians and Surgeons.—Dr Hermann Maters- 
dorf of Dresden, who is said to have been the senior member 
of the profession in Germany, at the age of 98 years.—Dr. 
Michael van Puteren, formerly privat-docent of children’s 
diseases in the St. Petersburg Military Medical Academy. 


Stf&iral iUtos. 


Royal Colleges of Physicians of London 
and Surgeons of England.— The Comitia of the Royal 
College of Physicians on Jan. 30th conferred Licences to 
practise upon the following gentlemen who had completed 
the Final Examination of the Examining Board in England 
in Medicine, Surgery, and Midwifery, and the Council of the 
Royal College of Surgeons conferred the Diploma of Member 
upon the same gentlemen on Feb. 13th 

Alexander Charles Anderson, Cambridge University and St. Thomas's 
Hospital; Charles Brnest Anderson, King's College Hospital; 
Arthur George Atkinson, B.A. Cantab., Cambridge University and 
St. George's Hospital; Tobias Kustat Hemsted Blake, B.A. Cantab., 
Cambridge University and St. Bartholomew's Hospital; Harry 
Blakeway, B Sc. Lond., St. Bartholomew’s Hospital; Stanley 
Leemore Brimbleeombe, St. Mary’s Hospital; John Philip Buckley, 
B.A. Cantab., Cambridge and Manchester Universities; William 
Alexander Burr, M.D. Toronto, Toronto University and London 
Hospital; Howard James Barrell Cane, B.A Cantab., Cambridge 
University and Guy's Hospital; Ernest Patrick Carmody, 
St. Bartholomew’s Hospital; Arthur John Wellington Cunning¬ 
ham, B.A. Cantab., Cambridge University and St. Bartholo¬ 
mew’s Hospital; Sidney Trevor Davies, St. Bartholomew's 
Hospital; Bernard Day, B.A. Cantab., Cambridge University 
and St. George’s Hospital; Arthur Ffollfott William Denning, 
Guy's Hospital; Alban Dixon, St. Mary’s Hospital; John McDougall 
Eckstein, St. Bartholomew's Hospital; John Everidge, Durham 
University and King’s College Hospital; Arthur Leslie Foster, 
Guy’s Hospital; Herbert Gall, St. Bartholomew's Hospital; Eric 
Worsley Gandy, B.A. Cantab., Cambridge University and West¬ 
minster Hospital; Eric Gerald Gauntlett. King's College Hospital; 
William Gilliatt, Middlesex Hospital; Harold Delf Gillies, Cam¬ 
bridge University and St. Bartholomew's Hospital; Gathorne 
Robert Girdlestone, B.A. Oxon., Oxford University and St. Thomas's 
Hospital; Alexander Edward Gow, St. Bartholomew’s Hospital; 
•John Lawrence Graham-Jones, B.A. Cantab., Cambridge Uni¬ 
versity and 8t. Thomas's Hospital; Archibald Hamilton, B.A. 
Cantab., Cambridge University and St. Mary's Hospital; Charles 
Thomas Hawkins, University College, Cardiff, and St. Mary’s 
Hospital; Claud Anthony Holburn, Sheffield University; 
Nelson West JeDkin, B.A. Cantab., Cambridge University 
and St. Thomas's Hospital; Gordon Ley, London Hospital; 
Edward Leslie Mart-yn Lobb. Guy’s Hospital; Derrnot Loughlio, 
London Hospital; Alexander Todd McCaw, New Zealand University 
and London Hospital; Donald Macrae, London Hospital; Claude 
Herbert Marshall, Guy’s Hospital; John Birch Martin, Guy’s 
Hospital; Thomas Mackinlay Miller, St. Bartholomew's Hospital; 
Roderick Joseph Graham Parnell, University College, Bristol, and 
King's College Hospital; Eustace Macartney Parsons-Smith, 
St. Thomas’s Hospital; Hubert Pinto-Leite, B.A. Cantab., 
Cambridge University and St. George’s Hospital; Horace John 
D'Arcy Gerard Price, Birmingham University; Robert Bernard 
Price, St. Bartholomew's Hospital; Joseph Francis Engledue 
Prideaux, University College Hospital; Edward John Joseph 
Quirk, Charing Cross Hospital; Percy Charles Raiment, London 
Hospital; Roland Waters Rix, St. Thomas's Hospital; Harold 
Trenchard Rossiter, St. Thomas’s Hospital; Mulk Raj Sawhney, 
St. Bart holomew’s Hospital; Francis Charles Searle, St. 
Bartholomew’s Hospital; Leonard Whittaker Sharp, B.A. Cantab., 
Cambridge University and London Hospital; "Charles Harold 


Smith, M.B. Lfverp., Liverpool University ; Frank Harold 
Stephens,St. Mary's Hospital; Hugh Stott, Guy's Hospital; Gilbert 
Francis Syms, Guy's Hospital ; Wilfrid Reginald Taylor, St.. Mary’s 
Hospital; Ernest William Toulmln, St. Mary's Hospital; 
Nusserwanjl II or mas ji Vakeel, Bombay University and St. Bar¬ 
tholomew's Hospital; Cuthbert Ferguson Walker, B.A., Royal 
University of Ireland. Galway, Belfast, and St. Mary a Hospital; 
Alan Geoffrey Wells, St. Mary's Hospital ; Ernest Godfrey Wheat, 
Cambridge University and King's College Hospital; James Norman 
Wheeler, B A. Cantab., Cambridge University and St. Thomas's 
Hospital; Edward Barton Cartwright White, London Hospital ; 
William Cecil Wigan, Oxford University and St. Bartholomew's 
Hospital; Cyril Oswald Oxford Williams, St. Bartholomew’s Hos¬ 
pital ; kajaiya Robert Williams, L.R.C.P. & S. EdiD., Edinburgh, 
Madras, and University College Hospital; John Samuel Williamson, 
St. Bartholomew's Hospital; and William Louis Rene Wcod, L.S.A. 
Leeds University. 

• Diplomas of M.R.C.S. were conferred upon these gentlemen on 
Jan. 16th. 

Diplomas in Public Health have been granted to the following 
gentlemen 

Robert Cecil Turle Evans, L.S.A., University College Hospital; 
Ernest Edward Scott Joseph Galbraith, L.R.C.P. & S. Edin., 
L F.P.S. Glaag., Queen's College, Cork, and London Hospital; 
William Henry Htllyer, M.D. Durh., L.RC.P., M.R.C.S.. Vienna 
and St. Thomas’s Hospital : Wharram Henry Lamplough, M.D., 
B.S. Durh.. L.R.C.I*., M.R.C.S., Durham University and St. Bartho¬ 
lomew's Hospital; Arthur Rieussett Littlejohn, L.R.C.P., 
M.R.C.S., St. Mary’s and University College Hospitals ; James 
Mair, M B.. C.M.GIasg, Glas* jow University and London Hos¬ 
pital; Fairlee Russell Ozzard, Major, I.M.S., L.RC.P, M.R.C.S., 
London Hospital; George Elliott Frank Stammers, Captain, 
R.A.M.C., L.R.C.P., M.R.C.S., University College, Bristol, and 
Royal Army Medical College; James Batson Stephens, M.B., 
B.S. Lond., L.R.C.P., M.R.C.S., St. Mary's and University College 
Hospitals; and John Tate, L it.C.P., M.R.C.S., University College 
Hospital. 

The Council of the Royal College of Surgeons of England also con¬ 
ferred the Licence In Dental Surgery upon Harold Walker, Guy’s 
Hospital, who has passed the examinations and complied with the 
necessary by-laws. 

University of Cambridge.— A change in the 

regulations for the M.B. degree has been made and it has 
been decided to hold three examinations for the first M.B , 
two as at present in June and December and a third early in 
the October term. By this change a student who is well 
prepared will be able to pass the first M.B. on coming up and 
to begin on the courses in anatomy and physiology at once. 
Also a stndentwho just fails to pass the examination in Jnne 
will have a chance of passing in the following October 
instead of waiting till December.—The following degrees 
were conferred on Feb. 13th :— 

M.D.—Ot. G. Bilett, Catharine. 

M B., B.C.—L. J. Austin and D. W. Hoy, Sidney Sussex. 

M.B.—D. Holroyde, Trinity. 

University of London.— At the Intermediate 

Examination in Medicine held in January the lollowing 
candidates were successful:— 

John Wroth Adams, St. Bartholomew’s Hospital; Francis Cooko 
Alton, St. Thomas's Hospital; Kathleen Jane Armstrong, London 
(Royal Free Hospital) School of Medicine for Women; Edwin 
Augustus Attenborough, London Hospital; tCyril Banks, Uni¬ 
versity oi Sheffield ; Maurice Beddow Bayly, Charing Cross Hospital; 
Claude Alexander Birts. University College: Kenneth C. Bomford, 
St. Bartholomew’s Hospital; Kenneth James Charles Bradshaw, Uni¬ 
versity of Liverpool; Frederick Leslie Biewer, University College; 
tEdward Spencer Calthrop, Charing Cross Hospital; Sydney James 
Clegg, Victoria University of Manchester; Guy Barton Cockrem, 
Guy’s Hospital; Ardeshir Koyaji Contractor. University College ; 
Grace Marion Cordingley, London (Royal Free Hospital) School of 
Medicine for Women : Goronwy Meredith Davies, St. Thomas's Hos¬ 
pital ; Frederick Adolph Dick and John Adamson Edmond, Guy’s Hos¬ 
pital; Reginald Robert Elworthy, Westminster Hospital; Thomas 
Charles Cann Evans, St. Mary's Hospital; Aichibald Ferguson, 
St. Bartholomew's Hospital; Violet Evangeline Fox, London 
(Royal Free Hospital) School of Medicine for Women ; 
Walter Egbert Fox. Guy’s Hospital; Thomas Woodcock 
George and Charles Gibson. London Hospital; Katherine Anne 
Gill and Edith Croft Goodison, London (Royal Free Hospital) 
School of Medicine for Women; Charles D’Uyly Grange, Uni¬ 
versity of Leeds ; Hugh Arrowsmlth Grierson, University of Liver¬ 
pool ; Henry Pollard Hacker, B.Sc., King's College; Arthur 
William Havard, London Hospital and University College, 
Cardiff; Reginald Melville Hiley. University College, Bristol; 
Henry IIingston, King’s College: Hairie Marguerite Hood Barrs, 
London (Royal Fiee Hospital) School of Meoicine for Women; 
Edward Leslie Horeburgb, Victoria University of Manchester; 
Thomas Lewis Jones, Guv’s Hospital; "tNorman Claudius Lake, 
Charing Cross Hospital; Frederick Norton H. Maidment, London 
Hospital; Kenneth D. Marriner, St. Thomas's Hospital; Guy 
Matihews, King's College; James Menzies, St. Marv's Hospital; 
Raymond Montgomery, University of Leeds; Adrian Leonard 
Moreton, St. Bartholomew's Hospital; George Edmund E\re 
Nicholls, Victoria University of Manchester; Alexander Croydon 
Palmer, London Hospital ; Helen Lawson Peacock and Cicely 
May Peake, London (Royal Free Hospital) School of Medicine 
for Women ; Edward Austen Penny, Guy's Hospital ; 
Moma Lloyd Rawlins, London (Royal Free Hospital) School of 
Medicine for Women: Arnold Renshaw, Victoria University of 
Manchester; Harold Ferdinand Renton, University of Leeds; 
Maude Margaret Richards, London (Royal Fric Hospital) School of 




<306 The Lancet,] 


MEDICAL NEWS. 


[Feb. 22, 1908. 


Medicine for Women ; Cecil George Richardson. King’s College and 
Westminster Hospital; Edward Heskcth Roberts, University 
College : Arthur Denys Rope. Middlesex Hospital; David Scurlock, 
St. Mary's Hospital; Edward Albert Seymour, St. Thomas’s Hos¬ 
pital; Robert Stout and JGraham Yalden Thomson, Guy's Hos¬ 
pital; Marjorie Edith Wagstaff, London (Royal Free Hospital) 
School of Medicine for Women ; Ernest White, St. Bartholomew’s 
Hospital; ^William Stanley Wildman, London Hospital; and 
Charles Witts, Guy s Hospital. 

The following candidate having qualified in organic 
chemistry has now completed the Intermediate Examination 
in Medicine :— 

Phirozshaw Cooverji Bharucha, University College. 

* Distinguished in Anatomy. t Distinguished In Physiology. 

I Distinguished in Pharmacology. 

N.B.—This list, published for the convenience of candidates, is issued 
subject to its approval by the Senate. 

University of Oxford.— The following have 

been re-elected members of the Board of the Faculty of 
Medicipe: J. R. Magrat.h, D.D., Provost of Queen's College ; 
F. A. Dixey, D.M., Fellow of Wadham College ; A. L. 
Ormerod, D.M., New College; W. Bruce Clarke, B.M., 
Pembroke College; and A. P. Parker, B.M., Magdalen 
College. 

The Treatment of Stammering at Ele- 

mentary Schools —In our it sues of Oct. 19th and 
Nov. 16th, 1907, we commented on the success which 
had been obtained in the treatment of stammering in 
children attending elementary schools, the instructors 
being Mr. W. A. Yearsley in Darwen and Miss Mona Clay 
and Professor Berquand in Manchester. Mr. Yearsley 
employs what he calls the “ auto-phonic ” system ; it 
commences with “breathing exercises,” after which come 
vocal gymnastics, and then a combination of vocal, breath¬ 
ing, and physical exercises, together with dumb-bell prac¬ 
tice. The course of instruction lasts for about six weeks. The 
system has received the approval of the education authority 
in Radcliffe, Lancashire, where a class was formed of 23 
boys and nine girls, all of whom suffered from stammering, 
stuttering, or defective articulation. Dr. D. P. M. 
Farquharson, the medical officer of health of Radcliffe, in 
a report presented to the education authority, gave a very 
favourable account of the results, and eight weeks after the 
termination of the instruction the education committee on 
putting the children to practical tests found that the im¬ 
provement was well maintained. 

Medical Inspection of School Children in 

Sussex. —The West Sussex county council had before it 
at its meeting on Feb. 7th the application of the West 
Sussex education committee for the appointment of a 
county medical officer for the purpose of working and 
supervising and, as far as possible, performing the duties 
required by the Act. The fi Dance committee of the county 
council recommended that the education committee should 
be empowered to proceed with its proposals upon the 
estimate submitted—viz., £675 psr annum. Consider¬ 
able objection was raised, it being considered inex¬ 
pedient for the education committee to appoint a medical 
officer, as it was considered that those duties could, and 
should, be carried out in intimate conjunction with the 
public health authorities under the direct supervision of 
their own medical officers of health. Another objection 
was that there were enough inspectors going about already 
and that if the education committee appointed a man he 
would be a specialist, “ and specialists are always men of 
narrow minds,” to use the councillor’s own words. But 
beyond being emphasised the various objections were not put 
to the vote, and in the result the committee’s recommenda¬ 
tion was carried. At a subsequent meeting of the education 
committee, however, it was announced that Mr. E, I. 
Bostock of Horsham, who has recently retired from practice, 
had offered to carry out, without remuneration, the duties 
until the committee had made further arrangements. This 
ofe ■ was accepted as an experiment, the chairman remarking 
that, of course, the committee would give Mr. Bostock an 
honorarium.—Acting upon the advice of Dr. A. News- 
holme, the late medical officer of health of the borough, the 
Brighton town council on Feb. 6th decided to appoint a 
whole-time medical officer to carryout the medical inspection 
of schools under Section 13 of the Education (Administrative 
Provisions) Act, 1907. There are 18,000 children in the 
elementary schools of the town, and the council, reckoning 
that of this number 6000 will require to be inspected medi¬ 
cally annually, decided that the salary should be at the 


rate of one shilling per head per inspection, or £300 per 
annum. At the same meeting it was decided to appoint an 
additional school nurse at a salary of £90 or £100 per annum. 

Chelsea Clinical Society. — The annual 
dinner of this society will take place at the New Gaiety 
Restaurant, Strand, on Thursday, Feb. 27tb, at 7.45 
p.m. All information concerning dinner tickets and tickets 
for guests can be obtained from Dr. E. R. Collis Hallowes, 
104, Buckingham Palace-road, London, S.W. 

Clifton Dispensary.— The annual meeting of 
the subscribers to this institution was held on Feb. 4th. The 
medical report stated that during 1907 there were 3149 
patients treated (including 67 cases of midwifery), as com¬ 
pared with 3612 in the previous year. The financial state¬ 
ment showed a small unfavourable balance. 

Bristol Eye Hospital.— The annual meeting 

of the subscribers to this hospital was held on Feb. 5th under 
the presidency of the Lord Mayor. The annual report stated 
that during 1907 the in-patients numbered 513, being 59 in 
excess of the previous year ; and that 7337 out-patients had 
been treated as compared with 6805 in 1906. The financial 
statement showed an unfavourable balance of £537. 

Metropolitan Asylums Board.— This Board 
at a recent meeting decided to increase the remuneration 
of medical superintendents in the hospitals as follows: 
Salary (1) commencing at £5C0 per annum and rising by 
four annual increments of £25 to £600 per annum, and 
thence by two further annual increments of £50 to £700 per 
annum ; and (2) after the expiration of ten completed years 
of service as a medical superintendent to rise from £700 per 
annum by £50 annually to a maximum of £800 per annum. 
The emoluments consist of unfurnished house (or furnished 
apartments) and washing. The salary hitherto assigned to 
a medical superintendent commenced at £400 and rose 
annually by £25 to a maximum of £700 per annum with 
emoluments of unfurnished house (or furnished apartments), 
washing, fire, and lighting. 

University of Sheffield.— The Council of 

the University has appointed Mr. John L. Annan, M B., 
Ch B Edin., to the post of Demonstrator in Anatomy. Dr. 
Annan is at present Demonstrator of Anatomy in the Uni¬ 
versity of Edinburgh and house physician in the skin wards 
of the Edinburgh Royal Infirmary. The Council has also 
appointed the following gentlemen to the newly instituted 
clinical tutorships : Mr. Miles H. Phillips, M.B , B S Lond., 
F.R.C.S.Enp., in Obstetrics and Gynaecology; Mr, Graham S. 
Simpson, F.R C.S. Eng., in Surgery ; and Mr. A. E. Barnes, 
M B. Lond., M.R.C.P. Lond., in Medicine. Dr. Phillips is the 
assistant medical officer at the Jessop Hospital for Women 
and Mr. Simpson is the assistant surgeon at the Sheffield 
Royal Hospital. Dr. Barnes holds a British Medical 
Association Research Scholarship and is at present 
engaged in research in the Pathological Laboratory of the 
University. 

The Anniversary Dinner of tiie West 
London MedicoCiiirurgical Society. —The twenty-sixth 
anniversary dinner of this society was held under the chair¬ 
manship of Mr. Richard Lake, the President, on Feb. 13th 
at the Whamcliffe Rooms, Hotel Great Central, Marylebone, 
London, and the occasion proved a great success, for which 
due praise was accorded to Dr. F. G. Crookshank, the 
senior secretary, and his colleague, Mr. A. Baldwin. "The 
Imperial Forces ” was proposed by Mr. Herbert W. Chambers 
and was responded to by Colonel A. T. Sloggett, R.A.M.C. 
The chairman submitted the toast of the evening, "The 
West London Medico-Chiiurgical Society.” He was able 
to report that the finances were in a healthy condition 
and that the ordinary meetings of the society, of which 
nine were held during the session, had beeD well attended, 
the average number present at each meeting being 41. He 
was happy to state that there was an increase in the total 
membership, the number of members nearly reaching the 
total of 700. More books were being added to the library and 
there was a satisfactory arrangement for supplying members 
with an opportunity of seeing newly published works. He 
concluded his speech with a graceful reference to the founder 
of the society, Mr. C. R. B. Keetley. Dr. A. J. R. Oxley 
proposed the toast of "The Kindred Societies and Guest6,” 
in the course of which he referred to the services 
rendered to the profession by Sir William S. Church, 
President of the Royal Sooiety of Medicine. Sir 






The Lancet,] 


MEDICAL NEWS.—PARLIAMENTARY INTELLIGENCE. 


[Feb. 22, 1908. 607 


William Church, in replying, praised the results achieved 
by societies like the West London Medico-Chirurgical 
Society and pointed out that it was no part of the scheme 
of the Royal Society of Medicine to absorb societies such as 
theirs. Mr. Arbnthnot Lane, who also replied to this toast, 
concluded his remarks by proposing the health of the chair¬ 
man, and that gentleman, in the course of aclntwledging 
the toast, thanked the officers of the society for the help 
which they had accorded to him in his duties as President. 

Royal London Ophthalmic Hospital (Moor- 
fields Eye Hospital). —The annual general meeting of 
governors of this charity will be held on Tuesday, Feb. 25'h, 
at 3 o'clock, at the Mansion House, by permission of 
the Lord Mayor, who has consented to preside. Lord 
Avebury. Sir Charles Wyndbam, Dr. Hermann Adler, and 
Mr. H. Curtis Bennett have promised to speak in support of 
the hospital. 

London Inter collegiate Scholarships Board. 
—It will be remembered that this board was constituted in 
1904 with the approval of the governing bodies of University 
College, King’s College, and the East London College, for the 
purpose of holding a combined annual examination for 
entrance scholarships and exhibitions tenable at those 
Colleges, and that tbe examination may be made use of by 
other bodies for the award of scholarships and exhibi¬ 
tions, subject to arrangement with the board. We are 
asked to state that the board will hold a com¬ 
bined examination for 20 scholarships and exhibitions in 
classics, languages, literature, history, science, and mathe¬ 
matics, tenable at University College, King's College, and the 
East London College, on May 12th and following days. No 
candidates will be admitted to the examination unless they 
have passed the London University matriculation or an 
equivalent examination and are under the age of 19 years on 
Oct. 1st, 1908. The total value of the scholarships offered 
exceeds £1700. Most of them are open to students of both 
sexes. Full particulars and forms of entry may be obtained 
from the secretary of the board (Mr. Alfred E. G. Attoe), 
University College, Gower-street, London, W.C. 

The British Association for the Advance¬ 
ment of Science. —The following have been elected by the 
council to be presidents of sections at the meeting of tbe 
association to be held in Dublin in September next under the 
general presidency of Mr.Francis Darwin, F.R.S.:—SectionA 
(mathematical and physical science), Dr. W. N. Shaw, 
F.R.S., director of the Meteorological Office ; Section B 
(chemistry). Professor F. S. Kipping, F.R.8., professor of 
chemistry in University College, Nottingham ; Section C 
(geology), Professor J. Joly, F.R.S , professor of geology 
and mineralogy in the University of Dublin ; Section £> 
(zoology), Dr. S F. Harmer, superintendent of the University 
Museum of Zoology, Cambridge; Section E (geography), 
Major E. H Hills, C.M.G. ; Section F (economic science and 
statistics), Lord Brassey; Section G (engineering), Mr. Dugald 
Clerk, M.Inst. C.E : Section H (anthropology), Professor W. 
Ridgeway, professor of archaeology in the University of Cam¬ 
bridge; Section I (physiology). Dr. John Scott Haldane. 
F.R.S., University reader in Pnysiology at Oxford ; Section K 
(botany). Dr. F. F. Blackman, F.R.S., professor ot botany in 
the University of Leeds ; and Section L (educational science), 
Professor L. C. Miall, formerly professor of biology in the 
University of LeedB. Invitations to deliver evening dis¬ 
courses during the meeting of the Association at Dublin 
have been accepted by Professor H. H. Turner, F.RS., 
Savilian professor of astronomy at Oxford, who will take as 
his subject “ Halley’s Comet” ; and Professor W. M. Davis, 
of Harvard University, whose lecture will be entitled "The 
Lessons of the Colorado Canon.” 

London Fever Hospital — The annual general 

meeting of the governors' of this hospital was held at the 
Hotel Victoria, Northumberland-avenue, on Feb. 14th the 
chair being taken by the Right Hon. Lord Balfour of Burleigh, 
K.T., the president, who said he thought that he could 
fairly ask the meeting to express their appreciation in this 
regard because they had had a satisfactory year, 781 patients 
having been admitted during the year, which with 71 brought 
forward made a total of 852 patients treated for all diseases, 
this number being 250 more than the average of the last 
20 years. Notwithstanding the increase of numbers the 
average rate of mortality in scarlet fever had been down so 
low as 1'50 lower than the previous years. Although during 
the rebuilding of the hospital they had had to refuse 35 


patients, they were now able fully to meet the demands made 
upon them. 216 patients bad been treated free in virtue of 
tbe subscriptions of private governors aDd managers of 
business houses, 476 had paid the ordinary fee of 3 guineas, 
51 had paid 3 guineas a week in private rooms, and 38 
had had their like fees remitted owing to their having 
established their inability to meet the charge. 72 of 
those who were charged 3 guineas had supplemented their 
fee not only by expressions of gratitude for the kindly care 
and attention which they had received but had sent sums 
totalling £227 in amounts varying from 1 guinea to £25. 
He appealed to the public for a continuation of their 
support which had hitherto been so generously given. He. 
was afraid the completion of the new wing for measles would 
have to wait until further funds were forthcoming. The 
adoption of the report (which had been previously read by 
Dr. Sidney P. Phillips, the senior physician, and moved by 
Sir Shirley F. Murphy, medical officer of the London County 
Council) was carried unanimously. On the motion of 
Mr. Edward Norman, Lord Balfour was re-elected as president 
for the ensuing year, the vice-presidents, treasurer, honorary 
secretary, and members of the committee being elected. A 
vote of thanks (proposed by Mr. Mead) to Lord Balfour for 
presiding concluded the proceedings. 


^arlianttnlarj Jittelligem. 


NOTES ON CURRENT TOPICS. 

The Children's Bill. 

Mr. IIf.rbert Samifi., when he introduced the Children's Bill in the 
House of Commons, was prevented by the exigencies of time from ex¬ 
plaining in detail many parts of this comprehensive measure. The text 
of the Bill is now available and.lt is possible to fill in with precision its 
various proposals. To recapitulate them would be a lengthy process, for 
the Bill contains 119 clauses, many of them of a complicated character. 
However, several points which were alluded to in this column last 
week may be further elaborated. For instance, it was mentioned 
that under the measure a penalty was proposed for exposing 
children to the risk of burning. The clause dealing with this matter 
lays down that if a person who has the custody or care of a child under 
the age of seven years, “allows that child to be in any room contain¬ 
ing an open fire grate not sufficiently protected to guard against the 
risk of the child being burnt or scalded, and without taking reasonable 
precautions against that risk, and if by reason thereof the child is 
killed or suffers serious injury,” he shall on summary conviction be 
liable to a fine not exceeding £10. This section does not extinguish the 
liability of such person to be proceeded against by indictment for any 
indictable offence. The penalty for causing the death of an infant 
under three years by overlying it is also a fine not exceeding £10. If the 
offender is proved to have been under the influence of drink the fine may 
amount to £25 and the court has the power to impose an alternative or 
an additional sentence of imprisonment for a term not cxeeeding three 
months if the offence is accompanied by aggravating circumstances. 

Juvenile Smoking. 

Six clauses In the Children's Bill deal with the Prohibition of 
Juvenile Smoking. An ascending scale of penalties for selling 
tobacco to children and young persons is set out. The first offence 
may be visited with a fine not exceeding £2 and the second with a 
fine not exceeding £5. but the third offence makes the offender liable 
to a penalty of £20. The words of the section have been carefully 
chosen and any person is liable to conviction if he “sells or gives to a 
person apparently under the age of 16 years any cigarette or cigarette 
papers, whether tor his own use or not, or sells or gives to such a 
person any other tobacco which he knows or has reason to believe is 
for tbe use of that person.” Constables, park-keepers, and persons 
authorised by special by-laws are to seize cigarettes and tobacco 
in the possession of "any person apparently under the age 
of sixteen” who Is found smoking or about t> smoke in any 
street or public place. A penalty is also proposed to be laid on 
the juvenile smoker hinmelf. This clause, which deals directly with 
the evil, is of such Importance that, it may be quoted in extenso. 
It runs thus : “If a child or young person smokes in a street or public 
place, or purchases or has in his possession, whether for his own use or 
not, any cigarettes or cigarette papers, or purchases or has in his 
possession for his own use any other tobacco, he shall be liable on 
summary conviction in the case of a first offence to be reprimanded, 
and in the case of a second offence to a fine not exceeding 5*., and in 
the case of & third or subsequent offence to a fine not exceeding 10s.” 
The phraseology of this section of the Bill is worthy of attention, as a 
distinction is drawn between the terms “cigarette" and “other 
tobacco.” It seems to be the proposal of the Home Office that the 
actual possession of a cigarette, quite apart from the intention to 
smoke it, shall he an offence in a person under the age of 





(508 The Lancet,] 


PARLIAMENTARY INTELLIGENCE. 


[Feb. 22, 1908. 


16. In the case of “ other tobacco" mere possession does not 
constitute the proposed offence. It must be destined for the use of the 
juvenile delinquent. Exemption to young persons employed in the 
tobacco trade Is given, in so far that they may continue their employ¬ 
ment, but they are prohibited from smoking in the same way as if they 
were not employed in the business. A clause of the Bill deals with 
automatic machines for the sale of tobacco or cigarettes. It is proposed 
to endow courts of summary jurisdiction with powers to order the 
person on whose premises such a machine is kept to prevent it being 
extensively used by children and young persons for obtaining tobacco. 
Non-compliance with this order renders the person against whom it is 
made liable to a fine, which may be increased daily so long as his 
offence continues. However, he may either himself or by his agents 
make seizures of the cigarettes and tobacco obtained from the machine 
by young persons apparently under the age of 16. 

The Children’s Bill has been received with much satisfaction in all 
quarters of the House of Commons. Mauy of its provisions are 
generally conceded to be long overdue. In a measure of such length, 
however, there are almoit bound to be clauses which in their drafting 
are unacceptable to 6ome members. Mr. Samuel, who has been taking 
charge of the Bill, has approached the House in such a conciliatory 
spirit as to give the impression that the Government will exert itself 
to remove difficulties of this kind from the progress of the measure. 

Infant Life Protection Committee. 

The promised select committee of the House of Commons has been 
constituted to inquire into the advisability of extending the Infant 
Life Protection Act, 1897. The committee, which is a email one, has 
already set to work. Mr. John Ellis has been choseu as chairman* 
Steps have been taken to secure the attendance of witnesses competent 
to speak on the subject. The committee will meet again this week 
and it is understood that it w-ill use the utmost despatch in com¬ 
pleting the Inquiry. 

Poisons and Pharmacy Bill. 

The Earl of Crewe has introduced into the House of Lords a Bill 
“ to regulate the sale of certain poisonous substances, and to amend the 
Pharmacy Acts." The Bill was read a first time. 

Nurses < Registration ) Bill. 

Mr. Claude IIay has introduced into the House of Commons a Bill 
“to regulate the qualifications and registration of trlined nurses." 
Sir Arthur Bioxoi.d is associated with Mr. IIay in bringing in this 
Bill, which was read a first time. 

Medical Practice by Companies. 

Sir John Batty Turk on Wednesday introduced into the House of 
Commons a Bill to prohibit joint-stock companies from acting as 
physicians, surgeons, or medical practitioners. Tne Bill as a matter 
of form was read a first time. Legislation dealing with this subject 
passed through the House oi Lords last year, but owing to the conges¬ 
tion of business it failed to be considered by the House of Commons. 

HOUSE OF COMMONS. 

Wednesday, Feb. 12th. 

Deaths from Starvation in London. 

Mr. Summkrbell asked the President of the Local Government 
Board what were the number of deaths in 1907 in London upon which a 
coroner's jury returned a verdict of death from starvation or death 
accelerated by privation; how many of these took place in 
Whitechapel; if he hid not yet received the Home Office returns as to 
these deaths, whether he would without delay obtain from the 
Whitechapel guardiaus or from the Poor-law inspector of the district 
the number of such deaths from starvation in Whitechapel in 1907; 
and whether he had conferred, or would confer, with the guardians of 
Whitechapel as to steps to prevent or diminish the number of 6uch 
deaths.—Mr. Burns replied in a written answer: I am not able 
to give the numbers for the year 1907, as the necessary particulars 
have not yet been obtained by the Home Office from the coroners. 
I have communicated with the clerk to the Whitechapel guardians 
as to the occurrence in that union in 1907 of cases of the kind 
referred to. and I am informed that the medical superintendent of the 
infirmary has caused a search to be made and cau find only one such 
case—namely, that of George Wright who died on July 25th last and 
in respect of whom the verdict of the coroner’s jury w as that he died 
from pneumonia accelerated by neglect and want of food. I will 
inquire ns to the circumstances of this case, but I am not at present 
aware of any need for action of the kiud suggested in the concluding 
part of the question. In connexion with this matter the character of 
the district and the large number of persons of migratory habits 
attracted thereto by free shelters and common loiging houses must be 
borne in mind. 

Overcrowding in Scotland. 

Mr. Dindas White asked the President of the Board of Trade 
whether his attention had been called to the fact that in the recent 
report on the cost of living of the working classes in the principal 
industrial towns of the United Kingdom, the percentages of the total 
populations occupying overcrowded tenements —i.e., more than two 

f ersons |>er room—were given for the specified towns of England, 
reland, and Wales, but not for the specified towns of Scotland, it 
being stated that the figures for the Scottish towns were not available ; 
w hether he could state what were the corresponding figures for these 
Scottish towns; and whether he would consider the advisability of 
framing the forms ior the next Census so as to obtain that informa¬ 
tion.—Mr. Sinclair the Secretary for Scotland, sent the following 
writteu reply:—My attention was directed sometime ago to the fact 
that the figures referred to are riot given in the Scottish Census lteport, 
and under my instructions a return his been prepared for presentation 


to the House which will give full information on the subject, for the 
whole of Scotland. The figures for the specified Scotch towns are as 


follows !— 

Percentage of population 

Town. 

living more than 
two in a room. 

Aberdeen . 

. 381 

Dundee . 

. 49-44 

Edinburgh. 

. 32 94 

Glasgow . 

. 54-7 

Greenock . 

. 54-17 

Kilmarnock . 

. 5594 

Leith . 

. 438 

Paisley . 

. 58 76 

Perth . 

. 28 26 


My honourable friend will remember that the Board of Trade report 
draws attention to the fact that the tenement system of blocks of small 
flats is in Scotland the normal type of working-class dwelling, and tint 
the rooms are generally much iarger than those of an English cottage. 
The question of including these figures in the next Census Report will 
receive consideration. 

Thursday, Feb. 13th. 

The Sale of Tuberculous Cattle in Scotland. 

Mr. Cathcakt Wason asked the Secretary for Scotland whether lie 
was aware that in Scotland cattle in the last stages of tuberculosis 
were occasionally exposed for sale and food in the open market, with 
consequent risk of spread of the disease and danger to human life ; and 
whether he proposed to take any steps by legislation or otherwise in 
order that persons submitting dying diseased cattle for Bale might l>e 
prosecuted.—Mr. Sinclair replied : Section 43, la of the Public Health 
^Scotland) Act, 1897, enables the officials of the local authority to seize 
animals that are intended for the food of man and are exposed for Bale 
if they are diseased or unsound or unfit for the food of man. and the 
person to whom the animal belongs iB liable to prosecution. The 
officials of the local authorities make use of this power and there does 
not seem need for fresh legislation in the direction suggested. 

St. Andrew's Ambulance Classes . 

Major Anstruther-Gray asked the President of the Board of Trade 
whet her instructions had been given to oblige Scotch candidates for 
master and mates first-aid certificates to qualify through St. Audrew’s 
Ambulance instead of St. John’s •. whether he was aware that the 
yearly St. Andrew’s course consisted of 144 lectures, while that of St. 
John’s was only 52, and that the St. Andrew's Ambulance course 
was therefore more expensive in time and money thaa that of 
St. John’s; whether the St.John’s Ambulance classes, hibhcrio con¬ 
ducted on the East Coast of Scotland, had proved satisfactory; and, if 
so, why a system involving more time, trouble and expense was 
enforced in Scotland and an easier system deemed sufficient for 
English candidates.—Mr. Kearlky (Parliamentary Secretary to the 
Board of Trade) replied: Before granting a certificate for master or 
mate we require a man to have a knowledge of first-aid to the injured. 
This he can acquire through attending a course under either of the 
societies mentioned in the q uestion. We have been in communication 
with the two societies, and as the St John Ambulance Association 
informs us that it has centres at one or two Scottish ports only we 
have arranged with the St. Andrew's Society that courses should he 
available at all the chief ports in Scotland. If the suggestion in the 
question is that the Board imposes attendance at one society’s course 
rather than the other the honourable and gallant Member is under a 
misapprehension. 

Medical Inspection of School Children in Ireland. 

Mr. Jeremiah MacVeagh asked the Chief Secretary to the Lord 
Lieutenant of Ireland whether his attention had been called to the 
resolution of the Irish Committee of the British Medical Association, 
urging the necessity of the medical inspection of school children 
in Ireland on the lines already adopted by legislation with regard to 
England; and whether, having regard to the fact that every 
argument for such inspection ia England applied with even 
greater force to Ireland, he would consider whether steps could 
be taken to give effoct to this recommendation.—Mr. Birhkll 
answered : 1 have received a communication from the Irish Committee 
of the British Medical Association to the effect stated in the question. I 
have beon in communication with the Commissioners oi National 
Education upon the subject generally and the matter is to be further 
considered by the Commissioners at their meeting next week I would 
therefore ask the honourable Member to defer the question for the 
present. 

Friday, Feb. 14th. 

Diphtheria in Wood-Pigeons. 

In answer to Major Axstruther Gray, 

Sir Edward Strachey (representing the Board of Agriculture) 
stated that the Board was awprc of the prevalence of the disease called 
diphtheria in wood-pigeons in several counties in England. That 
department understood that scientific investigations were being made, 
the results of which would be carefully watched. They did not think 
that the matter could with advantage be made the subject of inquiry 
by a commission. As to whether the disease was of a nature to be 
dangerous to man, he would bring the subject before the Local 
Government Board, by which questions concerning the public health 
fell to be considered. 

Monday, Feb. 17th. 

Malta Fever. 

Mr. Mallet asked the Secretary of State for War whether he was 
aware of the public service rendered by a commission of the Royal 
Society, at the request of the War Office and the Admiralty, in dia- 
eweriug the cause of Malta fever, from *hich many hundreds annually 
of our soldiers and sailors on that island till recently suffered; and 
whether, in view of the importance of this discovery in the annals of 
preventive medicine, inasmuch as at the present moment the disease 
had been entirely stamped out, he would consider the desirability of 
giving the thanks of the Government to the Royal Society for this 
instance of the successful application of British scientific research.— 







The Lancet,] 


PARLIAMENTARY INTELLIGENCE.—BOOKS, ETC., RECEIVED. [Feb. 2 7 ,. 1908. 609 


Mr. Haldane replied : I am aware of the great service rendered by 
the commission in question. The commission’s investigations and 
the adoption of preventive measures as the outcome of its 
recommendations have been followed by the practical dis¬ 
appearance of Malta fever from the garrison of the island. I think 
that the Royal Society is well aware how genuine is the appreciation of 
the Government. We owe much to the Royal Society’s Commission 
for the successful issue of this remarkable investigation and for the 
excellent results which have followed. These results illustrate the 
enormous importance of bringing science into our business of govern¬ 
ment. 

The Belfast Health Commission. 

Mr. Devlin asked the Chief Secretary to the Lord Lieutenant, of 
Ireland whether any report had yet been receivod from the Health 
Commission which recently sat in Belfast; or, if not, when was the 
report likely to be published. —Tlie Attorney-General for Ireland (Mr. 
Cherry) replied in the absence of Mr. Bikrell : The report has not 
yet been received, but I am Informed by the Chairman of the Commis¬ 
sion that it may be expected early next month. 

Milk-blended Batter. 

Mr. O’ShAughnessy asked the honourable Member for South 
Somerset, as representing the President of the Board of Agriculture, 
whether he could say under what name was milk-blended butter sold 
with the approval of the Board of Agriculture, In accordance with the 
Butter and Margarine Act, 1907, when it contains more than 16 per 
cent, and under 24 per cent, of water; and whether, undor the Act, 
there was any change in the description of margarine when offered for 
sale to the public.—sJir Edward Strachey replied -. 19 names have up 
to the present time been approved by tho Board for milk-blended 
butter. The law as to the manner in which margarine is to be 
described was amended by Section 8 of this Act, to which the honour¬ 
able Member refers. 

Milk legislation. 

Mr. Courthope asked the President of the Local Government Board 
whether, in view of the Intention of the Government to introduce 
general legislation on the subject of the milk-supply, he would move 
instructions to the committees on all private Bills containing milk 
clauses that such clauses be struck out.—Mr. Burns wrote in reply : It 
does not seem to me that the course proposed could well be adopted. 
I think that the best plan will be that the clauses should for the 
present be retained on the understanding that they will be subject to 
reconsideration at a later stage in the event of a public Bill being 
passed. 

Tuberculosis in Frozen Meat. 

Mr. Courthope asked the President of the Local Government 
Board whether he was aware that frozen beef from the Argentine had 
recently been seized In. Hull affected with glandular tuberculosis, 
although accompanied bj r the official label of the Argentine Govern¬ 
ment certifying that the meat was sound ; and what steps he proposed 
to take to safeguard the health of the community from such occur¬ 
rences in future.—Mr. Burns furnished the following written reply : 
The answer to the first part of the question is in the affirmative. 
Regulations under the Public Health (Regulations as to Food) Act, 
1807, are in preparation and will, I hope, Boon be issued to confer 
additional powers on port sanitary authorities and to enable them to 
deal suitably with any diseased meat which may be detected on arrival 
in this country. 

Tuesday, Feb. 18th. 

Horse Meat and Sausages. 

Mr. Richardson asked the President of the Local Government 
Board whether he had any official information as to the number of 
worn-out horses sent from Nottingham and Worksop to the continent, 
and as to whether these animals were there converted into sausages and 
then imported into this country for consumption as human food, if so, 
could he say to what port on the continent they were exported, and 
what proportion of this sausage was consumed in this country.—Mr. 
Burns answered: I have no official information as to the number of 
worn-out horses sent from Nottingham and Worksop to the continent. 

I have not met with any definite evidence pointing to the importation 
into this country of sausages prepared from horses, though it is some¬ 
times alleged that sausage meat imported in bulk contains horse meat. 

I have the subject of the importation of sausage meat under con¬ 
sideration in connexion with the regulations which I am preparing 
under the Public Health (Regulations as to Food) Act of last session. 

Soldiers and Tuberculosis. 

Mr. Summebbell asked the Secretary of State for War what action 
he proposed to take in regard to soldiers suffering from tuberculosis in 
view of the findings of the Select Committee appointed to go into the 
matter.—Mr. Haldane replied: The recommendations of the Select 
Committoe have been recently considered by the Government as a whole. 
The decision is that, however desirable the special provision recom¬ 
mended by the committee in the case of soldiers discharged from the 
army because of tuberculosis, it is impossible to justify the assumption 
of this new kind of obligation by the State unless it is extended to other 
services as well as the army, and possibly more widely still. The 
question thus raised becomes one of great gravity and cannot be decided 
by any siDgle department. 

The London County Council and Inebriate Institutions. 

In answer to Mr. Charles Roberts, Mr. Gladstone, the Home 
Secretary, wrote that he had received with much regret a letter 
from the London County Council stating that bhe Council did 
not see its way to renew its contracts with the national institutions 
for the care and reformation of inebriate persons. The accounts 
of seven out of the eight institutions of this kind in full working 
order during 1906 showed a maintenance cost varying from 10s. 4ef. to 
14s. per inmate per week, but the eighth, " Farm field,” managed 
by the London County Council, was not conducted at less 
than a weekly rate of 18s. 6<i. per head. It was felt that 
14s. per week should be considered the total amount required 
for maintenance and that the managers of reformatories should be 
induced to bring down their expenses to that sum per head. In 
furtherance of the view that the segregation of inebriates relieved 
imperial and local funds about equally, it was decided tha